Nausea and vomiting (peds)

Background

• Broad differential: Gastrointestinal, Neurologic, Metabolic, Respiratory, Renal, Infectious, Endocrine, Toxin-related, Behavioral

Clinical Features

• Assess general appearance and behavior
• Evaluate volume status
• Abdominal and genitourinary examinations are important for potential surgical causes

Differential Diagnosis

Nausea and vomiting (newborn)

Newborn	'
Obstructive intestinal anomalies	Esophageal stenosis/atresia Pyloric stenosis Intestinal stenosis/atresia Duodenal atresia Malrotation ± volvulus Incarcerated hernia Meconium ileus/plug Hirschsprung's disease Imperforate anus Enteric duplications
Neurologic	Intracranial bleed/mass Hydrocephalus Cerebral edema Kernicterus
Renal	Urinary tract infection Obstructive uropathy Renal insufficiency
Infectious	Viral illness Acute gastroenteritis Meningitis Sepsis
Metabolic/endocrine	Inborn errors of metabolism Adrenal insufficiency Congenital adrenal hyperplasia
Miscellaneous	Ileus Gastroesophageal reflux disease Necrotizing enterocolitis Milk allergy, FPIES GI perforation

Nausea and vomiting infant (<12 mo)

	'
Obstructive intestinal anomalies	Pyloric stenosis Malrotation ± volvulus Incarcerated hernia Hirschsprung's disease Enteric duplications Intussusception Foreign body Bezoar Meckel diverticulum
Neurologic	Intracranial hemorrhage/mass Hydrocephalus Cerebral edema (e.g. in DKA or cancer)
Renal	Urinary tract infection Obstructive uropathy Renal insufficiency
Infectious	Viral illness Acute gastroenteritis Meningitis Sepsis Otitis media Pneumonia Pertussis Hepatitis
Metabolic/endocrine	Inborn errors of metabolism Adrenal insufficiency Renal tubular acidosis DKA
Miscellaneous	Ileus Gastroesophageal reflux disease Post-tussive Peritonitis Drug overdose

Nausea and vomiting child (>12 mo)

'	'
Obstructive intestinal anomalies	Malrotation ± volvulus Incarcerated hernia Hirschsprung's disease Intussusception Foreign body Bezoar Meckel diverticulum Acquired esophageal stricture Peptic ulcer disease SBO, adhesions Superior mesenteric artery syndrome
Neurologic	Intracranial hemorrhage/mass Hydrocephalus Cerebral edema (e.g. in DKA or cancer) Migraine Postconcussion syndrome
Renal	Urinary tract infection Obstructive uropathy Renal insufficiency
Infectious	Viral illness Acute gastroenteritis Meningitis Sepsis Otitis media Pneumonia Pertussis Hepatitis Streptococcal pharyngitis
Metabolic/endocrine	Inborn errors of metabolism Adrenal insufficiency Renal tubular acidosis DKA Reye syndrome Porphyria
Miscellaneous	Ileus Gastroesophageal reflux disease Post-tussive Peritonitis Drug overdose Appendicitis Pancreatitis Gastritis Crohn's disease Pregnancy Psychogenic Cyclic vomiting syndrome

Evaluation

Pediatric signs of dehydration

Significantly dehydrated if has 2 or more of the following (LR+ 6.1, CI:3.8-9.8):

• Prolonged capillary refill (>2 sec)
• Dry mucous membranes
• Absence of tears
• Abnormal overall appearance
• Sunken fontanelle in an infant

Management

• Largely depends on etiology
• If ill appearing, establish rapid IV access, or if needed IO.
  • Rapid finger stick blood sugar
  • Point of care pH and electrolytes (iSTAT)

Pediatric acute gastroenteritis treatment

1. Oral rehydration therapy
   • Avoid IV fluids before doing a trial of oral rehydration therapy in uncomplicated cases of mild to moderate dehydration in children.
2. If fails, oral ondansetron as a single dose PO (>6 months of age)
3. If fails, IV fluids (e.g. normal saline)

Probiotics have NOT been shown to provide any benefit

Disposition

Discharge

• Presumed self-limited etiology
• Well appearing
• Tolerating fluids

Admission and/or Observation

• All others

See Also

• Nausea and vomiting
• Abdominal pain (peds)
• Acute gastroenteritis (peds)
• Diarrhea (peds)
• Dehydration (peds)

External Links

Pediatric Emergency Playbook -- Vomiting in the Young Child: Nothing or Nightmare