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

Child (>12 mo)	'
Obstructive intestinal anomalies	Malrotation ± volvulus, incarcerated hernia, Hirschsprung disease, intussusception, foreign body, bezoars, Meckel diverticulum, acquired esophageal stricture, peptic ulcer disease, adhesions, superior mesenteric artery syndrome
Neurologic	Intracranial bleed/mass, cerebral edema, postconcussive, migraine
Renal	Urinary tract infection, obstructive uropathy, renal insufficiency
Infectious	Viral illness, gastroenteritis, meningitis, sepsis, otitis media, pneumonia, hepatitis, streptococcal pharyngitis
Metabolic/endocrine	Inborn errors of metabolism, adrenal insufficiency, renal tubular acidosis, diabetes mellitus, Reye syndrome, porphyria
Miscellaneous	Ileus, gastroesophageal reflux, post-tussive, peritonitis, drug overdose, appendicitis, pancreatitis, gastritis, Crohn disease, pregnancy, psychogenic, cyclic vomiting syndrome

Diagnosis

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

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)

External Links

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