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, malrotation ± volvulus, incarcerated hernia, meconium ileus/plug, Hirschsprung disease, imperforate anus, enteric duplications, duodenal atresia
Neurologic Intracranial bleed/mass, hydrocephalus, cerebral edema, kernicterus
Renal Urinary tract infection, obstructive uropathy, renal insufficiency
Infectious Viral illness, gastroenteritis, meningitis, sepsis
Metabolic/endocrine Inborn errors of metabolism (urea cycle, amino/organic acid, carbohydrate), congenital adrenal hyperplasia
Miscellaneous Ileus, gastroesophageal reflux, necrotizing enterocolitis, milk allergy, GI perforation

Nausea and vomiting infant (<12 mo)

'
Obstructive intestinal anomalies Pyloric stenosis, malrotation ± volvulus, incarcerated hernia, Hirschsprung disease, enteric duplications, intussusception, foreign body, bezoars, Meckel diverticulum
Neurologic Intracranial bleed/mass, hydrocephalus, cerebral edema
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
Miscellaneous Ileus, gastroesophageal reflux, post-tussive, peritonitis, drug overdose

Nausea and vomiting 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

Evaluation

Pediatric signs of dehydration

Significantly dehydrated if has 2 or more of the following (LR+ 6.1, CI:3.8-9.8):[1]

  • 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]
  2. If fails, oral ondansetron as a single dose PO (>6 months of age)[3][4]
  3. If fails, IV fluids (e.g. normal saline)

Disposition

Discharge

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

Admission and/or Observation

  • All others

See Also

External Links

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

References

  1. Gorelick MH et al. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997; 99(5):E6
  2. Choosing wisely ACEP
  3. Cheng A. Emergency department use of oral ondansetron for acute gastroenteritis-related vomiting in infants and children. Paediatrics & Child Health. 2011;16(3):177-179.
  4. A Cheng; Canadian Paediatric Society, Acute Care Committee. Paediatr Child Health 2011;16(3):177-9