Vomiting resident survival guide (pediatrics)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Asra Firdous, M.B.B.S.[2]

Synonyms and Keywords: Vomiting in childhood, Vomiting in children, An approach to vomiting in children

Vomiting resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Vomiting is a protective reflex mechanism that causes forceful reflux of stomach or esophageal contents outside the mouth. It is a common pediatric problem with varied etiology. It may be the presenting symptom of an underlying life-threatening illness. Management of vomiting in children usually involves treating dehydration, electrolyte imbalance, and the underlying cause. Antiemetic therapy is given in older children with persistent vomiting.

Causes

Life Threatening Causes

Common Causes

Common causes of Vomiting in children
Birth-1 month 1 month-12 months 1 years-4 years 5 years-11 years 12 years-18 years

FIRE: Focused Initial Rapid Evaluation

  • A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the patients in need of immediate intervention:[1]
 
 
Check ABCDE
Airway
Breathing
Circulation
Deformity
Exposure
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess vital signs
❑ Obtain IV access
NPO (if persistent vomiting)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable vital signs
 
Stable vital signs
 
 
 
 
 
 
 
 
 
 
Satbilize hemodynamics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signs of dehydration
❑ Dry lips and mouth
❑ Sunken eyes
❑ Sunken fontanelle
Drowsiness
Irritabiltity
Lethargy
❑ Decreased skin turgor
❑ Decreased urine output
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fluid replacement therapy
 
Electrolyte imbalance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat electrolyte imbalance
 
Detailed history and physical examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Regurgitation
 
True Vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reassurance and Follow-up in OPD
 
❑ Frequency
❑ Effect on oral intake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Persistent and Hampering oral intake
 
Occasional and does not hamper oral intake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antiemetics
Ondansetron
❑ Domeperidone
 
Observation and Reassurance
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigate and treat the underlying cause
 

Complete Diagnostic Approach

 
 
 
 
Vomiting in children
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Characterization of Vomiting
❑ Onset (Abrupt or insidious)
❑ Frequency (persistent or occasional)
❑ Duration
❑ Time
Color
Odor
❑ Quantity
❑ Vomitus content (bile, blood, food particles)
❑ Effect on oral intake
❑ Projectile vomiting
❑ Relationship with food
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask about associated symptoms
Fever
Abdominal pain
Diarrhea
Constipation
Melena
Headache
Dizziness
❑ Visual problems
Polyuria
Polydipsia
Dysuria
Hematuria
Flank pain
Urinary problems
Weight loss
Early satiety
Postprandial bloating
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain a detailed history
Age (common causes of vomiting varies with age)
❑ Past medical history (recurrent episodes, diabetes mellitus)
❑ Any history of surgeries
Medications/Foreign body ingestion/Poisoning
Menstrual History (Pregnancy should be excluded in adolescent females)
❑ Travel History
❑ Exposure to contaminated food or water
Illness in other family members
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Assess the volume status:
❑ General condition
Thirst
Pulse
Blood pressure
Respiratory rate
Eyes
Mucosa


Perform a general physical exam:
Skin

Pallor
Jaundice
Dehydration

Mouth and Pharynx

Ulcers
Thrush

Abdominal examination

❑ Inspection
❑ Signs of previous surgery
Abdominal distension
Abdominal pulsations
Abdominal peristalsis
Palpation
Abdominal tenderness
❑ Rigidity
Guarding
Abdominal mass
CVA tenderness
Rovsing's sign
Psoas sign (suggestive of retrocecal appendix)
Obturator sign
Auscultation
❑ Decreased bowel sounds
❑ Increased bowel sounds

Digital rectal exam (constipation or fecal loading)
Testicular examination in males
Neurological examination (increased intracranial pressure)
Extremities examination (sepsis)
Cardiovascular examination

Respiratory examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order routine laboratory tests:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Regurgitation
 
Bilious vomiting
 
Bloody vomiting
 
Non-bilious, non-bloody vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abdominal X-ray
 
Upper GI bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Double bubble sign
 
Free air under the diaphragm
 
NG tube in misplaced duodenum
 
 
 
Dilated loops of bowel
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Duodenal atresia
 
Perforation
 
Upper GI series
 
 
 
Contrast enema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Emergency laparotomy
 
Ligament of Treitz on the right side of abdomen
 
Microcolon
 
Rectosigmoid transition zone
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Malrotation
 
Meconium ileus
 
Hirschsprung disease
 


Non-bilious, Non-bloody Vomiting

 
 
 
 
 
Non-bilious, Non-bloody vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Present
 
Absent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-GI causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fever
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Present
 
 
 
Absent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptoms/signs localize to a particular system
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Antiemetics

Do's

Don'ts

  • Do not give milk or solid food if the child is vomiting continuously.[1]
  • Do not give any solid food until 24 hours of vomiting onset.
  • Do not give foods with sugars such as juices and carbonated drinks.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Singhi SC, Shah R, Bansal A, Jayashree M (2013). "Management of a child with vomiting". Indian J Pediatr. 80 (4): 318–25. doi:10.1007/s12098-012-0959-6. PMID 23340985.
  2. Shields TM, Lightdale JR (2018). "Vomiting in Children". Pediatr Rev. 39 (7): 342–358. doi:10.1542/pir.2017-0053. PMID 29967079.
  3. 3.0 3.1 Samprathi M, Jayashree M (2017). "Child with Vomiting". Indian J Pediatr. 84 (10): 787–791. doi:10.1007/s12098-017-2456-4. PMID 28887737.