Vomiting resident survival guide (pediatrics)
Synonyms and keywords: Vomiting in childhood, Vomiting in children, An approach to vomiting in children
|Vomiting resident survival guide (pediatrics) Microchapters|
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.
Life Threatening Causes
- Following is a list of life-threatening causes for vomiting in children. These etiologies include the conditions that may result in either death or permanent disability within 24 hours if left untreated:
- Pyloric stenosis
- Intestinal malrotation with volvulus
- Congenital intestinal obstruction
- Diabetic ketoacidosis
- Necrotizing enterocolitis
- Shaken baby syndrome
- Congenital adrenal hyperplasia
- Inborn errors of metabolism
- Obstructive uropathy
- Common causes of vomiting in the pediatric population varies with the age as elaborated in the following table:
|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:
|Unstable vital signs||Stable vital signs|
Rule out life-threatening causes
❑ Pyloric stenosis
❑ Intestinal malrotation with volvulus
❑ Congenital intestinal obstruction
|Fluid replacement therapy||Electrolyte imbalance|
|Treat electrolyte imbalance||Detailed history and physical examination|
|Reassurance and Follow-up in OPD|
❑ Effect on oral intake
|Persistent and Hampering oral intake||Occasional and does not hamper oral intake|
|Observation and Reassurance|
|Investigate and treat the underlying cause|
Complete Diagnostic Approach
Non-bilious, Non-bloody Vomiting
|Non-bilious, Non-bloody vomiting|
|Symptoms/signs localize to a particular system|
- The mainstay of therapy for vomiting in children is supportive care.
- Supportive therapy for vomiting in children include the following:
- In bilious vomiting, do the following:
- Antiemetics such as metoclopramide, promethazine, and prochlorperazine are not routinely indicated in children due to severe adverse effects like somnolence, nervousness, dystonia, and other extrapyramidal symptoms.
- Avoid antiemetics before ruling out any life-threatening illness and surgical emergency.
- Children with occasional episodes of vomiting can be managed with observation for worsening of symptoms.
- If the child is improving, reassure parents and discharge the child.
- Antiemetics should be given to:
- Preferred antiemetics are ondansetron (5-HT3 receptor blocker) and domeperidone (dopamine antagonist).
- Preferred dose of ondansetron is 2 mg thrice a day in children aged between 2-4 years and 4 mg thrice a day in children above 4 years.
- Preferred dose of domeperidone is 0.2-0.4 mg/kg/dose thrice daily.
- Antihistamines are used in motion sickness.
- Start oral fluids 30-60 minutes after the vomiting has stopped. Give clear fluids like water and clear broth frequently in small quantities.
- Continue breastfeeding in small and frequent doses.
- Continue the regular and full-strength formula in small and frequent doses.
- Give 5-10 ml of oral rehydration solutions (ORS) such as Pedialyte every 15-20 minutes.
- Reintroduce solid food like rice, toast, applesauce, cereals, and crackers 8 hours after the vomiting has stopped in kids.
- Start the normal diet 24 hours after the vomiting has stopped.
- Wash hands before feeding, eating, and cooking.
- Do not give milk or solid food if the child is vomiting continuously.
- Do not give any solid food until 24 hours of vomiting onset.
- Do not give foods with sugars such as juices and carbonated drinks.
- 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.
- Shields TM, Lightdale JR (2018). "Vomiting in Children". Pediatr Rev. 39 (7): 342–358. doi:10.1542/pir.2017-0053. PMID 29967079.
- Samprathi M, Jayashree M (2017). "Child with Vomiting". Indian J Pediatr. 84 (10): 787–791. doi:10.1007/s12098-017-2456-4. PMID 28887737.