Vomiting resident survival guide (pediatrics)

Resident Survival Guide

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

• 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
  • Intussusception
  • Necrotizing enterocolitis
  • Gastroenteritis
  • Meningitis
  • Sepsis
  • Shaken baby syndrome
  • Hydrocephalus
  • Congenital adrenal hyperplasia
  • Inborn errors of metabolism
  • Obstructive uropathy

Common Causes

• Common causes of vomiting in the pediatric population varies with the age as elaborated in the following table:

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
Gastroesophageal reflux Pyloric stenosis Intestinal atresia Intestinal malrotation with or without volvulus Milk protein intolerance Tracheoesophageal fistula Inborn errors of metabolism Meningitis Sepsis Urinary tract infection	Gastroenteritis Gastroesophageal reflux Over feeding Food protein-induced enterocolitis syndrome Post-tussive emesis Urinary tract infection Infections Intussusception Foreign body ingestion Inborn errors of metabolism	Gastroenteritis Gastritis Urinary tract infection Infections such as otitis media, sinusitis, and pharyngitis Foreign body ingestion Post-tussive emesis Toxic ingestion Food poisoning Celiac disease Constipation	Gastroenteritis Diabetic ketoacidosis Acute appendicitis Gastritis GERD Urinary tract infection Food poisoning Toxic ingestion Celiac disease Cyclic vomiting syndrome Migraine	Gastroenteritis Food poisoning Acute appendicitis Diabetic ketoacidosis Cyclic vomiting syndrome Migraine Pregnancy Eating disorder Toxic ingestion Drug induced vomiting Bowel obstruction Inflammatory bowel disease

FIRE: Focused Initial Rapid Evaluation

• A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the patients in need of immediate intervention:

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

Rule out life-threatening causes ❑ Pyloric stenosis ❑ Intestinal malrotation with volvulus ❑ Congenital intestinal obstruction ❑ Diabetic ketoacidosis ❑ Intussusception ❑ Necrotizing enterocolitis ❑ Gastroenteritis ❑ Meningitis ❑ Sepsis ❑ Shaken baby syndrome ❑ Hydrocephalus ❑ Congenital adrenal hyperplasia ❑ Inborn errors of metabolism ❑ Obstructive uropathy

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

• Shown below is an algorithm summarizing the diagnosis of vomiting in children:

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: ❑ CBC and differential ❑ ESR ❑ Basic Metabolic Profile ❑ Urinalysis ❑ LFT ❑ Serum glucose ❑ Pregnancy test

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

❑ Diarrhea ❑ Abdominal pain

Present

Absent

GI causes ❑ Gastroenteritis ❑ Gastritis ❑ Appendicitis

Non-GI causes

Fever

Present

Absent

Infectious etiology ❑ Urinary tract infection ❑ Meningitis ❑ Sepsis ❑ Acute otitis media ❑ Pharyngitis

Symptoms/signs localize to a particular system

❑ Dysuria ❑ Oliguria ❑ Costovertebral angle tenderness

❑ Polyuria ❑ Polydipsia ❑ Electrolyte abnormalities

❑ Headache ❑ Lethargy ❑ Altered mental status

Renal etiology ❑ Urinary tract infection ❑ Obstructive uropathy ❑ Pyelonephritis

Endocrine or Metabolic etiology ❑ Diabetic Ketoacidosis ❑ Adrenal crisis ❑ Congenital adrenal hyperplasia

Neurological or Metabolic etiology ❑ Hydrocephalus ❑ Intracranial mass occupying lesion ❑ Inborn errors of metabolism

Treatment

• The mainstay of therapy for vomiting in children is supportive care.
• Supportive therapy for vomiting in children include the following:
  • Treat dehydration
  • Correct electrolyte imbalance
  • Identify, address, and treat the underlying cause
• In bilious vomiting, do the following:
  • Avoid oral intake
  • Advice NPO
  • Decompress the stomach with nasogastric tube
  • Start IV fluids
  • Consult for surgical opinion

Antiemetics

• 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:
  • Older children who are continuously vomiting and unable to take anything orally.
  • Cyclic vomiting syndrome
  • Post-operative vomiting
  • Chemotherapy induced vomiting
• 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.

Do's

• 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.

Don'ts

• 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.