Pediatric presentation

Vomiting in children

A symptom of the whole child: obstruction in the newborn, intussusception in the infant, the head and the ketones in the older child.

What are you worried about?
- Bilious vomiting: malrotation with volvulus at any age, obstruction
- Intussusception in the infant and toddler
- Pyloric stenosis in the 3 to 8 week old
- Diabetic ketoacidosis
- Raised intracranial pressure
- Dehydration and hypochloremic alkalosis
Differential, by age
Newborn birth to 28 days
Malrotation with volvulus
Pyloric stenosis (from about 3 weeks)
Necrotizing enterocolitis in the preterm
Sepsis
Inborn errors of metabolism
Gastro-esophageal reflux (effortless, thriving)
Infant 1 to 12 months
Gastroenteritis
Intussusception
Urinary tract infection
Cow's milk protein allergy
Raised intracranial pressure
Toddler 1 to 3 years
Gastroenteritis
Intussusception
Ingestion
Otitis media or pneumonia
Appendicitis (atypical, often perforated at diagnosis)
Preschool 3 to 5 years
Gastroenteritis
Appendicitis
Diabetic ketoacidosis
Streptococcal pharyngitis
Brain tumour
School age 6 to 11 years
Gastroenteritis
Appendicitis
Diabetic ketoacidosis
Migraine
Cyclic vomiting
Adolescent 12 to 17 years
Gastroenteritis
Diabetic ketoacidosis
Pregnancy
Ingestion
Eating disorder
Pancreatitis
Key history
- Colour: green (bilious) changes everything; blood; coffee grounds
- Timing relative to feeds and to pain; projectile; early morning
- The stool: diarrhea, blood, red-currant jelly, none at all
- Intake and output: feeds taken, wet diapers, last urine
- Polyuria, polydipsia, weight loss, breathing pattern (ketoacidosis)
- Headache, gait, vision, behaviour (pressure); trauma; possible ingestion; menstrual and sexual history in adolescents
Key examination
- Hydration and perfusion first
- The abdomen: distension, tenderness, a mass (the olive, the sausage), bowel sounds; the hernial orifices and the testes
- Fontanelle, head circumference, fundi, gait and coordination
- Ketotic breath, Kussmaul breathing
- Weight, and the weight trend
Red flags
- Bilious or bloody vomiting
- A distended or tender abdomen, or an infant who screams then goes floppy
- Signs of dehydration with reduced urine output, or lethargy
- Early morning vomiting, headache, ataxia, a new squint
- Kussmaul breathing, a fruity breath, polyuria
- Vomiting in a young infant with poor weight gain
Initial investigations
- Bedside glucose in any significant vomiting; ketones if raised
- Electrolytes and a gas in persistent vomiting (hypochloremic hypokalemic alkalosis in pyloric stenosis)
- Abdominal ultrasound for suspected intussusception or pyloric stenosis
- Upper gastrointestinal contrast study, urgently, for bilious vomiting
- Neuroimaging for the pressure pattern; a pregnancy test in adolescents
How to interpret them
- A chloride below the reference range with a high bicarbonate in a hungry vomiting infant is pyloric stenosis physiology
- Ultrasound is operator-dependent: a negative scan with a strong story is repeated, not believed
- Ketones with a high glucose is ketoacidosis; ketones with a low or normal glucose is starvation or a metabolic disease
When the child is deteriorating
- Shock from dehydration: bolus, reassess, repeat; correct sodium slowly
- A surgical abdomen: nil by mouth, nasogastric tube, fluids, surgeons at the bedside
- Ketoacidosis: fluids by protocol, potassium before insulin, watch the mental status for cerebral edema
Cases and practice
Vomiting and diarrhea, and only two wet diapers18 months old · An 18-month-old has had two days of vomiting and watery stools. Her father counts diapers, and today's count is two.Thirsty for weeks, vomiting since this morning12 years old · A 12-year-old has been drinking litres, wetting the bed again, and losing weight. Today he cannot keep water down and is breathing strangely.
Practice drills Acute pediatrics