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):

• 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. If fails, oral ondansetron as a single dose PO (>6 months of age)
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

• Nausea and vomiting
• Abdominal pain (peds)
• Acute gastroenteritis (peds)
• Diarrhea (peds)
• Dehydration (peds)

External Links

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

References

Authors

Ross Donaldson, Tim Horeczko, Claire, Daniel Ostermayer, Neil Young