Child with vomiting

Subtopics

Terms/Definitions
Physiology of Emesis
Approach
Evaluation
Disease based
References
Others essential reading

Terms
Vomit:
Forced ORAL expulsion of GI content
Contraction of abdominal and chest wall

Nausea:
Unpleasant sensation on the need to
vomit/imminent vomitting

Vomit
Nausea
Nausea>Vomit

 Regurgitation: effortless and not

preceded by nausea. without the
abdominal and diaphragmatic muscular
activity (immature LES)
Rumination: effortless
regurgitationand/orre-swallowing of food
Retching: Spasmodic respiration against
a closed glottis+ contractions of muscle
without expulsion of any gastric contents

Physiology
1. Neurological Pathway
vagal afferents (1), the area postrema
*CTZ* (2), the vestibular system (3), and
the amygdala (4)

2. Neurotransmitter
1)5-HT3
2)M1, D2, 5-HT3, NK-1
3)H1
4)M1, D2, H1, 5-HT3, NK-1 +
Emotion/olfactory

APPROACH
History
Physical
Examination
Investigations
Diagnosis
Targeted
treatment
Aetiolgy

1)
2)
3)
4)

Diagnosis
Differential Diagnosis
Risk Factors
Complications
1) -hydration assessment

RED FLAGS
1)Nonspecific symptoms
(severity)
2) Surgical GIT (obstruction)
3) Neurologic/Systemic (raised
ICP, recurrent)

Complication

Treatment

EVALUATION
Concerning Signs
History and Physical Examination
Investigations

History
Vomit vs regurgitation (presence of effort)
Triggers?(lactose/fructose/onset minutesto hours of
food intake+ cutaneous+ respiratory symptoms)
Projectile/absence of nausea
Periodic episodes? (IEM, migraine, cyclic)
Time (early morning+positional triggers)
Duration
Infective cause (contacts, febrile, associated diarrhea)
Content-billious/blood/undigested/feculent/surgical
cause of vomitting.
Determinant for intervention.

Physical examination
General examination
Well vs toxic, signs of dehydration,

Abdominal examination
Pain, Distension , Vomiting, Obstipation
Visible bowel loops/absent vs borborygmi
Surgical cause by tenderness site (appendix, gall bladder,
pancreas, renal, epigastric)
organomegaly

Neurologic examination
Conscious level (CNS lesion, IEM, toxic, severe dehydration)
Raised ICP signs/ localizing signs

Others
Unusual odour, enlarged parotids, abnormal external genitalia

Laboratory
investigations

Hydration assessment
No clinically detectable dehydration
(<5% loss of body weight)
Clinical dehydration (5-10%)
Shock (>10%)
Mnemonic ( Head (4)/ Thorax (4)/
Limbs (4)/ Genitalia (1) = 13 signs

Illustrated textbook of pediatric 4th edition,

4 in the Head

General appearance/ GCS

Eye (sunken/with or without tear)
Fontanelle
Mucous membrane

Using oral mucosa to assess for dehydration-Nursingtimesjournal

http://www.nursingtimes.net/Journals/2014/01/22/c/s/u/080114-Usingoral-mucosa-to-assess-for-dehydration.pdf

4 in the thorax

Skin color
Breathing rate (tachypnea)
Tissue turgor
Weight*

4 in the limbs
Cold peripheries
Capillary refill time
Increase pulse rate (tachycardia)/
weak pulse
Blood poressure (hypotension in
decompensated shocl)
Those in red is at risk of progression
to shock

GERD
is a normal physiologic process
occurring several times per day in
healthy infants, children, and adults.
Last <3 minutes, occur in the
postprandial period, and cause few or
no symptoms.
GERD is present when the reflux of
gastric contents causes troublesome
symptoms and/or complications

 Diagnosis (barium study, upper endoscopy*)

Treatment (80% by lifestyle changes)
Avoidance of overfeeding
Positioning (upright and calm up to 20mins post
meal)
Avoid exposure to tobacco smoke,
a milk-free diet (Almost all infants with a dietary
protein intolerance outgrow the problem by one
year of age, )
thickened feeds.

Pyloric stenosis

Apple core, caterpillar sign

Intussusception
vast majority of intussusceptions
occur in children (95%), usually after
the first three months of life
no lead point can usually be
identified (90%) and this most
frequently thought to relate to
enlarged lymphoid tissue following
an infection

 Presentation: classic triad of

intermittent abdominal pain,
vomiting and right upper quadrant
mass, plus occult or gross blood on
rectal examination has great positive
predictive value for intussusception
in children

Plain film

Case courtesy of Dr Eric F Greif,

Radiopaedia.org

References
Nelson textbook of pediatric 19th Edition
Illustrated textbook of pediatric, Sunflower 4th edition
Website
Uptodate.com on Approach to the infant or child with nausea and
vomiting http://
www.uptodate.com/contents/approach-to-the-infant-or-child-with-na
usea-and-vomiting
Infantile hypertrophic pyloric stenosis
Acid reflux (gastroesophageal reflux) in infants
Empem.org Emergency Medicine and Paediatric Emergency Medicine
Radiopedia.org on intussusception

Online publised presentations

Approach to hypovolemic and septic shock
http://www.slideshare.net/ahmedbahamid/approach-to-hypovolemicand-septic-shock

Other essential reading

AGE
NEC
Hirschprung
Volvolus
Inborn errors of metabolism
Whooping cough
Strangulated hernia
Coeliac disease
Testicular torsion