Pediatric approaches to a vomiting child

1. Approach to a vomiting
child
PRESENTER: ACHILLA ARNOLD BMS/12498/182/DU
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2. Definitions
Nausea
The unpleasant sensation of the imminent need to vomit, a sensation that may or may not lead to act
of vomiting.
Retching
Muscular activity of the abdomen and thorax, often voluntarily leading to forced inspiration against a
closed mouth and glottis without oral discharge of gastric contents.
Vomiting
Forceful oral expulsion of gastric contents associated with contraction of the abdominal and chest
wall musculature
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3. Defn cont..
Regurgitation
The act by which food is brought back into the mouth, without the abdominal and
diaphragmatic muscular activity.
Rumination
Food that is regurgitated in the postprandial period , re-chewed and then re –swallowed
(psychological)
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4. Neurophysiology
There are four major pathways by which nausea and vomiting is induced
1. Vagal afferent
Abdominal vagal afferent are involved in emetic response
Can be evoked by either mechanical or chemo sensory sensations e.g over distention, food
poisoning, mucosal irritation, cytotoxic drugs and radiation.
2. Area of postrema
Also referred to as Chemoreceptor Trigger Zone.
Anatomically located at the caudal extremity of the floor of the 4th ventricle. This area represent
a relatively permeable BBB region, its is the place where many but not all systemic chemicals act
to induce emesis.
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5. Neurophysiology cont..
3. Vestibular system
It is involved in emetic response to motion and it is exacerbated by visual sensation, irritation or
labyrinthine inflammation.
4. Amygdala
It is involved in a variety of stress and emotional responses. Among other structures it receives
input from olfactory bulb and olfactory cortex and sends impulses to the hypothalamus.
Aberrant activation of Amygdala may lead to sensation of Nausea and vomiting.
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6. Etiology of vomiting
Central
Vestibular – motion sickness and vertigo
Infectious – gastroenteritis, septicaemia, non GI infection
Cortical- pain, strong emotion, smell, taste
Drugs –chemotherapy, opiate
Metabolic- acidosis, uremia, hyperthyroidism, hypercalcemia, adrenal disorders
Peripheral
Pharyngeal stimulation
Gastric mucosal irritation
Gastric and intestinal obstruction/ dilation
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7. Common causes of vomiting
neonates Infants adolescents
Gastroenteritis
GERD or physiologic reflux
Overfeeding/ feeding intolorance
Anatomic obstruction
Necrotising enterocolitis
Hirshprung disease
Congenital atresia, stenosis
Metabolic disorders
Acute
Gastroenteritis
Pyloric stenosis
hirsprung’s disease
Acutely evolving surgical
abdomen
Malrotation
Intussusception
Sepsis
Chronic
GERD
Food intolerance
Intussusception
malrotation
GE
Gastritis
IBD
Appendicitis
Toxic ingestion
Systemic infection
Sinusitis
Migraine
Pregnancy
Medication
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8. Clinical approach
The appropriate urgency with which various diagnostic modalities should be pursued depends
upon a number of factors including:
 The duration of illness,
 overall clinical status of the patient (especially hydration, circulatory, and neurologic status)
and
associated findings on the physical examination and history.
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9. Approach cont….
A standardized approach is not recommended
Vomiting may be caused by many pathologic states involving several systems including
GI
Neurologic
Renal
Psychiatric
NB the best course of action should be dictated by the medical history
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10. History of presenting illness (HPI)
Childs age
Characteristic of vomitus
Smell
Quantity
Colour
Blood – bright red/ dark red / coffee ground
Billous
Timing- onset, duration, frequency and time of day
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11. Durration of vomiting
Prolonged if
>12 hours in a neonate,
>24 hours in children younger than two years of age, or
>48 hours in older children
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12. HPI cont..
Triggers/ associated symptoms
Diarrhoea
Fever
Abdominal pain/ distention
Anorexia
Stool frequency
Urinary output
Headache
Vertigo
Lethagy
Stiff neck
Cough and sore throat
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13. Past medical
Chronic illness like DM
Travel Hx ( infectious GE)
Recent head trauma
Toxin exposure
Medications
allergies
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14. Few important interpretation of history
Type Likely cause
Billous
Undigested
Blood or coffee ground
Malodorous
feculent
Post ampullary obstruction
Achalasia
Gastritis, ulcer
Mallory Weiss tear
Obstruction
Force of vomiting
Forceless
Projectile
Regurgitation, gastroeosophageal reflux
Pyloric stenosis, obstruction, metabolic disease
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15. Temporal association of chronic or
recurrent vomiting
Temporal association diagnosis
Time of day
Early morning Increased ICP, sinusitis with postnasal
mucous, pregnancy, uremia
During meals PUD, reflux (epigastric pain, heart
burn, )hereditary fructose intolerance,
inborn errors of metabolism
After fasting Gastric obstruction, metabolic disease
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16. Clues on physical examination
Certain physical findings may offer diagnostic clues that can aid in narrowing the differential
diagnosis
A tense, bulging fontanelle in a neonate or young infant should increase the level of suspicion
for meningitis
Fever can suggest an infectious cause.
Projectile vomiting in an infant three to six weeks of age suggests pyloric stenosis as a diagnosis
Ambiguous genitalia and/or hyperkalemia suggest the possibility of adrenal crisis (usually due
to congenital adrenal hyperplasia),
Marked distension, visible bowel loops, absent bowel sounds, green or yellow bile, or increased
"rumbling" bowel sounds
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17. Clues cont..
Enlarged parotid glands in an adolescent should raise suspicion for bulimia
Vomiting in association with trauma should prompt imaging studies to rule out intracranial or
intraabdominal injury.
Hypotension disproportionate to the apparent illness and/or hyperkalemia suggests the
possibility of adrenal crisis
Headache, positional triggers for vomiting, lack of nausea, and/or vomiting on awakening
should suggest the possibility of intracranial hypertension
An unusual odour emanating from the patient should prompt an investigation for metabolic
causes of vomiting
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18. Investigations
Screening laboratory tests should include
 a complete blood count,
electrolytes,
glucose,
blood urea nitrogen,
amylase, lipase,
 liver function tests,
urinalysis, urine culture,
and stool studies for occult blood,
 leukocytes, and parasites.
Additional testing should be based upon the history and physical examination
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19. Complication of vomiting
nutrition adults weght loss, kids failure to thrive
Cutaneous Petechia, purpura
oropharyngeal Dental erosion, sore throat
eosophageal Esophagitis/ hematoma
GE junction M-W tears, rupture of oesophagus
metabolic Electrolyte, acid-base, water balance
Renal Pre renal azotemia, hypokalemic nephropathy
Infection Spread of infection to close contact and care givers
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20. Treatment
Treatment should be directed towards the underlying etiology
Electrolyte abnormalities, metabolic abnormalities and nutritiona deficiencies should be
corrected.
Cognitive behavioural intervention are useful for vomiting associated with functional dyspepsia,
adolescent rumination syndrome and bulimia
Prokinetic medication such as metroclopramide, domperidone and erythromycin are
benefficialwhen there are abnormalities in esophago-gastric motility
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21. Rx cont..
Anti emetic which is useful in persistent vomiting to avoid electrolyte abnormalities or
nutritional squalae, typically have not been recommended in cse of vomiting of unknown
etiology.
NB this agents are contraindicated In infants, anatomic abnormalities or surgical abdomen.
Instead antiemetics are most useful for motion sickness, postoperative vomiting, cyclic vomiting
syndrome and gastrointestinal motility disorder.
A single dose of ondansentran may facilitate oral hydration in children with gastroenteritis who
are unable to tolerate oral intake
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22. Dietary recommendations
Children who are vomiting but are not dehydrated can continue to eat a regular diet as tolerated. mildly
Dehydrated children require oral fluids and moderate to severe require iv fluids
Infants — If a breastfeeding infant vomits, he or she should continue to breastfeed
Older infants and children — Older infants and children who vomit can continue to eat, if desired. However, it is
common for children to have little or no appetite during a vomiting illness.
Monitor for signs of dehydration, and do not force the child to eat, especially during the first 24 hours. Encourage
the child to drink fluids.
Apple, pear, and cherry juice, and other beverages with high sugar content, should be avoided. Sports drinks (eg,
Gatorade) should also be avoided since they have too much sugar and have inappropriate electrolyte levels.
Recommended foods include a combination of complex carbohydrates (rice, wheat, potatoes, bread), lean meats,
yogurt, fruits, and vegetables. High fat foods are more difficult to digest, and should be avoided.
It is not necessary to restrict a child's diet to clear liquids or the BRAT diet (bananas, rice, applesauce, toast).
Although these and similar foods might be recommended to decrease diarrhea, these foods do not contain
enough nutrients for a child.
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23. Reference
Nelson book for paediatric
Uptodate 21.6 ed
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