This document provides guidance on evaluating and diagnosing the cause of vomiting in children. It discusses the various centers in the brain responsible for vomiting and the different types of vomiting. Common causes of vomiting are then reviewed based on the age of the child, including conditions affecting the gastrointestinal tract, central nervous system, and various metabolic disorders. The document emphasizes taking a thorough history and physical exam, including assessing associated symptoms, to determine the underlying etiology. A problem-oriented approach is recommended to diagnose the cause of vomiting.

1. Aproach to child with vomiting
Dr. Riddhi Patel
Resident dept pediatrics
Sir Guru Gobindsingh Hospital -
Jamnagar
Ref : uptodate.com
practical stratagy in pediatric diagnosis 2nd ed
website of european society of radiology
schwartz handbook of pediatrics

2. Why to discuss?
• Very common complaint
• Can involve any system, associated with mild illness like
AGE to severe illness like raised ICT, DKA etc
• Diagnosis require good history , examinations supported by
lab evidence.
• Require “Problem oriented approach”

3. Vomiting in Children
• Vomiting is a symptom, presenting
complaint in multitude of disorders
– Range from gastrointestinal pathology to
disease in distant organ (otitis media or
intracranial lesion)
• In children, especially infants, must
distinguish from regurgitation –
effortless expulsion of gastric contents
• Integrated response to noxious stimuli,
coordinated by central nervous system

4. Definations :
• Nausea:.
• Vomiting:
• Regurgitation:
• Retching :
• Rumination:

6. Centres responsible for vomiting
• Vomiting centre
– Nucleus solitarius and series of nuclei in
brainstem medulla
– Stimulation results in
• integrated motor responses involved in
vomiting
• associated vasomotor activity (pallor,
flushing), salivation, bulbar responses
– Afferent input arises from
• posterior pharynx, GIT, brain

7. • Chemoreceptor trigger zone
– Stimulated by humoral stimuli such as
opiates, cytotoxins, ketones, ammonia
– Lies in area postrema – floor of 4th
ventricle, outside blood-brain barrier
– Processes most of afferent input for the
vomiting centre
• Receptors and neurotransmitters
involved
– Dopamine (D2), histamine (H1), serotonin
(5-HT3), vasopressin, substance P

8. Cause of vomiting
vomiting
mechanical reflex central

9. Age based approach
• New born v/s Infant and child

10. NEW BORN
• Large number of neonate vomit on first day of
life due to gastritis as a result of amniotic fluid
ingesion
• Regurgitation is normal phenomenon in
infants esp if he is gaining weight. It is due to
normal developemental phenomenon in
which there is poor lower esophageal
sphincter tone which stengthen with age. It
can also be due to aerophagy common in
bottle fed babies.

11. NEW BORN
• GIT: HPS,Congenital atresias,meconium
ileus,malrotation of gut/volvulus,hirshsprung
disease
• CNS:IVH,birth asphyxia,meningoencephalitis
• METABOLIC
DISORDERS/IEM:Galactosemia,Fructose
intolerance
• ENDOCRINE: CAH
• SEPTICEMIA

12. Older Infants & Children
• By far, the most common is gastroenteritis.
• However, GERD, gastroparesis, mechanical
obstruction, anaphylaxis, Munchausen
syndrome by proxy (factitious disorder by
proxy), intracranial masses, peptic ulcer
disease, and cyclic vomiting also may be
diagnostic considerations.

13. Infants
• GERD
• Gastroenteritis
• Gi
obstuction:intussusce
ption,malrotation,hps
• Dietary protein
intolerance
• Bartter syndrome
• Renal tubular acidosis
type 1 and type 2
• Adrenal crisis
• Uti
• Increased ICT
• Hepatobiliary
diseases
• pancreatitis

14. CHILDREN
• Gastroenteritis
• Hepatobiliary
diseases
• Obstruction:malrotati
on,intususception,inc
arcenated hernia
• Posttussive:asthma,fo
reign body
• Psychogenic
• Increased ICT
• Gitelman syndrome
• UTI
• Adrenal crisis
• Streptococcal
pharyngitis
• Cyclic vomiting
syndrome

15. Adolescents
• Gastoenteritis
• Hepatobiliary diseses
• Pancreatitis
• Appendicitis
• Psychogenic
• Cyclic vomiting
• Pregnancy
• Post tussive
• Bulimia
• Adolescent rumination
syndrome
• Functional dyspepsia

16. HPS
• MC congenital anomaly of children
• Age of presentation:2-6 week.
• First born male child
• 3 in 1000 live birth
• Non-billious vomotting, projectile, recurrant
• Pt dehydrated, FTT , wt loss
• Inspection of abdomen: shortly after infant
feeding may reveal paristaltic wave lt to rt
•

17. Ix : usg abdo - 85 to 100% sensitivity
pyloric muscle mass : thickness 4 mm
length 14mm
diagnostic of HPS
Treatment : correction of dehydration
surgical lapromyotomy (ramstead’s operation)

18. CONGENITAL ATRESIA
• At the level of duodenum or jejunum or illium
• Vomitting is billious if atresia is distal to
opening of amulla of vater
• Non billious if proximal to opening of ampulla
of vater
• In first 24 to 48 hr of life
• Associated with abdominal distention
•

19. Ix : xray abdomen standing
contrast study
Treatment : surgical resection of atresia f/b reanastamosis

20. MECONIUM ILEUS
• Bilious vomiting strongly associated with cystic
fibrosis
• Genetic testing is required
• Recurrent respiratory tract infection occurs.

21. MALROTATION WITH VOLVULUS
• Disruption of 2nd and 3rd stage of intestinal
rotation.
• Present in 1st week of life if with midgut
volvulus otherwise malrotaion will remain
undetectable for many years
• Vomitting : billious , intermittant , asso with
abdominal distention

22. Ix: xray abdomen – air fluid level & pausity of
distal bowel gas
Contrast usg : spiral configuration of jejunum
failure of contrast to pass beyond 2nd part of
duodenum
Surgical correction by LADD PROCEDURE

23. HIRSHSPRUNG’S DISEAES
Usually diagnosed in neonatal period..
• Pt presenting with symptoms of distal
intestinal obstruction:bilious
emesis,abdominal distension and failure to
pass meconium in first 24 hour of life.
• Affected children may present with
enterocolitis,a sepsis like picture with
fever,vomiting,diarrhoea,abdominal
distension progresses to toxic megacolon.

24. • Diagnosis: anorectal menometry
• barium enema
• rectal biopsy is GOLD STANDARD
• Treatment:resection of aganglionic colon and
reanastomosis

25. CONGENITAL ADRENAL
HYPERPLASIA
• MC DSD in neonatal period.
• Mc cause is 21 alfa hydroxylase deficiency
• Salt losing type.
• Virilization of female genitalia.
• Biochemical
abnormality:hyponatremia,hyperkalemia,hypo
glycaemia.

26. IEM
• Billious or non billious
• Associated with - metabolic acidosis
• hypoglycemia
• poor feeding
• FTT
• hapatospleenomegaly
• jaundice
• dysmorphic feature
• unsual odour

27. Ix : serum electroytes
serum ammonia
RFT / LFT
CBC
PT/APTT/INR
ABG
Specific test based on findins

28. GASTROESOPHAGEAL REFLUX
• MC cause of recurrent vomiting in infancy
• Retrogate movement of gastric contents into
esophagus as a result of abnormally
functioning LES.
• Present with
recurrent,postprandial,nonbilious
regurgitation of ingested milk within 30 min of
feeding.

29. •Treatment
child who are thriving and have normal physical
examination needs no treatment
•Thickening of human milk by adding serials
•Child who have FTT, feeding problems , respiratory
problems due to aspiration : PPI or H2 antagonist
•Prokinetic agenta : metoclopramide , erythromycine
•Reduces the process of GER by acting on LES

30. INTUSSUSCEPTION
• Telescoping of one portion of bowel into
another
• 3 month to 3 year
• MC terminal illium into the cecum by
lymphatic hypertrophy of peyer patches
following viral infection
• Billious vomotting , recurrant episodes of
abdominal cramps, currant jelly stool
• O/ E : P/A olive shaped mass in the right
lower quadrant

31. Investigations : USG abdo
contrast enema
Treatment : hydroreduction
surgical reduction

32. RAISED ICT
• D/T intracranial mass or tumour, meningitis,
encephalitis, creats pressure at area
prostrema causes vomitting
• Young child present with irritability ,sleep and
behavioural abnormality
• Older child : headache more common
• asso with neck or retroorbital
• pain
• vomitting is projectile and in

33. DIETORY PROTEIN INTOLERANCE
• Non IgE mediated food hypersensitivity
shortly after exposer to offending allergen in
1st post natal year
• Commonly proteins are cow milk protein
(lacto globulin) , egg protein, soy protein
• Recurrant vomitting asso with
diarrhoea,irritability , feeding intolerance

34. Ix :
stool for occult blood positive
stool for reducing substance positive
Treatment:
removal of allergen from diet
Symptoms resolves in 3 to 10 days of removal of allergens
Subsided by 18 to 24 months

35. CYCLIC VOMITING SYNDROME
• All of the criteria must be met for definition of
cyclic vomiting syndrome
1. Atleast 5 attacks in any interval or minimum 3
attacks in 6 months period
2. Episodic attacks of intence nausea and
vomiting lasted 1 hour to 10 days occuring
atleast one week apart
3. Stereotypical pattern and symptoms in
individual patients
4. Vomiting during the attacks occurs >=4/hour
for >=1 hour
5. Return to baseline health in between episodes
6. Not attributed to another disorder

36. Features of CVS
• Age of the onset: 2-5 year
• Episodes usually occur in early hours of
morning or on awakening
• Patients can have prodrome of nausea
pallor, intolerance of the noise or light,
lethargy, headache
• Precipitants include the infection, physical
stress, psychological stress.

37. DIFFERENTIAL DIAGNOSIS
• GI anomalies (malrotation, choledocal cyst)
• CNS disorders (epilepsy, neoplasm, vestibular
pathology)
• Nephrolithiasis
• Cholelithiasis
• Hydronephrosis
• Metabolic-endocrine disorder (urea cycle.
Porphyria, addison’s disease)

38. Treatment
• Only empiric therapy at present
• 5 aspects
– Avoidance of precipitating factors
• Food and stressful events possible
• Mostly unavoidable
– Prophylactic agents
• Anti-migraine – propranolol, amitryptiline
• Anti-epileptic – phenobarbital, valproate
• Prokinetic agents – erythromycin
– Abortive agents

39. – Family support
• Crucial – unpredictable, disruptive,
unexplained illness, often misdiagnosed, few
definitive answers

40. PROPHYLAXIS
• Lifestyle changes
• Beta blockers: propranolol 0.5-2 mg/kg po bd
• Anti histaminics: cyproheptadine 0.25-0.5 mg/kg
po bd/tds
• TCA : amitryptiline 0.3-0.5 mg/kg po tds
• Antiepileptic : phenobarbiturate 2-3 mg/kg qds

41. History
• What to ask for?
a) history of diabetis in mother
b) Polyhydroamnions in mother
c) Birth asphyxia
d) Gestational age
e) Day of onset of vomit
f) Colour of vomit
g) Relationship with feeding
h) h/o meconium passage
i) On/ off feed; top feed; pre lactal feed
j) H/o seizure
k) Passage of blood in stool

42. What to look for ?
• Growth assessment
• Dysmorphic face
• Sex
• General appearance
• Fontanelle
• Jaundice
• Cataract
• Temperature
• Umbilical cord
• Exam of abdomen
• Exam of genitalia
• Per rectal exam

43. P/A
• Abd distension
– Localize to epigestrium : Upper GI Obs ( duodunal
stenosis/ atresia)
– Genrelize : ileal or jejunal atresia, meconium ilius,
hirschprung’s
– Marked distention with engorged vein : giant
cystic meconium peritonitis, meconium ileus
• Visible peristalsis
– Lt rt : pyloric stenosis
– Generalized peristalsis : normal newborn

44. • Guarding of abdominal muscles: absent in
newborn bt erythema of abdominal wall
suggest intraperitoneal infection.
• Lump:in HPS palpable olive in epigastrium or
rt hypochondrium just above and to rt of
umbilicus.
• Hepatospleenomegaly:galactosemia.

45. • Duration either
–Acute – short-term episode, abrupt
onset
–Recurrent – at least 3 episodes over
3-month period
–chronic - relatively mild episodes
that occur frequently
–cyclic – recurrent, intense episodes
separated by asymptomatic periods

46. • Age Of Child
• Characteristics of vomitus
– Smell
– Quantity
– Colour (content )
– Blood - bright red/dark
– red/coffee-ground
– Bilious
• Timing
– Onset
– Duration
– Frequency
– Time of day
– Triggers

47. Association with meal
• After any meal : peptic ulcer disease, GERD
• Specific food :
– Gluten : gluten sensitivity
– Fructose : hereditary fructosemia
– Galactose : galactosemia
– High Protein : hyper ammonemia
– Cow milk : milk protein allergy

48. Associated symptoms
•Fever: infectious etiology
• Abdominal pain/distension :
•Site of pain
•Nature of pain : colicky v/s non coliky
hepatitis , pyelonephritis, cholecystitis, intestinal
obstruction, UTI
DKA
• Anorexia : hepatitis
• failure to thrive :
•pyloric stenosis, IEM, Addison’s disease, CRF, RTA

49. Associated symptoms
• Stool frequency
• Urinary output / color
• Jaundice
• Headache
• Vertigo
• Lethargy
• Stiff neck
• Cough
• Sore throat

50. Past history
• Chronic illnesses (diabetes)
• Travel history (infectious gastroenteritis)
• Sexual history (pregnancy)
– Ineffective use of birth control
– Last menstrual period
• Recent head trauma
• Toxin exposure

51. Physical examination
1. Vitals : (A) fever : sign of sepsis
(B) hypotention , tachycardia : volume loss
(C) tachypnoea / acid tic breathing : DKA
2. General examination
a) Consciousness : raised ICT, meningitis, metabolic
derangements, toxic ingestion
b) Weight loss : eating disorder, subacute intestinal
obstruction, IEM, CRF, Addison disease
c) Assess for sign of dehydration
 Depressed anterion fontanalle
 Loss of skin turger
 Sunken eyes
 Dry oral mucosa

52. Systemic examination
• Abdominal exam
– Abdominal distention – obstruction, mass,
congenital abnormality, Organomegaly
– Bowel sounds – high pitched tinkle (obstruction),
absent (ileus)
– Guarding, rigidity, rebound tenderness –
appendicitis, peritoneal inflammation
– Tender hepatomegaly : hepatitis

53. Systemic exam cont…
• CVS : tachycardia – dehydration
sick looking child with vomiting, respi distress, gallop
rhythm : myocarditis
• R/S : tachypnoa without increase in work of
breathing- metabolic disturbances (DKA, Uremia,
• CNS : sign of meningitis
– Fundus examination
– Neuro deficit
– Nystagmus with dizziness and vertigo: vestibular
dysfunction

54. investigations
• Septic screen
• Cultures
• X ray Abdomen , chest x ray
• Usg abdomen
• Urine exam
• Serum electrolytes,ABG

55. LABORATORY INVESTIGATION
• Endoscopy
• Contrast gi radiography
• MRI brain
• Metabolic studies(serum lactate, serum
organic acid, serum ammonia)

56. • 1st x ray : coiling of tube : esophageal atresia
• 2 nd xray : double bubble sign : duodenal
atresia

57. • 3rd X ary : multiple air fluid level
( intestinal obstruction )
• 4th & 5th x ray : intra abd calcification in
meconium peritonitis

58. • (b) and (c) Lateral and AP views of contrast enema examination of the
same neonate illustrating a narrowed rectum compared to the sigmoid.
The rectum shows irregular contractions. This is the classic 'inverted cone
shape' rectum and 'saw-tooth' appearance. Rectal biopsy confirmed short
segment Hirschsprung disease.

59. • Necrotizing enterocolitis. (a) Supine AXR of a premature neonate who
developed severe NEC on 14th day of life, demonstrating multiple dilated bowel
loop with intramural gas (pneumatosis) (arrow) and portal venous gas (branching
linear lucencies in the liver extending to the periphery). (b) The same infant
developed bowel obstruction several weeks after the NEC episode. (c) Contrast
enema study demonstrates a focal stricture (curved arrow) with a localized
perforation at the site of previous NEC (short arrow).

60. Ix… cont…
• USG abd : HPS, CAH, Tumour
• Doppler USG : malrotation of Gut
• Urine benedict +ve, Glucose –ve =
galactosemia….send gas chromatography for
galactosemia
• ABG with electrolytes:

61. REMEMBER RED FLEG SIGN
• Lethargy and listlessness
• Inconsolability and bulging fontanelle in an
infant
• Nuchal rigidity, photophobia, and fever in an
older child
• Peritoneal signs or abdominal distention
(“surgical” abdomen)
• Persistent vomiting with poor growth or
development

62. Management
• Depends on specific cause
• early identification of surgical cause / life
threatening medical cause
• While investigating/ treating underlying
pathology
• replace lost fluids, maintain hydration
• If mild and child able to drink, can try
oral rehydration. Intravenous may also be
required
• Pharmacologic agents not usually
recommended
– May mask signs of serious disease
– Undesirable side-effects in children

63. Dimenhydrinate
Use: Prevention and treatment of nausea, vomiting
and vertigo associated with motion sickness.
Dosage: PO, IV, IM: Not indicated below 2 yr.
2-5 yr: 12.5-25 mg q 6-8 hr (Max: 75 mg/day).
6-12 yr: 25-50 mg q 6-8 hr (Max: 150 mg/day).
Brands: 50 mg Tab; Draminate, Gravol. 15.6 mg/5 ml
Syrup;
50 mg/ml Inj; Draminate.
• May cause excitation in young children; use with
precautions in patients with seizure disorder. May
lead to masking of signs and symptoms of ototoxicity
in patients on aminoglycosides, furosemide therapy.
.

64. • Domperidone
• Use: Nausea and vomiting, reflux
esophagitis, dyspepsia.
• Doses: PO: 0.3 mg/kg/dose q 4-8 hr.
• Brands: 10 mg Tab; 1 mg/ml Syrup;
Domperon, Domstal,
• Normetic. 1 mg/ml drops; Vomistop.
• Combinations: Domperidone + PCM: 10 + 500
mg Tab;
• Dompar, Domstal-P, Motinorm-P.
• Domperidone + Pantoprazole: 10 + 20 mg Tab;
Dompan.

65. Ondansetron
Use: Prevention of nausea and vomiting of various
etiology.
Dosage: PO: < 4 yr, 1-3 mg; 4-11 yr. 4 mg; >11 yr, 8 mg
q 8 hrly. IV: 0.15-0.45 mg/kg/dose q 8 hr.
Brands: 4 and 8 mg Tab; 2 mg/5 ml Syrup; 4 mg/ml
Inj;
Emeset, Ondem, Periset.
Combinations: Ondansetron + PCM and Ondansetron
+Ranitidine.
Administration: For IV dilute to 1 mg/ml and be given
over 15 minutes.

66. • Granisetron
• Use: Antiemetic in chemotherapy, radiation related
and postoperated nausea and vomiting.
• Dosage: IV: Children > 2 yr: 10-20 mcg/kg half an
hour before chemotherapy; 2-3 doses may be given.
PO:
• Adults: 1 mg BD or 2 mg OD 1 hour before
chemotherapy.
• Brands: 1 and 2 mg Tab; 1 mg/ml Inj; Granicip,
Topit. 1 mg/ml drops; Graniset.
• • May cause hypo or hypertension, arrhythmias,
agitation.
.

67. Metoclopramide
• Use: Gastroesophageal reflux, prevention of nausea and
• vomiting due to various causes, symptomatic treatment of
• diabetic gastric stasis.
• Dosage:
• • GE reflux: PO, IV, IM: 0.4-0.8 mg/kg/day divided q 6-8 hr.
• • Postoperative nausea and vomiting: IV: 0.1-0.2 mg/kg/dose.
• • Chemotherapy induced vomiting: PO, IV: 1-2 mg/kg/ dose q
2-4 hr as required.
• Brands: 100 mg Tab; 5 mg/ml Syrup; 5 mg/ml Inj;
Maxeron,Perinorm, Reglan, etc.
• • Contraindicated in GI obstruction, past history of seizures.
Causes extrapyramidal reactions and these can be prevented
and treated with diphenhydramine.
• .

68. Prochlorperazine
Use: Nausea, vomiting, vertigo, severe intractable migraine.
Dosage:
• Not indicated in < 2 yr or < 9 kg. PO: 0.4 mg/kg/day
divided q 6-8 hr. IM: 0.1-0.15 mg/kg/day divided q 8-12 hr.
Brands: 5 mg Tab; Bemetil, Stemetil, Vometil. 12.5 mg/ml Inj; Stemetil,
Steminol.
• Chances of extrapyramidal reactions are high in children so always use
lowest possible dose.
8

69. . Promethazine
Use: Allergic conditions, motion sickness, antiemetic and sedation.
Dosage: Not indicated below 2 yr of age.
• Antihistamine: PO: 0.1 mg/kg/dose q 6 hr (Max: 12.5 mg/day).
• Antiemetic: PO, IM, IV: 0.25-1 mg/kg/dose q 6 hr (Max:25 mg/dose).
• Sedation: PO, IV, IM: 0.5-1 mg/kg/dose q 6 hr (Max: 50 mg/dose).
• Motion sickness: PO: 0.5 mg/kg half an hour before journey, can be
repeated after 12 hr as needed.
Brands: 10 and 25 mg Tab; 5 mg/5 ml Elixir; Phenergan, Prometh, Promet. 5
mg/ml Inj; Phenergan.
• IM route is preferred, avoid IV use. May cause hypotension in fast IV and
hypertension in slow IV use.
Children with dehydration are prone to develop dystonic reactions.
Chlorpromazine and hydroxyzine also have antiemetic actions.
Dexamethasone and Lorazepam are used as adjunctive antiemetic.

70. CASE SCENARIO
A 5 yr old male child presented with loose stool nd
vomiting since last 2 days.. No history of fever nd
no past history of admission present.
On admission child was irritable,suncken eyeball
present,nd skin pinch goes back slowly.
Consindering some dehydration correction
started. With otherwise no significant history in
this child considered as a case of gastoenteritis..

71. • A 1 month old male child presented with
complain of vomiting since last 15 days
immediately after takind breast feeding nd
child not gaining weight since 15 days.
• on detailed history birth weight of child was
2.5 kg,vaginal delivered full term baby. On
admission child was lethargic,dehydrated,poor
feeding,weight is 2.9 kg. aftr correction of
dehydration usg abdo done s/o incresed
thickness nd length of pylorus p/o pyloric
stenosis. Child referred for further surgical
management

72. • A 4 yr old female child presented with c/o
vomiting since 2 days,abdominal pain since 2
days nd rapid breathing since 1 day.
• On detailed history child having increased
frequency of urine nd increased oral intake
since last 2-3 months.
• On admission child was lethargic,acidotic
breathing present, RBS done which was
high,urine sugar kitone 4+ nd large so
considered as diabetic ketoacidosis and
management started as protocols of DKA.

73. Take home message
• Vomiting is a vague symptom, Early
identification of serious disease needed in sick
child is key to successful mx
• Urgent medical as well as sx intervention may
needed
• History and examination with lab and
radiological support establish the diagnosis