Pediatric Vomiting

Definition and Etiology

Definition

Vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia (emesis) refers to the forceful oral expulsion of gastric contents.

Etiology

• Newborns:
  • Esophageal atresia Atresia Hypoplastic Left Heart Syndrome (HLHS)
  • Vascular rings Vascular rings Vascular rings are a group of rare malformations featuring congenital abnormalities of the aortic arch. The aberrant arteries often form a ring around the esophagus and trachea, putting pressure on these structures. Vascular Rings
  • CNS lesions
• Infants:
  • Gastroenteritis Gastroenteritis Gastroenteritis is inflammation of the stomach and intestines, commonly caused by infections from bacteria, viruses, or parasites. Transmission may be foodborne, fecal-oral, or through animal contact. Common clinical features include abdominal pain, diarrhea, vomiting, fever, and dehydration. Gastroenteritis
  • Pyloric stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS)
  • GERD GERD Gastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). Gastroesophageal Reflux Disease (GERD)
  • Food allergies Allergies A medical specialty concerned with the hypersensitivity of the individual to foreign substances and protection from the resultant infection or disorder. Selective IgA Deficiency
  • Milk-protein intolerance
  • Overfeeding
  • Inborn errors of metabolism
  • Vascular rings Vascular rings Vascular rings are a group of rare malformations featuring congenital abnormalities of the aortic arch. The aberrant arteries often form a ring around the esophagus and trachea, putting pressure on these structures. Vascular Rings
• Children and adolescents:
  • Gastroenteritis Gastroenteritis Gastroenteritis is inflammation of the stomach and intestines, commonly caused by infections from bacteria, viruses, or parasites. Transmission may be foodborne, fecal-oral, or through animal contact. Common clinical features include abdominal pain, diarrhea, vomiting, fever, and dehydration. Gastroenteritis
  • Pyelonephritis Pyelonephritis Pyelonephritis is infection affecting the renal pelvis and the renal parenchyma. This condition arises mostly as a complication of bladder infection that ascends to the upper urinary tract. Pyelonephritis can be acute or chronic (which results from persistent or chronic infections). Typical acute symptoms are flank pain, fever, and nausea with vomiting. T Pyelonephritis and Perinephric Abscess
  • Systemic infection
  • Toxic ingestions
  • Appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis
  • Ulcers
  • Pancreatitis Pancreatitis Inflammation of the pancreas. Pancreatitis is classified as acute unless there are computed tomographic or endoscopic retrograde cholangiopancreatographic findings of chronic pancreatitis. The two most common forms of acute pancreatitis are alcoholic pancreatitis and gallstone pancreatitis. Acute Pancreatitis
  • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care

Clinical Presentation

History

A complete history should be elicited to narrow the differential diagnosis of vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia in a child.

• Demographics:
  • Age
  • Sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria
  • Place of residence (important in cases of epidemics Epidemics Sudden outbreaks of a disease in a country or region not previously recognized in that area, or a rapid increase in the number of new cases of a previous existing endemic disease. Epidemics can also refer to outbreaks of disease in animal or plant populations. Influenza Viruses/Influenza and food poisoning Food poisoning Acute illnesses, usually affecting the gastrointestinal tract, brought on by consuming contaminated food or beverages. Most of these diseases are infectious, caused by a variety of bacteria, viruses, or parasites that can be foodborne. Sometimes the diseases are caused by harmful toxins from the microbes or other chemicals present in the food. Especially in the latter case, the condition is often called food poisoning. Clostridia)
• Onset/duration/progress of symptoms
• Association of food intake
• Fluid balance:
  • Number of wet diapers/urinations per day
  • Increase in drinking or asking for water
• Associated symptoms:
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
  • Earache
  • Headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess
  • Abdominal pain Abdominal Pain Acute Abdomen
  • Dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming “stuck.” Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia
  • Chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways (referred heartburn Heartburn Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus. Gastroesophageal Reflux Disease (GERD) in esophagitis Esophagitis Esophagitis is the inflammation or irritation of the esophagus. The major types of esophagitis are medication-induced, infectious, eosinophilic, corrosive, and acid reflux. Patients typically present with odynophagia, dysphagia, and retrosternal chest pain. Esophagitis)
• Nature of the vomitus:
  • Projectile/nonprojectile
  • Color
  • Contents
  • Painful/painless
  • Hematemesis Hematemesis Vomiting of blood that is either fresh bright red, or older ‘coffee-ground’ in character. It generally indicates bleeding of the upper gastrointestinal tract. Mallory-Weiss Syndrome (Mallory-Weiss Tear) can occur in:
    • Mallory–Weiss syndrome (indicating forceful vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia)
    • Coagulopathies Coagulopathies Hemothorax
  • Severe, persistent vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia in cases of:
    • CNS compromise ( meningitis in children Meningitis in Children Meningitis is inflammation of the meninges around the brain and spinal cord. The majority of cases occur during childhood and are predominantly viral or bacterial in etiology. Clinical presentation is influenced by the age of the child and the causative pathogen, but meningitis typically presents with signs of meningeal irritation, fever, and lethargy. Meningitis in Children, hydrocephalus Hydrocephalus Excessive accumulation of cerebrospinal fluid within the cranium which may be associated with dilation of cerebral ventricles, intracranial. Subarachnoid Hemorrhage)
    • Metabolic derangement
    • Chemotherapy-induced
  • Sexual activity in adolescent girls (for potential pregnancy-induced vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia)

Physical examination

• Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever in GI and CNS infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
• Bulging or sunken fontanelle Fontanelle Any of six membrane-covered openings between the cranial sutures in the incompletely ossified skull of the fetus or newborn infant. The fontanelles normally close sometime after birth. Skull: Anatomy:
  • Bulging (↑ intracranial pressure Intracranial Pressure Idiopathic Intracranial Hypertension)
  • Sunken ( dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration)
• Poor feeding
• Signs of dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration or shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock ( fluid replacement therapy in children Fluid replacement therapy in children Children are particularly vulnerable to developing dehydration because they have higher insensible water loss and more elevated metabolic rates than adults. In addition, children’s inability to communicate their needs compounds with large losses of fluids (e.g., diarrhea, vomiting), putting them at even higher risk. Fluid Replacement Therapy in Children)
• Low height and weight for age in cases of anorexia Anorexia The lack or loss of appetite accompanied by an aversion to food and the inability to eat. It is the defining characteristic of the disorder anorexia nervosa. Anorexia Nervosa due to loss of calories and nutrients:
  • Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive
  • Malnutrition Malnutrition Malnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema). Malnutrition in children in resource-limited countries
• Nystagmus Nystagmus Involuntary movements of the eye that are divided into two types, jerk and pendular. Jerk nystagmus has a slow phase in one direction followed by a corrective fast phase in the opposite direction, and is usually caused by central or peripheral vestibular dysfunction. Pendular nystagmus features oscillations that are of equal velocity in both directions and this condition is often associated with visual loss early in life. Albinism in vestibular disorders ( vertigo Vertigo Vertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo)
• Marked abdominal distention Abdominal distention Megacolon and tenderness in appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis or acute abdomen Acute Abdomen Acute abdomen, which is in many cases a surgical emergency, is the sudden onset of abdominal pain that may be caused by inflammation, infection, perforation, ischemia, or obstruction. The location of the pain, its characteristics, and associated symptoms (e.g., jaundice) are important tools that help narrow the differential diagnosis. Acute Abdomen
• Presumptive signs of pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care

Diagnosis and Management

Laboratory testing

• Basic metabolic panel Basic Metabolic Panel Primary vs Secondary Headaches:
  • In cases of severe dehydration Severe Dehydration Fluid Replacement Therapy in Children can show:
    • ↓ Glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance
    • ↑ BUN
    • ↑ Sodium Sodium A member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23. Hyponatremia and chloride Chloride Inorganic compounds derived from hydrochloric acid that contain the Cl- ion. Electrolytes
    • ↓ Bicarbonate Bicarbonate Inorganic salts that contain the -HCO3 radical. They are an important factor in determining the ph of the blood and the concentration of bicarbonate ions is regulated by the kidney. Levels in the blood are an index of the alkali reserve or buffering capacity. Electrolytes
    • ↑ Creatinine
• CK:
  • When concerned about rhabdomyolysis Rhabdomyolysis Rhabdomyolysis is characterized by muscle necrosis and the release of toxic intracellular contents, especially myoglobin, into the circulation. Rhabdomyolysis
  • Elevated in severe dehydration Severe Dehydration Fluid Replacement Therapy in Children

Pharmacologic therapy

• IV hydration Iv Hydration Crush Syndrome for:
  •   Hypovolemic shock Hypovolemic Shock Types of Shock
  • Severe dehydration Severe Dehydration Fluid Replacement Therapy in Children
  • Intractable vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia
• Antiemetics Antiemetics Antiemetics are medications used to treat and/or prevent nausea and vomiting. These drugs act on different target receptors. The main classes include benzodiazepines, corticosteroids, atypical antipsychotics, cannabinoids, and antagonists of the following receptors: serotonin, dopamine, and muscarinic and neurokinin receptors. Antiemetics:
  • Ondansetron Ondansetron A competitive serotonin type 3 receptor antagonist. It is effective in the treatment of nausea and vomiting caused by cytotoxic chemotherapy drugs, including cisplatin, and has reported anxiolytic and neuroleptic properties. Antiemetics IV or oral (first line)
  • Metoclopramide Metoclopramide A dopamine d2 antagonist that is used as an antiemetic. Antiemetics oral or IV
  • Dimenhydrinate Dimenhydrinate A drug combination that contains diphenhydramine and theophylline. It is used for treating vertigo, motion sickness, and nausea associated with pregnancy. Antihistamines orally (in motion sickness for ages 12 and up)

Nonpharmacologic therapy

• Oral rehydration Rehydration Dengue Virus (preferred and is first line in mild or moderate dehydration Moderate Dehydration Fluid Replacement Therapy in Children)
• Surgical intervention for intestinal obstructions (i.e., pyloric stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS))
• Proton pump Pump ACES and RUSH: Resuscitation Ultrasound Protocols inhibitors (PPI) in peptic disease (i.e., gastroesophageal reflux disease Gastroesophageal Reflux Disease Gastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). Gastroesophageal Reflux Disease (GERD))

Mild to moderate dehydration Moderate Dehydration Fluid Replacement Therapy in Children

• Oral rehydration Rehydration Dengue Virus therapy (ORT) is first-line treatment in mild or moderate dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration.
• Oral rehydration Rehydration Dengue Virus solutions with electrolyte contents similar to those of fluid lost should be used:
  • E.g., Pedialyte Pedialyte Fluid Replacement Therapy in Children or Enfalyte
  • Breast-fed infants should continue to nurse
• Goal: Provide 50–100 mL/kg of fluids over 2–4 hours. Route of administration depends on patient age and frailty:
  • Syringe or spoon-feeding
  • NG tube
• +/– Ondansetron Ondansetron A competitive serotonin type 3 receptor antagonist. It is effective in the treatment of nausea and vomiting caused by cytotoxic chemotherapy drugs, including cisplatin, and has reported anxiolytic and neuroleptic properties. Antiemetics to prevent vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia
• Clinical hydration status should be monitored frequently.
• Failure to improve with ORT should prompt IV hydration Iv Hydration Crush Syndrome.

Severe dehydration Severe Dehydration Fluid Replacement Therapy in Children

Severe dehydration Severe Dehydration Fluid Replacement Therapy in Children can cause hypoperfusion of the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification and vital organs and is considered a medical emergency to be addressed rapidly.

• Acute resuscitation phase Acute resuscitation phase Malnutrition in children in resource-limited countries:
  • Goal: correct or prevent hypovolemic shock Hypovolemic Shock Types of Shock
  • Rapid volume expansion through fluid boluses:
    • 20 mL/kg given over 20 minutes.
    • Can be repeated up to 3 times
    • Monitor vital signs between each bolus.
  • Choice of replacement fluid:
    • Isotonic Isotonic Solutions having the same osmotic pressure as blood serum, or another solution with which they are compared. Renal Sodium and Water Regulation fluids only
    • Either lactated Ringer’s Lactated Ringer’s A crystalloid solution that contains sodium chloride; sodium lactate; potassium chloride; and calcium chloride. It is used for fluid therapy. Fluid Replacement Therapy in Children or normal saline Normal saline A crystalloid solution that contains 9. 0g of sodium chloride per liter of water. It has a variety of uses, including: as a contact lens solution, in ophthalmic solutions and nasal lavage, in wound irrigation, and for fluid therapy. Intravenous Fluids is appropriate.
  • Glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance monitoring:
    • Point-of-care monitoring for hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia
    • IV glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance should be administered.
    • 5–10 mL/kg of 10% dextrose Dextrose Intravenous Fluids in normal saline Normal saline A crystalloid solution that contains 9. 0g of sodium chloride per liter of water. It has a variety of uses, including: as a contact lens solution, in ophthalmic solutions and nasal lavage, in wound irrigation, and for fluid therapy. Intravenous Fluids OR 2–4 mL/kg of 25% dextrose Dextrose Intravenous Fluids in normal saline Normal saline A crystalloid solution that contains 9. 0g of sodium chloride per liter of water. It has a variety of uses, including: as a contact lens solution, in ophthalmic solutions and nasal lavage, in wound irrigation, and for fluid therapy. Intravenous Fluids
• Resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome phase:
  • Slower replacement of lost fluids over 24 hours
  • Total fluid for resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome phase = maintenance fluids + ( rehydration Rehydration Dengue Virus – bolus already given)
  • Rehydration Rehydration Dengue Virus is divided into 2 phases:
    • 50% over 1st 8 hours
    • 50% over next 16 hours
  • 5% dextrose Dextrose Intravenous Fluids with 0.2% sodium Sodium A member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23. Hyponatremia chloride Chloride Inorganic compounds derived from hydrochloric acid that contain the Cl- ion. Electrolytes compensates for maintenance requirement of sodium Sodium A member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23. Hyponatremia in most children
• After 24 hours if clinically stable → continue maintenance fluids

Volume replacement calculations

• Standard bolus:
  • 20 mL/kg/20 minutes
  • Up to 3 times
  • Monitor vital signs.
• Maintenance calculations:
  • 4-2-1 rule:
    • 1st 10 kg = 4 mL/kg/hour
    • 2nd 10 kg = 2 mL/kg/hour
    • Additional kg = 1 mL/kg/hour
  • Example: For a child who weighs 37 kg:
    • (10 kg × 4 mL/kg/hour) + (10 kg × 2 mL/kg/hour) + (17 kg × 1 mL/kg/hour) =
    • (40 mL/hour) + (20 mL/hour) + (17 mL/hour) = 77 mL/hour
• Rehydration Rehydration Dengue Virus is calculated by weight and severity of dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration:
  • Amount calculated is added to maintenance amount, spread throughout the day.
  • < 10 kg:
    • Mild: 50 mL/kg/day
    • Moderate: 100 mL/kg/day
    • Severe: 150 mL/kg/day
  • ≥ 10 kg:
    • Mild: 30 mL/kg/day
    • Moderate: 60 mL/kg/day
    • Severe: 90 mL/kg/day

Complications

• Dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration
• Malnutrition Malnutrition Malnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema). Malnutrition in children in resource-limited countries
• Esophagitis Esophagitis Esophagitis is the inflammation or irritation of the esophagus. The major types of esophagitis are medication-induced, infectious, eosinophilic, corrosive, and acid reflux. Patients typically present with odynophagia, dysphagia, and retrosternal chest pain. Esophagitis
• Intussusception Intussusception Intussusception occurs when a part of the intestine (intussusceptum) telescopes into another part (intussuscipiens) of the intestine. The condition can cause obstruction and, if untreated, progress to bowel ischemia. Intussusception is most common in the pediatric population, but is occasionally encountered in adults. Intussusception
• Sigmoid volvulus Sigmoid volvulus Volvulus
• Reflux