Clinical Notes : Paediatrics

12. Nausea and Vomiting in Children

Nausea and vomiting are common in children and are due to a diverse range of conditions.

Despite there being many complex tests available, diagnosis primarily relies on a thorough history and physical examination 

Etiology

Infectious

  • Viral gastroenteritis:

    • Viral gastroenteritis: highly contagious infection that may present as an epidemic in a particular region

    • makes up 50% to 70% of cases of acute gastroenteritis.

    • In most cases, the infection is self-limiting and resolves on its own, necessitating supportive measures only.

    • The most common causative viral agents are norovirus, rotavirus, enteric adenovirus (types 40 and 41), astrovirus, coronavirus, and some picornaviruses.

  • Bacterial gastroenteritis:

    • infection generally produces more severe and prolonged symptoms.

    • An estimated 15% to 20% of acute gastroenteritis episodes are thought to be caused by bacterial infection, but stool studies are positive in only 1.5% to 5.6% of cases.

    • The most common causative bacteria are Salmonella , Shigella , Campylobacter , Escherichia coli , Vibrio , Yersinia , and Clostridium difficile .

  • Parasitic gastroenteritis:

    • parasitic infections are typically more prolonged and make up an estimated 10% to 15% of cases of acute gastroenteritis

    • Giardiasis, an enteric infection caused by the protozoan parasite Giardia lamblia , is the most common parasitic infection and can be spread by ingestion of contaminated food or water, or person-to-person spread via the faecal-oral route.

    • Other parasitic agents include Amoebas , Cryptosporidium , Isospora , Cyclospora , and Microsporidium .

 

Neurological

Neurological causes of nausea or vomiting are always concerning and often demand prompt evaluation and treatment.

  • Meningitis

  • Functional neurological syndromes:

  • migraine,

  • motion/travel sickness 

  • vertigo 

  • Brain tumours

  • Intracranial hypertension

  • Concussion

 

Gastroenterological: obstructive

Gastrointestinal obstruction is a common and very concerning cause of nausea and vomiting in children.

The aetiology is mostly age-dependent, but may also be contingent on pre-existing abdominal surgery.

  • Pyloric stenosis: 

  • Small bowel atresia: 

  • Intestinal malrotation:

  • Intussusception

  • Superior mesenteric artery syndrome

 

Gastroenterological: functional

  • Gastroesophageal reflux disease

  • Cyclic vomiting:

    • defined as a pattern of intermittent and often paroxysmal vomiting, alternating with asymptomatic periods without vomiting.

    • It is a diagnosis of exclusion and can only be diagnosed in patients after the exclusion of inflammatory, metabolic, or neoplastic causes.

    • It is frequently seen in children, particularly adolescents and females, with an estimated prevalence of 2% in school-aged children.  

    • Suspicion should arise when the stereotypical pattern is established.

  • Dysautonomia (e.g., postural orthostatic tachycardia [POTS]): is rare

  • Gastroparesis:

    • defined as delayed gastric emptying and associated with nausea and vomiting.

    • It is an uncommon cause of vomiting in children

    • It frequently occurs after a viral infection (i.e., post-viral gastroparesis)

  • Hirschsprung's disease:

  • a congenital condition, generally in the distal segments of the colon, caused by absence of ganglion cells in the myenteric and submucosal plexus. 

  • Constipation

    • prevalence of 0.7% to 29.6% worldwide in children. 

Gastroenterological: inflammatory

  • Peptic ulcer disease: 

  • Acute appendicitis: .

  • Acute pancreatitis: 

  • Hepatitis A:

    • spread via close contact with an infected person (including faecal-oral contact) or contaminated food or water.

 

Gastroenterological: allergic

  • Food allergies:

Gastroenterological: malignancy

  • Small bowel lymphoma:

 

Metabolic/endocrine

  • Diabetic ketoacidosis: 

  • Adrenal insufficiency

  • Inborn errors of metabolism

 

Urological/gynaecological and renal

Nausea and vomiting are frequent symptoms of renal, urological, and gynaecological diseases.

  • Gonadal torsion: 

  • Urinary tract infection (UTI): 

  • Haemolytic uraemic syndrome:

  • Nephrolithiasis: 

  • Ureteropelvic junction obstruction:

Psychiatric

  • Eating disorders

    • bulimia nervosa

    • anorexia nervosa 

  • Rumination syndrome:

    • defined as the presence of repeated oral regurgitation of small amounts of food from the stomach, which is often then re-swallowed.

  • Factitious disorder (medical abuse): should be suspected when symptoms seem fabricated or out of proportion to the examination.

    • The perpetrator is often one of the child’s parents or carers. 

 

Environmental

  • Toxic ingestions

  • Medication adverse effects

  • Cannabis hyperemesis syndrome:

 

Respiratory/ear, nose, and throat

  • Otitis media

  • Pneumonia:

History

 

The following history should be elicited from the patient, parent, or carer.:

  • Travel, food or fresh water intake, sick contacts: may indicate an infection.

  • Travel with passive movement: may indicate motion/travel sickness.

  • Previous trauma: may indicate concussion.

  • Ingestion of toxin(s) or use of medication(s)

  • Family history: may indicate a chronic inflammatory condition, genetic conditions (e.g., metabolism disorders), or liver disorders.

  • Relation of symptoms to types of food: may indicate a food allergy.

The presence of associated symptoms may help direct the clinician towards a diagnosis.

  • Diarrhoea (especially bloody, watery, or foul-smelling), abdominal pain, and fever are common presenting symptoms of gastroenteritis.

    • Diarrhoea and abdominal pain may also indicate small bowel lymphoma.

    • If diarrhoea is explosive, it may indicate Hirschsprung's disease.

    • Bloody diarrhoea may also indicate haemolytic uraemic syndrome.

    • Haematochezia may indicate intussusception (may be described as currant jelly stool) or intestinal malrotation.

    • Melaena may indicate peptic ulcer disease.

  • Fever, headache, photophobia, confusion, and nuchal rigidity may indicate meningitis.

    • Nuchal rigidity is uncommon in children <2 years of age.

  • Fever may also indicate other infectious causes. which commonly are associated with nausea and vomit

    • otitis media

    • urinary tract infection

    • pneumonia.

  • Headache, photophobia, and the absence of fever may suggest migraine as a precipitating factor.

  • A baby being very hungry immediately after feeding (seems to be 'starving to death') is characteristic of pyloric stenosis.

  • Acute onset of severe testicular/scrotal or sharp abdominal pain may indicate testicular or ovarian torsion, respectively.

  • Mid-epigastric pain that radiates through to the back may indicate acute pancreatitis.

  • Polyuria, polydipsia, and polyphagia can indicate diabetic ketoacidosis.

  • Dysphagia including choking, food impaction, as well as odynophagia may indicate eosinophilic oesophagitis; 

  • Failure to pass meconium within 48 hours of birth may indicate Hirschsprung's disease or small bowel atresia.

Physical examination :

A complete physical examination is always warranted; however, patients often have no specific findings on examination.

Every body system should be examined carefully.

  • Volume depletion: a decrease of more than 5% of the previous weight should raise concern about the possibility of volume depletion.

    • The presence of tachycardia and hypotension with weight loss >10% to 15% is associated with a more pronounced hypovolaemia and the need for appropriate fluid resuscitation.

    • Other signs of volume depletion include the presence of a sunken anterior fontanelle (in infants) or eyes, dry mucosal membranes, sticky saliva, loss of skin turgor, and slow capillary refill.

    • Volume depletion may be associated with infections, an obstruction, or metabolic disorders.

  • Fever, pallor, and lethargy: typical signs of infection.

  • Wheezing or rales: may be revealed on chest examination and may indicate pneumonia.

  • Skin changes: jaundice, petechiae, or a purpuric rash may suggest an infectious process.

    • Jaundice may also be seen in infants with pyloric stenosis, hepatitis A, or metabolism disorders.

    • Hyperpigmentation of mucosa suggests Addison's disease.

    • Loss of skin turgor suggests volume depletion, and pallor suggests anaemia.

  • Neurological signs: seizures, confusion/altered mental status, behavioural changes, nuchal rigidity, papilloedema, abnormal gait, vision dysfunction, cranial nerve paralysis, or retinal haemorrhages may be suggestive of trauma or intracranial hypertension.

    • A bulging fontanelle in infants may also suggest intracranial hypertension.

    • Amnesia may suggest concussion.

  • Acetone breath: specific for diabetic ketoacidosis.

    • Other signs include tachycardia, hypotension, hyperventilation, and altered mental status.

  • Failure to thrive: a non-specific sign that can occur in metabolic disorders, obstruction, food allergies, and functional gastrointestinal disorders.

  • Unexplained symptoms may indicate factitious disorder.

    • Symptoms that do not respond to medical management also support a diagnosis of the latter, or possibly cannabis hyperemesis syndrome.

 

The abdominal examination often gives multiple clues for the diagnosis.

  • Absence of bowel sounds and presence of abdominal distension: may suggest gastrointestinal obstruction.

  • Tenderness or pain on palpation: should alert the examiner to a possible acute abdominal inflammatory process such as enteritis or appendicitis.

  • Epigastric mass or visible peristalsis: can suggest pyloric stenosis in infants.

    • A palpable mass may also indicate some other type of obstruction, or possibly gonadal torsion or nephrolithiasis, depending on the location of the mass.

  • Hepatomegaly: often seen in the context of metabolic conditions such as fructose intolerance or hepatitis A.

  • Right upper quadrant tenderness: suggests viral hepatitis or a toxic insult to the liver.

  • Costovertebral tenderness: present in teenagers with urinary tract infections, or patients with nephrolithiasis.

  • Bloating or distension may indicate gastroenteritis or an obstruction.

 

A rectal examination should always be performed if an abdominal inflammatory process or obstruction is suspected.

This simple, and often underutilised, examination technique can confirm the presence of hard stool in the rectal vault or a mass without the need for x-rays.

Otoscopy should be performed if otitis media is suspected (e.g., older children with otalgia or younger children who are seen to be pulling their ears). A bulging tympanic membrane and myringitis are diagnostic for otitis media.

Refer to A+E

  • Any neonate or infant with recurrent or bilious (yellow or green) emesis or projectile vomiting (GI obstruction)

  • An infant or young child with colicky abdominal pain, signs of intermittent pain or listlessness, and absent or bloody stools (intussusception)

  • A child or adolescent with fever, nuchal rigidity, and photophobia (meningitis)

  • A child or adolescent with fever and abdominal pain followed by vomiting, anorexia, and decreased bowel sounds or peritoneal signs (appendicitis)

  • Recent history of head trauma or chronic progressive headaches with morning vomiting and vision changes (intracranial hypertension)

 

Treatment (<2 yrs)

Persistent vomit : Refer

 

Treatment (>2 yrs)

Treatment is

  • targeted at the causative disorder.

  • Rehydration is important

  • Drugs frequently used in adults to decrease nausea and vomiting are used less often in children because the usefulness of treatment has not been proved and because these drugs have potential risks of adverse effects and of masking an underlying condition. However, if nausea or vomiting is severe or unremitting, antiemetic drugs can be used cautiously in children > 2 yr.

 

  • Promethazine (Phenergan Elixir : 5mg/5ml)

    • 0.25 to 1 mg/kg (maximum 25 mg) po, IM, IV, or rectally q 4 to 6 h

 

  • Prochlorperazine (Stemetil : 5mg tablet)

    • 9 to 13 kg, 2.5 mg po q 12 to 24 h;

    • 13 to 18 kg, 2.5 mg po q 8 to 12 h;

    • 18 to 39 kg, 2.5 mg po q 8 h;

    • > 39 kg, 5 to 10 mg po q 6 to 8 h

 

  • Ondansetron (Zofran 4mg/5ml)

    • 2 to 4 yr, 2 mg q 8 h; PO

    • 4 to 11 yr, 4 mg q 8 h; PO

    • ≥ 12 yr, 8 mg q 8 hPO

    • 0.15 mg/kg (maximum 8 mg) IV q 8 h

 
 
 
 
 
 
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Assessment of nausea and vomiting in children

BMJ Best Practice

October 2018

Access

Rosen R, Vandenplas Y, Singendonk M, et al.

Paediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.

J Pediatr Gastroenterol Nutr. 2018 Mar;66(3):516-54.

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Graves NS. Acute gastroenteritis.

Prim Care. 2013 Sep;40(3):727-41

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Rodriguez L, Irani K, Jiang H, Goldstein AM.

Clinical presentation, response to therapy, and outcome of gastroparesis in children.

J Pediatr Gastroenterol Nutr 2012; 55:185.

Access

Waseem S, Islam S, Kahn G, Moshiree B, Talley NJ.

Spectrum of gastroparesis in children.

J Pediatr Gastroenterol Nutr. 2012;55:166–17212; 55:185.

Access

Ireland notes.png

The following are available in Ireland :

Promethazine (Phenergan Elixir)

Prochlorperazine (Stemetil)

Ondansetron (Zofran)

 

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