Vomiting

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

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Aim

To guide PCH ED staff with the assessment and management of vomiting.

Background

Vomiting is one of the most common reasons for parents to take their child to see a doctor
Infection is the most common cause of vomiting in children, gastroenteritis being the leading cause
However, not all that vomits is gastroenteritis
Vomiting can be caused by a wide range of conditions, from the benign to the life threatening
Vomiting can be caused by a problem in many underlying conditions including gastrointestinal, neurological, endocrine conditions.

Assessment

In the younger the child, vomiting may be a non-specific symptom. Therefore, vomiting in infants and young babies requires careful clinical review and consideration of a wide range of causes.
In infants, positing and gastro-oesophageal reflux are ‘normal’ and are only a problem if they cause pain, failure to thrive, choking or apnoea.
Vomiting is rarely caused by constipation alone.
Bilious vomiting implies bowel obstruction distal to the ampulla of Vater in the duodenum, or dynamic ileus secondary to peritonitis, sepsis etc.
Vomiting of fresh blood usually implies bleeding proximal to the gastric cardia.
Vomiting of altered blood (‘coffee ground’) implies exposure of the blood to gastric juices over a period of time.
Vomitus with a faecal odour is consistent with peritonitis or a low GIT obstruction,

History

Important elements of the history

Nature of the vomiting:
- Colour: blood or bile
- Composition: undigested or digested food
- Frequency and progression
- Force: projectile?
- Relationship to feeding and position.

Bowel actions: child’s usual pattern
- When was stool last passed?
- Diarrhoea, with blood or mucous

Abdominal pain
Abdominal distension – may suggest lower bowel obstruction
Infectious contacts
Fever
- Suggests an infectious cause. Consider sepsis in an unwell child with fever and vomiting.
- Vomiting in an afebrile child may indicate an serious non-infectious cause.
Symptoms of a Urinary tract infection (UTI) – vomiting may be the only sign in infants
Preceding respiratory / diarrhoeal illness – consider as a cause of intussusception
Cough, grunting, respiratory distress – suggesting pneumonia
Features of CNS infection or raised intracranial pressure
History of trauma (especially head and abdomen)
Medications possibly causing a GIT upset (e.g. antibiotics)
Possibility of accidental or intentional poisoning
Neonates – delayed passage of meconium following birth (e.g. > 48 hours after delivery), or vomiting / abdominal distension in the first 36 hours of life.
Need to consider food protein induced enterocolitis syndrome (FPIES) in the context of an infant who has just started on solids – did they try a new food?

Examination

Full general examination: cardiovascular, respiratory, ENT etc.
Gastrointestinal exam: careful examination of abdomen, groin in both sexes and scrotum in boys
CNS: specifically look for signs of raised intracranial pressure and abnormal neurological signs.

Investigations

Pre-school children with unexplained vomiting should have a urinalysis (and urine culture if appropriate) performed to exclude urinary tract infection (UTI)
If abdominal trauma has occurred, presence of haematuria on urinalysis may indicate renal or urinary tract trauma
Special investigations should only be done after discussion with a senior emergency doctor.

Investigation	Indications
FBC, CRP and blood culture	Septic child – ? peritonitis
Stool microscopy and culture	Septic child, blood or mucus in stools, protracted diarrhoea
UEC	Profuse / prolonged vomiting Severe dehydration
Glucose	All neonates Suspected diabetic ketoacidosis A pale, quiet child, or one with profuse vomiting
Venous blood gas	Suspected diabetic ketoacidosis: Acidotic, profuse vomiting, IDDM with vomiting Suspected pyloric stenosis: metabolic alkalosis A young baby (>6 months) with repeated vomiting A capillary gas may be sufficient in the initial instance
LFT, Lipase, Amylase	Pancreatitis Abdominal trauma
Abdominal X-Ray	Any suspicion of bowel obstruction or peritonitis Constipation is not an indication
Abdominal ultrasound (in discussion with surgeon or Senior ED Doctor)	Suspected pyloric stenosis Suspected intussusception Occasionally for suspected appendicitis Gynaecological problems Suspected cholecystitis/choleolithiaisis Suspected kidney stones/renal mass

Differential diagnosis

Causes of Vomiting by Age
Neonates and Infants	Children	Adolescents	All Infants, Children and Adolescents
Gastro-oesophageal reflux	Diabetic ketoacidosis	Diabetic ketoacidosis	Gastroenteritis
Pyloric stenosis	Appendicitis	Appendicitis	Urinary tract infection, Otitis Media, Pneumonia, Sepsis
Dietary protein induced enteritis	Oesophagitis	Psychogenic, eating disorder	URTI: tonsillitis, pharyngitis
Intussusception	Cyclical vomiting syndrome	Cyclical vomiting syndrome	GIT obstruction: malrotation with volvulus
Hirschsprung disease		Gastric ulcer	Hepatobiliary, pancreatic disease
Metabolic disorders		Pregnancy	Adrenal crisis, metabolic disorders
Sepsis / Urinary tract infection (UTI)		Testicular torsion	Poisoning – toxic ingestion, self harm
			Central nervous system infection (e.g. meningitis), increased intracranial pressure (e.g. malignancy), head injury

Management

If shocked, correct with IV boluses of 20mL/kg of 0.9% Sodium Chloride and repeat if required. More information: Intravenous fluid therapy
If gastroenteritis is the cause of vomiting, manage as per Gastroenteritis guideline
Consider referral to the general surgical team if there is:
- bile stained vomiting
- bloody stools (unless explained by a medical cause such as bacterial enterocolitis)
- abdominal distension
- signs of peritonism: guarding, rebound tenderness, localised abdominal tenderness
- palpable abdominal mass
- inguinoscrotal / testicular pain or swelling (hernia)
- diagnosis unclear (unless trivial symptoms in a well child).
Correct dehydration and electrolyte abnormalities (e.g. hypokalaemia) as necessary
If bowel obstruction is present, keep fasted, insert a nasogastric tube and leave the tube on open drainage.

Medications

The use of anti-emetic medications such as ondansetron (dose 0.1 to 0.15mg/kg sublingual or IV) should not be routinely used, but can be considered in:
- gastroenteritis: to allow successful rehydration (oral or via nasogastric tube) to occur
- cyclical vomiting syndrome.
Use of anti-emetic medications such as metoclopramide and prochlorperazine are not recommended for children because of a significant risk of serious extra-pyramidal side effects and dystonic reactions.¹

References

Lewis K, O’Day CS, Dystonic Reactions, NCBI StatPearls Publishing LLC 2021, Dystonic Reactions - StatPearls - NCBI Bookshelf (nih.gov)

Bibliography

Textbook of Emergency Medicine 2nd edition, A Holland 565-570,222-224
Central neurocircuitry associated with emesis. Hornby PJ Am J Med. 2001;111 Suppl 8A:106
Abdominal surgical emergencies in infants and young children. McCollough M, Sharieff GQ Emerg Med Clin North Am. 2003;21(4):909.

Endorsed by:	Co-Director, Surgical Services	Date:	Oct 2021
		Review date:	Oct 2024

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