Vomiting


Parents may confuse regurgitation with vomiting. Vomiting results from forceful contraction of the diaphragm and abdominal muscles, whereas regurgitation is independent of any effort and likely represents the ultimate degree of GI reflux.

Vomiting results from many causes and is rarely an isolated symptom. During the first few weeks of life, vomiting is uncommon and may be confused with normal infant regurgitation.
Vomiting beginning at birth is most likely due to an anatomic abnormality, such as tracheoesophageal fistula (with esophageal atresia), upper GI obstruction (e.g., duodenal atresia, which has a higher incidence among Down's infants), or midgut malrotation.
Vomiting may be a symptom unrelated to the GI tract, such as increased intracranial pressure, metabolic disorders, or infections (e.g., shaken-baby syndrome, sepsis, urinary tract infections, and gastroenteritis).

Bilious vomiting in neonate = Surgical Emergency

DDx Vomiting in Pediatrics
TE Fistula /
Esophageal Atresia
GERD Pyloric Stenosis Duodenal Atresia Malrotation/
Volvulus
Necrotizing  Enterocolitis Intussusception Intersitnal Atresia
- Frothing, Bubbling
- Excessive salivation
- Chocking w/ 1st feed
- 20-30 miin after feeding
- Spitting up
- Present since birth
 
- Non-Bilious
- Projectile
- NOT present at birth
- Hungry baby
- HypoChloremic, Hypokalemic
- Metabolic Alkalosis
- Present AT BIRTH
- Vomit with feed
- BILIOUS
- Associated w/ Down Syndrome
 
-Bilious vomiting
-infant age <1 year
-dark blood in diaper
-abdominal distension
- Pre-term Baby
- Intramural Air
- Distended Abdomne
- (+) Blood in stool
-age 6 to 12 months
-male gender
-abdominal pain
-vomiting
-lethargy/irritability
-blood per rectum/currant jelly stool
-hypovolemic shock

 

MC site: Jejunal Atresia
- Bilious vomit at birth
- Distended Abdomen
  Dx:
- 24 hr pH monitoring
- Reflux scan
Dx:
US
Dx:
- Abd XR = Double Bubble
Dx:
-
Upper GI contrast series
-CT abdomen (WITH oral and IV contrast)
-Abdominal plain films
-CBC, ABG
-
Ultrasound
- lower GI contrast series
Dx:
- ABD XR = pneumonitis intestinalis or free air.
Dx:
- abdominal plain-film x-ray
-ultrasound
- diagnostic enema
- CT Abd
DX:
- Abd XR = Triple Bubble
  Tx:
Reglan 0.2mg/kg/dose

Ranitadine 10mg/kg/day
Tx:
Surgery
Tx:
- NG, Surgery
Tx:
Surgery
Tx:
- Bowel rest (NPO)
-
cefotaxime
- Pediatric surgeon Consult
Tx:
-IV Fluid
-Barium enema
-ABx
-Surgery
 


Etiologies of Vomiting

 
Etiologies of Vomiting That May Result in Significant Morbidity, Categorized by Age
Newborn Period (birth–2 wk)  
Obstructive intestinal anomaly Esophageal or intestinal stenosis/atresia, bowel malrotation ± midgut volvulus, meconium ileus/plug, Hirschsprung disease, imperforate anus, enteric duplications
Other GI disease processes Necrotizing enterocolitis, perforation with secondary peritonitis
Neurologic Mass lesion, hydrocephalus, cerebral edema, kernicterus
Renal Obstructive anomaly, uremia
Infectious Sepsis, meningitis
Metabolic Inborn errors of metabolism, congenital adrenal hyperplasia
Infant (2 wk–12 mo)  
Acquired esophageal disorders Foreign body, retropharyngeal abscess
GI obstruction Bezoar, foreign body, pyloric stenosis, malrotation ± volvulus, enteric duplications, complications of Meckel diverticulum, intussusception, incarcerated hernia, Hirschsprung disease
Other GI disease processes Gastroenteritis with dehydration, peritonitis
Neurologic Mass lesion, hydrocephalus
Renal Obstruction, uremia
Infectious Sepsis, meningitis, pertussis
Metabolic Inborn errors of metabolism
Toxic ingestions
Child (>12 mo)  
GI obstruction Bezoar, foreign body, posttraumatic intramural hematoma, malrotation ± volvulus, complications of Meckel diverticulum, intussusception, incarcerated hernia, Hirschsprung disease
Other GI disease processes Appendicitis, peptic ulcer disease, pancreatitis, peritonitis
Neurologic Mass lesions
Renal Uremia
Infectious Sepsis, meningitis
Metabolic Diabetic ketoacidosis, adrenal insufficiency, inborn errors of metabolism
Toxic ingestion

ED Care & Disposition

  1. Treat dehydration, hypoglycemia & electrolyte abnormalities.
    • Vomiting is not a contraindication for oral rehydration; the key is to give small amounts of the solution frequently. Use of a commercially available oral rehydration solution (ORS) containing 45-60 mmol/L of sodium is recommended. Many other beverages traditionally suggested for children with vomiting & diarrhea, such as tea, juice, or sports drink, are deficient in Sodium & may provide excessive sugar, resulting in amplified fluid losses.
    • Give 50-100 mL of ORS/kg of body weight, plus additional ORS to compensate for ongoing losses. Aim for about 1 oz (30 ml) or ORS per kg of body weight per hr.
    • Administer IV or IO isotonic crystalloid to children with severe dehydration, hemodynamic compromise, or when altered mental status precludes safe oral administration of fluid.
      • Give IV NS as 20 cc/kg bolus over 20 min. until perfusion improves and urine output is adequate.
    • Treat hypoglycemia with 10% dextrose (5 mL/kg) in infants or 25% dextrose (2 mL/kg) in toddlers and older children.
  2. Consider Zofran (0.15 mg/kg/dose) as an adjunct to oral rehydration therapy in children with persistent vomiting. PO is preferred as the main objective is to support the success of oral hydration.
    • Dopamine receptor agonists such as promethazine are NOT recommended in children & are contraindicated in young children.
  3. Most children can be discharged if they are:
    • Tolerating PO  hydration
    • Have adequate urine output, &
    • Ongoing fluid losses have been minimized.
    • Continuation of a normal diet (including lactose-containing milk or formula) is recommended.
  4. Pts who cannot tolerate PO fluids, having significant ongoing losses, severe electrolyte abnormalities, or surgical abdominal processes require admission to hospital.