There are a few kinds of vomiting children and parents may describe:

  • 'Posseting' refers to the non-forceful return of milk; almost all babies will do this from time to time.
  • 'Regurgitation' is similar to posseting, but it implies more frequent and larger amounts being returned, and may suggest that there is some degree of gastro-oesophageal reflux.
  • 'Projectile vomiting' is extremely forceful and is usually synonymous with a diagnosis of pyloric stenosis (at least when it comes to OSCEs and exam questions).

 

It is also important to remember that it is not just the gastro-intestinal tract that can cause vomiting. The central nervous system, electrolyte imbalances, drugs, poisons and infection in other systems can all result in vomiting.

 

Causes

History

There are two main aims when taking a vomiting history: (1) determine the cause of the vomiting; (2) assess the level of dehydration of the child. As with any peadiatric history, it is also important to assess the child's growth and development (which will give a good indication as to the presence of serious pathology), and any potential for child abuse (poisoning and head injury could both cause vomiting as a result of abuse).

 

Asking about dehydration:

  • How often and how much fluid is the child vomiting?
  • How much are they drinking (be as specific as possible)?
  • Is the child passing urine? If so, how much and is this less than normal?
  • Is the child crying tears or sweating? Is their mouth dry?
  • Is the child drowsy or irritable?

 

Systems review:

  • Diarrhoea or constipation
  • Headache or photophobia
  • Rash
  • Wieght loss or poor growth

 

Some important patterns:

  • 2-8 week old child projectile vomiting 20-30 mins after every meal - rule out pyloric stenosis.
  • Bile-stained vomit, abdominal distension or absolute constipation - rule out intestinal obstruction.
  • Blood-stained vomit - consider peptic ulceration, Mallory-Weiss tears.
  • Vomiting at the end of paroxysmal coughing - consider whooping cough.
  • Drowsy, pale or shocked child - consider dehydration, sepsis, meningitis.
  • Vomiting with weight loss or failure to thrive - consider coeliac disease, cow's milk intolerance, inborn errors of metabolism, renal failure.
  • Vomiting following foreign travel - consider bacterial gastroenteritis.

 

    Examination of the Abdomen

    The following is an example of some appropriate signs to look for to determine the potential cause. The degree of dehydration also needs to be determined as detailed below.

    Observations

    • Plot the child's height/length and weight on an appropriate growth chart
    • Temperature
    • Pulse
    • Respiratory rate 
    • Capillary refill time
    • Blood pressure in older children

     

    Inspection

    • Inspect the hands for clubbing, leukonychia and koilonychia
    • Inspect the skin for rashes
    • Observe the abdomen for distension, masses or visible peristalsis

     

    Palpation

    • Tenderness
    • Masses
    • Hepatosplenomegaly

     

    Auscultation

    • Bowel sounds, obstruction will cause high pitch, 'tinkling' bowel sounds.

     

    Closing

    • Examine the hernial orifices and testes for erythema, tenderness or swelling (VERY IMPORTANT).
    • Dipstick the urine.
    • Observe and palpate the abdomen before, during and after a test feed. Pyloric stenosis will lead to an 'olive-shaped mass' in the upper outer quadrant, with a visible peristaltic wave from left to right following a 'test feed'. The diagnosis is confirmed on ultrasound.

     

    Signs of Dehydration

    These can be found as a table in the NICE guidelines for Diarrhoea and Vomiting in Children. They are divided into 'no clinical dehydration', 'clinical dehydration' and 'clinical shock'. Here they have been rearranged to present a systematic way to approach such an examination in an OSCE:

    Behavior 

    • Thirst, irritable, lethargic (clinical dehydration)
    • Imparied consciousness (clinical shock)

     

    Peripheries 

    • Pale, cold or mottled (clinical shock)
    • Cold extremities (clinical shock)
    • Reduced skin turgor (clinical dehydration)
    • Rapid, thready pulse (clinical shock)
    • Hypotension (clinical shock)

     

    Face

    • Dry mucous membranes (clinical dehydration)
    • Sunken orbits (clinical dehydration)
    • Sunken fontanelle 
    • Central capillary refil >2secs (clinical shock)

     

    Urine output (ask or check the nappy)

    • Reduced (clinical dehydration)

     

        Management

        This is a brief summary of the investigation and treatment of some potential causes and complications of vomiting:

        Dehydration

        Dehydration should be managed based on its severity.

        • Children with features of clinical shock should be given intravenous fluid boluses of 20ml/kg 0.9% sodium chloride in line with APLS guidelines followed by IV fluid replacement.
        • Those with signs of clinical dehydration should be given oral rehydration solution (ORS), progressing to IV fluid replacement if there is evidence of deterioration or persistent vomiting of the ORS. 
        • Children with no clinical features of dehydration should be encouraged to maintain their fluid intake. 
        • Urea & electrolytes must be measured in children recieving IV fluid replacement
        • Capilliary blood gases should be checked in children with signs of shock
        • IV fluid requirements are calculated by: Deficit (5% body weight in clinical dehydration, 10% in shock) + Maintenance (first 10kg: 100ml/kg, second 10kg: 50ml/kg, subsequent kg: 20ml/kg) + continuing losses (fever, diarrhoea, vomiting, hyperventilation etc.)

         

        GORD

        GORD can be confirmed with a contrast swallow or 24 hour oesophageal pH studies in severe cases, although investigations are not usually required.

        Gastroenteritis

        In gastroenteritis, stool cultures are indicated if you suspect septicaemia, there is blood/mucus in the diarrhoea or the child is immunocompromised. Stool cultures may also be indicated if the child has been abroad, the diarrhoea has lasted >7 days, or there is uncertainty over the diagnosis.

        Antibiotics should not routinely be given. They are indicated for suspected septicaemia; extra-intestinal spread of bacterial infection; in salmonella gastroenteritis if the child is <6 months, immunocompromised or malnourished; clostridum difficile; giardiasis; shigella; dysenteric amoebiasis and cholera. Advice should be sought for children with recent travel abroad.

        Pyloric Stenosis

        Diagnosis is confirmed on ultrasound and requires and operation called a pyloromyotomy, following which the child can usually be fed the next day and discharged within 2-3 days.

        Appendicitis

        Diagnosis is more difficult in younger children. Feacoliths may be seen on abdominal X-ray. Repeated reviews to look for the progression of the condition may be required to make a diagnosis. Treatment is with appendicectomy.

        Intussusception

        Most commonly occurs at the ileoceocal valve. Abdominal X-ray may show features of intestinal obstruction. Ultrasound can also be used to confirm the diagnosis. If there are no signs of peritonitis rectal air insufflation is usually attempted with a 75% sucess rate; ultrasound is used to assess the response. Operative reduction is then attempted in the remainder. 

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