Vomiting in children: what can be there in your child?

 Q1. What is vomiting?

Vomiting is a way by which our digestive tract gets rid of its content when any part of it is excessively irritated or over-distended, however there are a plenty of situations where a non-digestive etiology can also manifest through vomiting along with some other symptoms.

It can be of short duration (Acute) or recurrent episodes over a long period of time (more than 1 week, known as chronic vomiting).

Vomiting itself is not a disease per se, rather it indicates an underlying disorder which can vary from a trivial cause like acute gastroenteritis to serious life-threatening disease like intra-cranial tumor. Besides this, vomiting itself may lead to complication such as dehydration and electrolyte abnormality which can impart to the morbidity and mortality associated with it. So, any child with this complaint should be evaluated by a physician specialist in child care (known as Pediatrician) to detect the etiology early and prevent the complications.

 

Q2. How to reach to the diagnosis?

All possible causes of vomiting in childhood (along with a brief summary) are enumerated in the table below. It has to be remembered that few causes of vomiting are usually exclusive for adult or old age (eg. vomiting due to inferior wall myocardial infarction is not seen in children). Your doctor can identify the exact cause of vomiting by two ways – history-examination of the child and investigations. However, the diagnostic investigations are barely needed in majority of cases. 

Table 1: enumerating the possible causes of vomiting in children [abbreviations used: A/w: associated with, Inv: investigations, Tx: treatment]

Causes of  VOMITING  in CHILDREN
	Gastrointestinal (GI) causes
Gastro-esophageal reflux (GER)	ü  Mostly physiologic event in infant, mostly resolves by one year of age. ü  Prone to develop : child with neurological abnormality like cerebral palsy, chronic respiratory disorders, hiatus hernia, obesity and those who underwent esophageal surgery in infancy. ü  A/w: excess crying, irritability, refusal to feed, sometimes apnea (temporary cessation of breathing) and Sandifer syndrome in infants (arching of the back and ophisthotonic posturing); older children may have heartburn, water brash, epigastric pain, dysphagia (difficulty in food ingestion), globus sensation ü  Inv: Barium study, GER scan, 24-hour esophageal pH monitoring, Endoscopy may be helpful in diagnosis ü  Tx: PPI (proton pump inhibitor eg. Lansoprazole), H2-blocker (eg. Ranitidine), Prokinetics eg. Domperidone, Fundoplication surgery in refractory cases or in complicated cases.
Zenker’s Diverticulum (Pharyngeal pouch)	ü  It’s a rare condition and uncommon in children. ü   A/w: Halitosis (foul breath) and regurgitation of food taken several days back; if large size, it can compress on esophagus causing dysphagia ü  Inv: Barium swallow ü  Tx: Surgical resection
Achalasia cardia	ü  A/w: Dysphagia (difficulty  in food ingestion): initially with solid food and later with liquids also. Child becomes a slow eater with frequent water drinking to push the food into stomach. Child may regurgitate food effortlessly at night; also recurrent aspiration may lead to chronic cough and halitosis (foul breath). ü  Look for syndromes: like Allgrove syndrome, Treacher-collins syndrome, Rozychi syndrome ü  Inv: Barium swallow, Endoscopy ü  Tx: Drugs like CCB (Calcium channel blocker eg. Nifedipine), Isosorbide dinitrate, Sildenafil; Endoscopic pneumatic dilatation; Surgical like Heller’s myotomy; recently POEEM (per-oral endoscopic esophageal myotomy).
Gastritis	ü  It implies the inflammation of the stomach lining. It is relatively common condition in older children and adolescents. ü  A/w: eating spicy food, prolonged analgesic drug intake (NSAID gastritis), Radiation therapy, corrosive ingestions, stressful situations like major surgery or traumatic injury or burns, alcohol intake or smoking [corrosive gastritis]; Helicobactor pylori infection, allergy or eosinophilia, Crohn’s disease [Non-erosive gastritis] ü  Child may have heartburn, water brash, epigastric pain. ü  Inv: Endoscopy and biopsy of stomach tissue. ü  Tx: PPI (proton pump inhibitor eg. Lansoprazole), H2-blocker (eg. Ranitidine); treatment of underlying etiology.
Peptic ulcer disease	ü  It is usually the complication of prolonged untreated gastritis, commonly seen in adolescent age group. ü  Child may have symptoms similar to gastritis along with weight gain (duodenal ulcer) or weight loss (gastric ulcer). It can lead to perforation of the wall and thereby peritonitis. ü  Management (investigations and treatment) is moreover similar to Gastritis.
Gastric outlet obstruction (GOO)
Hypertrophic pyloric stenosis (HPS)	ü  Occurs due to thickening of the pyloric portion of stomach; manifested in newborn baby at around 3-6 weeks of age; mostly occur  in male baby, bottle-fed infant and in infants who received Erythromycin in neonatal period. ü  A/w: non-bilious projectile vomiting after feeding; child remain very hungry after vomiting and feeds again, thus initiating a vicious cycle. A visible gastric peristalsis (VGP) may be noted over child’s abdomen. Child may lose weight, develop severe dehydration and electrolyte imbalance which needs urgent care in hospital.  Child may also have other developmental anomalies (in 5% cases) like hiatus hernia, duodenal atresia etc. ü  Inv: USG ultrasound abdomen, Barium study, endoscopy ü  Tx: Pre-surgical correction of dehydration and electrolyte imbalance followed by Pyloromyotomy surgery (Ramstedt procedure).
Pyloric stricture post corrosive ingestion	ü  History of corrosive ingestion (usually few weeks back) ü  Inv: Endoscopy, Barium study ü  Tx: Endoscopic balloon dilatation, Intra-lesional steroid, Antral Bypass surgery
Duodenal atresia	ü  Congenital absence of closure of lumen of duodenum; Manifests in newborn period- bilious vomiting; May have history of polyhydramnios (excess amniotic fluid) in pregnancy period ü  Inv: Plain X-ray abdomen (double bubble sign), USG abdomen,  endoscopy ü  Tx: Surgical repair (Duodeno-deodenostomy or duodeno-jejunostomy)
Annular pancreas	ü  Rare condition where the second part of duodenum is encircled by a ring of pancreatic tissue. ü  Presentation is similar to duodenal atresia. ü  Inv: Plain X-ray abdomen (double bubble sign), USG abdomen,  CT or MR scan of abdomen, endoscopy ü  Tx: Surgical repair ( duodeno-jejunostomy)
Acute gastroenteritis (AGE)	ü  One of the very common causes of vomiting during infancy and childhood. ü  A/w: loose stool, crampy abdominal pain, non-bilious vomiting ü  Inv: mostly clinical diagnosis, rarely investigations needed to assess the severity. ü  Tx: Supportive management as it is self-limiting in most of the time, ORS, antiementic, antibiotics if needed.
Acute appendicitis	ü  It is the most common abdominal surgical emergency in children. Can occur at any age, mostly in adolescent age group. ü  A/w: periumbilical pain followed by right lower abdominal pain, non-bilious vomiting, fever [Murphy’s triad]; sometimes mimic UTI (dysuria due to surrounding urinary bladder irritation- here urine may show pus cells, but culture will be sterile) ü  Few classical signs like McBurney’s sign, rovsing’s sign, Psoas sign may be positive. ü  Inv: CBC, USG abdomen, Urine analysis and culture, CT scan in selected cases. ü  Rule out: Meckel’s diverticulitis, Mesenteric adenitis, Acute diarrhoeal disorder, Intussusception, Henoch-Schonlein purpura and Mittleschmerz pain in menstruating woman. ü  Tx: Immediate appendicectomy or Conservative management followed by interval appendicectomy.
Meckel’s diverticulum	ü  It is the proximal remnant of omphalo-mesenteric duct; It may be associated with some congenital anomalies like Down syndrome, Esophageal or duodenal atresia, Hirschprung disease, Omphalocele, Malrotation etc. ü  ‘Rule of 2’ (2% people, 2 times common in male, 2 feet away from Ic valve, 2 inches long, 2 cm diameter, symptomatic before 2 year age, contains 2 typesof mucosa-gastric and pancreatic) ü  It can present as diverticulitis, intestinal obstruction, Litre’s hernia, hematochezia (fresh blood in stool); However, presentation of Meckel’s diverticulitis is very similar to that of acute appendicitis. ü  Inv: Meckel’s scan, Fistulogram if enteric fistula is suspected. ü  Tx: controversy is there. On incidental finding during operation, it is removed if thin base, thick mass, or alternative lesion for appendicitis.
Acute hepatitis	ü  Inflammation of liver tissue, may be due to viral infection, autoimmune process, drug induced or metabolic diseases. ü  The symptoms may vary according to nature of the underlying cause. However, few are common like anorexia (loss of appetite), nausea, vomiting, fever, jaundice (yellowish discoloration of sclera and body fluids) ü  Inv: LFT, PT-INR, Blood NH3, RBS, sometimes Liver biopsy ü  Tx: mostly supportive and treatment of underlying cause, if available.
Hepatic encephalopathy	ü  It is a neuropsychiatric state due to exposure to toxic chemicals (eg ammonia, false neurotransmitter) to brain as a result of acute or chronic liver disease. ü  There are few known precipitating factors (like infection-SBP or UTI, GI bleed, severe constipation, large protein meal, hepatotoxic drugs, electrolyte abnormalities and surgical procedures eg. TIPS) ü  A/w: excess sleepiness, drowsy, lethargy, irritability, reduced spontaneous movement, behavioral changes etc (clinically 4 grades are there) ü  Inv: Constructional apraxia, handwriting test, blood NH3, LFT ü  Tx: dietary restriction of protein, Rifaximin, Lactulose etc
Acute cholecystitis	ü  Relatively uncommon entity from its adult counterpart. ü  Mostly acalculous type (no stone); usually common in critically sick child or on parenteral nutrition ü  A/w: right upper abdominal pain, respiratory discomfort, nausea, vomiting ü  Inv: USG abdomen, CT scan abdomen ü  Tx: conservative or supportive care, Surgical resection
Acute pancreatitis	ü  A less commonly encountered entity in children, may occur due to infection, abdominal trauma, drug effect or as a part of systemic illness. ü  A/w: abdominal pain, anorexia, nausea, vomiting, respiratory discomfort. ü  Inv: USG and CT scan of abdomen. ü  Tx: conservative management, surgical dissection if needed.
Intestinal obstruction (IO)
Volvulus	ü  It is a twist of intestine around an axis, mostly due to malrotation or post-surgical. ü  A/w: nausea, bilious vomiting, abdominal pain and distention, constipation or bloody stool. ü  Inv: plain x-ray abdomen, USG or CT abdomen. ü  Tx: surgery in the mainstay of treatment.
Intussusception	ü  One of the most common causes of intestinal obstruction during infancy and childhood. Most cases (around 80%) are seen below 3 years age. ü  Usually a previously healthy baby, recently been weaned, suddenly develops abdominal pain, followed by vomiting and bloody stool (red currant jelly); The pain subsides for a short time and again recurs and it becomes continuous if obstruction not relieved. ü  Inv: USG abdomen (target sign), CT scan abdomen, Contrast enema; [rule out: dysentry, Rectal prolapsed and Henoch-Schonlein purpura] ü  Tx: dehydration correction, Hydrostatic or pneumatic reduction; Urgent surgery if two failed attempts, perforation or hemodynamic instability.
Wilkie syndrome Or SMA syndrome	ü  It is a rare but potentially life-threatening disease characterized by compression of a part of duodenum between two vessels namely abdominal aorta and superior mesenteric artery (SMA). ü  A/w: loss of abdominal fatty tissue as in malnutrition, rapid weight loss, thin built person. Complaints of abdominal pain, nausea, vomiting. ü  Inv: CT abdomen or angiography study. ü  Tx: medical management trial with treating the underlying etiology, if fails, then surgical management.
Post-operative adhesion	ü  Can occur few weeks to years after any intra-abdominal surgery. ü  A/w: nausea, vomiting, abdominal pain, distension ü  Inv: Plain x-ray or USG or CT scan of abdomen. ü  Tx: surgical exploration and adhesiolysis
	Non-Gastro-intestinal causes
Neurological
Meningitis	ü  Infection or inflammation of brain covering layer. ü  A/w: nausea, vomiting, headache, sensitivity to light etc. ü  Inv: Cerebrospinal fluid (CSF) study, neuro-imaging like Ct scan or MRI ü  Tx: supportive therapy with treatment of underlying etiology.
Encephalitis	ü  Infection or inflammation of brain parenchymal tissue. ü  A/w: nausea, vomiting, headache, confusion, seizure, behavioral changes etc. ü  Inv: Cerebrospinal fluid (CSF) study, neuro-imaging like Ct scan or MRI. ü  Tx: supportive therapy with treatment of underlying etiology.
Brain abscess	ü  Relatively uncommon now a days, usually having some underlying disorder like cardiac anomaly or immunodeficiency. ü  A/w: nausea, vomiting, headache, confusion, seizure, behavioral changes etc. ü  Inv: Cerebrospinal fluid (CSF) study, neuro-imaging like Ct scan or MRI. ü  Tx: supportive therapy with treatment of underlying etiology.
Intracranial space occupying lesion (ICSOL) eg tumor	ü  Mostly presents like a brain abscess, but may be less dramatic presentation. It can be a parasitic infection, vascular malformation, hematoma or tumor. ü  A/w: nausea, vomiting, headache, confusion, seizure, behavioral changes etc. ü  Inv: Cerebrospinal fluid (CSF) study, neuro-imaging like CT scan or MRI. ü  Tx: supportive therapy with treatment of underlying etiology.
Head injury	ü  There will be obvious history of head injury within few hours or days. ü  A/w: nausea, vomiting, headache, confusion, seizure, behavioral changes etc. ü  Inv: neuro-imaging like CT scan or MRI. ü  Tx: supportive therapy with evacuation of hematoma or bleed.
Migraine	ü  It is a common but often under-diagnosed condition of childhood. ü  A/w: headache, nausea, vomiting, sensitivity to light or sound; there may be some precipitating factors like emotional stress, environmental changes, strong light etc. ü  Diagnosis is clinical most of the time. ü  Tx: aborting acute attack (eg Sumatriptan or Rizatriptan), prophylactic therapy (eg Propranolol, Valproate etc), avoiding the triggers.
Cyclic vomiting syndrome (CVS)	ü  Abrupt onset of vomiting episodes, usually in morning with dramatic recovery, occurring cyclically every month. Many patients may have some triggers (like psychogenic stress, upper respiratory infection, weather changes, menstruation etc) and few may have migraines headache. ü  Inv: Mostly all investigations are normal ü  Tx: dehydration management, avoid the triggering factor, counseling of the patient and attendant, prophylactic drugs like Propranolol, Cyproheptadine etc
Rumination syndrome	ü  It resembles vomiting, however it lacks the somato-visceral response from vomiting centre. Rather it is repetitive effortless regurgitation of recently ingested food followed by re-chewing and re-swallowing or expulsion. ü  Tx: Diaphragmatic breathing exercise (5min for one chapatti) and Chewing gum may be helpful in preventing the episodes [habit reversal techniques].
Anorexia nervosa (AN)	ü  This is a psychological condition of excessive fear of gaining weight and thereby restriction of food intake, along with force vomiting sometimes leading to a thin built body. Most of the cases are seen in girls of adolescent age. ü  Diagnosis is mostly clinical. ü  Tx: supportive nutritional therapy, counseling or cognitive behavioral therapy ,management of underlying depression if present (Psychiatrist referral).
Bullimia nervosa (BN)	ü  Similar to AN, psychological condition characterized by excessive concern about body shape and weight, having a binge eating followed by purging (self-vomiting) ü  Diagnosis is clinical. ü  Tx: similar to AN
Vestibular	ü  There are a spectrum of disorders [like Vestibular neuritis, Labyrinthitis, Menetrier’s disease, Benign paroxysmal positional vertigo (BPPV), Motion sickness] ü  A/w: nausea, vomiting, dizziness, body balance issue, tinnitus (a ringing, buzzing sound in ear), sometimes transient hearing loss. ü  Inv: predominantly clinical diagnosis, sometimes neuro-imaging needed to exclude few diseases. ü  Tx: treatment of the underlying exact cause along with supportive therapy.
Psychogenic	ü  This is diagnosed when there is no obvious underlying organic etiology is found. ü  A/w: underlying psychological condition like depression, conversion disorder etc ü  Pattern of vomiting can be continuous, habitual post-prandial, irregular or self-induced. ü  Tx: counseling and psychotherapy, treatment of underlying psychological condition, may be challenging in some cases.
Chronic kidney disease (CKD)	ü  Vomiting may be the first symptom in a child with underlying CKD. It occurs as a result of built-up of waste product (eg Urea in blood) as a result of poorly functioning kidneys. ü  A/w: growth failure, anemia, bone disease like rickets ü  Inv: RFT, ABG, USG KUB, renal dynamic scan ü  Tx: supportive therapy of CKD, Dialysis, Kidney transplant
Renal tubular acidosis (RTA)	ü  It is suspected when a child have recurrent vomiting with polyuria (excess urine), growth failure and metabolic acidosis (on arterial blood gas analysis) ü  A vast number of conditions which can present with this (proximal or distal RTA) ü  Inv: RTA work up as per standard protocol ü  Tx: supportive and treatment of underlying etiology.
Congenital adrenal hyperplasia (CAH)	ü  It results from deficiency of one of the enzymes required for synthesis of cortisol hormone. ü  A/w: mostly manifested during neonatal period, with recurrent vomiting, diarrhea, low blood sugar, ambiguous genitalia ü  Inv: serum electrolytes, RBS, enzyme assay, genetic testing ü  Tx: Supplement therapy with glucocorticoids and mineralocorticoid.
Urinary tract infection (UTI)	ü  Relatively common condition in children, especially in girl child. ü  A/w: fever, nausea, vomiting, burning micturition or crying during micturition, lower abdominal pain. ü  Inv: Urine analysis and culture, CBC ü  Tx: appropriate antibiotics, supportive measures
Diabetic ketoacidosis (DKA)	ü  It is a life threatening complication of uncontrolled diabetes mellitus. It may occur in a known diabetic or may be the presenting symptom. ü  A/w: nausea, vomiting, abdominal pain, polyuria ü  Inv: RBS, ABG, Urine ketone ü  Tx: urgent correction of dehydration, Insulin, supportive measures.
Abdominal migraine	ü  Primarily diagnosed in older children ü  A/w: recurrent abdominal pain, nausea, vomiting, pallor. Few children may have headache during the episode. ü  Inv: mostly normal, diagnosed by exclusion of other possible causes. ü  Tx: aborting acute attack (eg Sumatriptan or Rizatriptan), prophylactic therapy (eg Propranolol, Topiramate etc), avoiding the triggers, behavioral therapy.
Drug/Toxin induced vomiting	ü  One of the commonest causes of vomiting in any age group. ü  History of recent drug use, there are innumerable drugs in this category (few examples are: anti-tubercular drug, anti-convulsants, Chemotherapy medications, antibiotics, analgesics etc) ü  Various poisons or toxins (eg Aflatoxin) also can  cause acute or chronic vomiting ü  A/w: jaundice, abdominal pain, diarrhea or dizziness sometimes. ü  Inv: drug level estimation, Liver function test ü  Tx: Stop the offending drug or toxin exposure, supportive management, dialysis if needed, Antidote if available (eg N-acetyl cystein in Paracetamol poisoning)
post-operative nausea vomiting (PONV)	ü  It is one of the most common condition after a major surgery. ü  A/w: pain at operation site, nausea, vomiting; there are many factors which can influence this including type of operation. ü  Tx: supportive therapy, combination anti-emetic
Preganancy	ü  Surprisingly, there are many instances when an adolescent girl found to be pregnant on evaluation of sole complaint of vomiting. ü  A/w: missing period, morning nausea and vomiting, history of coitus. ü  Inv: urine beta-hCG test (Preg-color test), ultrasound scan ü  Tx: Family counseling and decide accordingly.

Q3. What to look for in a child with vomiting?

(Relevant history and physical examination)

§    Your doctor may review with the following questions to ascertain the most probable cause of vomiting, its severity and the necessary management:

§  Onset of vomiting, frequency of episodes and total duration of vomiting.

§  Associated with nausea or retching?

§  Is it bilious? (contains bile, greenish vomiting> usually indicates intestinal obstruction after duodenum)

§  Is there abdominal distension? (indicates intestinal obstruction or ascites)

§  Blood in vomiting (indicates more severe causes, might need urgent intervention)

§  Stool characteristics (loose stool may indicate AGE, where non passage of stool with abdominal distension may indicate intestinal obstruction)

§  History of recent drug intakes

§  Presence of jaundice (hepatic causes)

§  Any headache, seizure, diplopia (double vision), ataxia (balance abnormality)

§  Vertigo, tinnitus, deafness

§  History of fever

§  Dysuria (pain or crying while passing urine), frequent passage of urine

§  Abdominal pain or tenderness

§  Hydration status (assessed by – sensorium of the child, shrunken eyes, thirst and skin pinch recoil; also anterior fontanelle in newborn baby or young infant)

§  Vitals (Pulse characteristics, Blood pressure), urine output

§  Ambiguous genitalia

Q4. How to investigate in a case of vomiting child?

Your doctor may advise for few of the following tests which can help out detecting the etiology and severity of the vomiting. (remember that these tests are complimentary only and most of the times, the possible causes can be narrowed down from a good history taking and your doctor may ask for few of the tests as per requirement)

§  Complete blood count (CBC)

§  Liver function tests (LFT)

§  Renal function tests (RFT)

§  Arterial blood gas (ABG)

§  GELAAK (Glucose, electrolytes, lactate, ammonia, acidosis, ketone)

§  Eye-Fundus examination (for papilloedema)

§  CT or MRI head

§  X-ray abdomen

§  USG abdomen

§  Barium study

§  GER (gastro-esophageal reflux) scan

§  Endoscopy

§  Esophageal manometry, pH monitoring

§  Pregnancy test

Q5: What are the Danger signs of a child with vomiting?

As a primary child care provider, one should know the danger signs of vomiting when the child should definitely be taken to a physician when any of these is present.

§  Sensorial changes (lethargy, confusion, drowsiness, headache)

§  Decreased urine output

§  Cold peripheral temperature or fever

§  Severe abdominal pain

§  Multiple episodes of loose stool or blood in stool

§  Blood-vomiting

Q6: What is the treatment for vomiting?

As vomiting indicates some underlying illness, the management is directed

§  to abort the vomiting episodes using enti-emetic drugs (drugs used to treat nausea vomiting) along with

§  diagnosis and treatment of the causative illness.

Few anti-emetic drugs in use are:

§  5-HT3 receptor antagonist: Ondansetron (Ondem, Zofer), Granisetron, Dolasetron, Palosetron

§  Prokinetic agent: Metoclopramide (Reglan), Domperidone (Domstal)

§  NK-1 receptor antagonist: Aprepitant

§  Cannabinoids: Nabilone

§  

In summary, there is a vast list of causes of vomiting in children and it is an art to diagnose the underlying problem in the hand of a trained pediatrician. The parents should follow the symptoms closely and any abnormality once noted (including the danger signs), should be taken as an alarming sign to take the help of a Pediatrician rather making any delay which might affect the outcome adversely. 

[Author contact: Dr Sabyasachi Mistri, MD Pediatrics (AIIMS) sabyasachimistri@gmail.com ]