See also

Dehydration
Gastroenteritis

Key points

1. Bilious (dark green) vomiting is due to a gastrointestinal obstruction until proven otherwise, and requires urgent surgical referral
2. In a vomiting child without diarrhoea, consider causes other than gastroenteritis
3. Intracranial causes eg non-accidental injury (NAI), should always be considered
4. Ondansetron can be used for symptomatic relief, however cessation of vomiting does not exclude a serious cause

Background

• Vomiting is a common and non-specific symptom, not a diagnosis
• Infection is the most common cause of acute vomiting
• Bilious vomiting occurs when there is a gastrointestinal obstruction. Bile is dark green rather than yellow. Using a visual aid to clarify vomitus colour with families is helpful
• Early morning vomiting and headache may be due to raised intracranial pressure

Differential Diagnoses by Age

Assessment

History

Symptoms and signs associated with possible diagnoses (table below is not an exhaustive list and presentations can overlap)

Examination

• Abdominal examination:
  • abdominal distension could suggest acute abdomen or bowel obstruction (ask parent if abdomen changed in appearance)
  • tenderness
  • “tinkling” high-pitched or absent of bowel sounds may suggest gastrointestinal obstruction
  • examination of testes for torsion, particularly in adolescent boys
• Neurological examination:
  • altered conscious state and/or abnormal neurological examination may suggest intracranial pathology
  • bulging fontanelle may be a sign of raised intracranial pressure

Look for effects of vomiting

• Hydration, see Dehydration

Management

Investigations

• BSL, ketones (if BSL <4 mmol/L or >11 mmol/L): most well children with isolated vomiting do not require any other investigations. If you are unsure consult with a senior clinician
• Targeted investigation is directed by likely differential diagnoses
• Ketotic hypoglycaemia can be a consequence of vomiting, more commonly in younger children

Treatment

• Treat shock with a bolus of 20 mL/kg sodium chloride 0.9%
• If BGL less than 2.6 mmol/L  (<1.5 mmol/L in newborns), treat with 2 mL/kg of glucose 10%. If the child is unable to tolerate oral intake or is unwell, start IV fluids with glucose at maintenance rate as per hypoglycaemia guideline

Definitive management of a vomiting child based on cause:

• Gastroenteritis: see gastroenteritis
• Use of Ondansetron
  • To assist with maintaining hydration in children >6 months of age
  • For dosage, please refer to gastroenteritis
  • Can be given with vomiting due to head injury provided other signs such as conscious state are carefully monitored
  • Cessation of vomiting does not exclude serious causes of vomiting
• If ondansetron is ineffective, consult senior advice before prescribing other anti-emetics due to side effects
• Refer to local surgical team if there is evidence of a surgical cause of vomiting eg bowel obstruction, testicular or ovarian torsion and appendicitis

Consider consultation with local paediatric team when

• Advice regarding escalation of care
• Patient is acutely unwell and not responding to fluid resuscitation
• Severe metabolic derangement
• Diagnostic uncertainty

Consider transfer when

Child requiring care beyond comfort level of the local hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

• Alert and able to tolerate small amounts of oral intake
• Normal vital signs
• The cause of vomiting has been identified and adequately managed OR
• High risk diagnoses have been considered AND there is an adequate follow up plan in place with clear instructions on when to seek earlier review

Parent information

• Diarrhoea and vomiting in children
• Vomiting
• Reflux and GORD
• Nausea

Last updated Nov 2020