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Vomiting

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  • 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

    Differential Diagnoses by Age



    Assessment

    History

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

    Nature of vomiting

    Differential diagnoses

    Bilious

    GIT obstruction

    Blood

    Swallowed blood (eg epistaxis, or in neonate from maternal blood due to delivery or nipple trauma)
    Upper GI haemorrhage

    Projectile

    Pyloric stenosis

    Early morning vomiting

    Raised ICP

    Associated signs and symptoms

     

    Evidence of diarrhoea

    Gastroenteritis

    Fever or systemic Illness

    Infection or sepsis

    Abdominal distension and tenderness, “tinkling”/absence of bowel sounds

    GIT obstruction

    Headache

    Migraine
    Intracranial pathology ie raised ICP
    Infection

    Rectal bleeding

    Gastroenteritis
    Colitis
    Intussusception
    Meckel’s diverticulum

    Other

     

    Previous history of head injury/NAI

    Intracranial bleeding

    Previous history of previous GIT obstruction or surgery

    GIT obstruction

    Other factors such as toxin ingestion/drug use, eating disorder, pregnancy

     

    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

    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

    Vomiting

    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 guideline
      • 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

    Last updated Nov 2020

  • Reference List

    1. Australian Medicines Handbook Children’s Dosing Companion, https://childrens.amh.net.au/  viewed Sept 2020
    2. Australian Product Information – Maxolon (Metoclopramide hydrochloride), 2019, Tablets and Injection, viewed August 2020 <https://medicines.org.au/files/iapmaxol.pdf>
    3. Lorenzo CD et al 2019, Approach to the infant or child with nausea and vomiting, UpToDate, viewed Apr 2020
    4. Perth Children’s Hospital, 2018, Emergency Department Guidelines on Vomiting, viewed May 2020. <https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Vomiting>
    5. Shields TM et al, 2018, Vomiting in Children, Paediatrics in Review, vol 39, no. 7, pp. 342-258
    6. Walker GM et al, 2006, Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study, BMJ 2006;332:1363 <https://www.bmj.com/content/332/7554/1363>