Approach to the

Child with Nausea

and Vomiting
by Dr.Ryan Al.Ghanemi

Introduction

Nausea: The unpleasant sensation of the imminent need to vomit, usually referred to
the throat or epigastrium; a sensation that may or may not ultimately lead to the act
of vomiting.

Vomiting:Forceful oral expulsion of gastric contents associated with contraction of

the abdominal and chest wall musculature.

Regurgitation:The act by which food is brought back into the mouth without the
abdominal and diaphragmatic muscular activity that characterizes vomiting.

Introduction

A standardized approach is not recommended because it may be caused by many

pathologic states involving several systems (including gastrointestinal, neurologic,
renal, and psychiatric).

The best course of action should be dictated by the medical history.

Neurophysiology

Nausea and vomiting are innate responses that induce a learned and conditioned
aversion to ingested toxins

There are four major pathways by which nausea and vomiting are induced.
Vagal afferents
Area postrema
Vestibular system
Amygdala

Vagal Afferents

Abdominal vagal afferents are involved in the emetic response.

Can be evoked by either mechanical or chemo-sensory sensations.

Examples of sensations that trigger this pathway include overdistension, food

poisoning, mucosal irritation, cytotoxic drugs, and radiation.

Area Postrema

Its a chemoreceptor trigger zone.

Anatomically, this region is located at the
caudal extremity of the floor of the fourth
ventricle.

Its a permeable blood-brain barrier region

in which systemic chemicals act to induce
emesis can reach

This area contains receptors for neuroactive

compounds such as dopamine, morphine,
acetylcholine, endorphin, and many others

A diagram summarizing the pathways

involved in emesis. Rache: Nucleus
Rache, AP: area postrema, IV: 4 th
ventricle, 5-HT: 5-hydroxytryptamine
(serotonin), EC: enterochromaffin cell, GI:
gastrointestinal.

Vestibular System

It involved in the emetic response to motion

Exacerbated by visual sensations, Irritation or labyrinthine inflammation.

Somatomotor Events

The diaphragm descends and the

intercostal muscles contract while the
glottis is closed.

The abdominal muscles contract and the

gastric contents are forced into upper
gastric vault and lower esophagus.

The abdominal muscle relaxes and the

esophageal refluxate empties back into the
gastric vault.

Several cycles of retching, each more

rhythmical and forceful in nature, occur,
with shorter intervals in between.

Abdominal contraction associated with

elevation of diaphragms results in forceful
expulsion of gastric contents.

Diagnosis by Age

Diagnosis by Age

Neonates & Young

Infants

Forceful and repeated vomiting in newborns is not normal and should be taken
seriously, particularly if there are other signs of illness (eg, fever, weight loss, or
feeding refusal).

The most frequent diagnostic considerations are gastroesophageal reflux, pyloric

stenosis, and intestinal obstruction.

& it may be sepsis, excessive feeding volume, or increased intracranial pressure.

Although much less common, inborn errors of metabolism also can present with
vomiting.

Neonates & Young

Infants

Gastroesophgeal Reflux
Disease

Physiologic reflux in newborns and infants is common, and is characterized by

effortless regurgitation in an othewise healthy infant (a "happy spitter").

A minority of infants who regurgitate have pathological gastroesophageal reflux.

No features definitively identify these infants, but they may have recurrent fussiness
or irritability and feeding aversion.

These symptoms are thought to result from pain caused by esophageal acid exposure.

Gastroesophgeal Reflux
Disease

Bradycardia or cyanotic episodes also may occur, particularly in preterm or

neurologically impaired infants.

Poor weight gain despite an adequate intake of calories should prompt evaluation for
causes of vomiting and weight loss other than GERD.

Milk protein Induced

Enteritis

Intolerance of dietary proteins (most commonly milk protein) typically manifest as

colitis, presenting with bloody stools.

However, in some infants the dietary protein causes an enteritis, with or without
associated colitis, and affected infants may present with vomiting.

Intestinal Obstruction

Causes of intestinal obstruction that present during early infancy include:

Malrotation with or without volvulus
Hirschsprung disease.
Intussusception
Intestinal atresia
Pyloric stenosis

Intestinal Obstruction

Intestinal obstruction frequently causes bile staining in the vomitus.

Bile-stained vomitus should be treated as a life-threatening emergency, although it

can be seen occasionally in infants without bowel obstruction.

Vomiting that is not bile-stained may be caused by proximal obstruction, such as

pyloric stenosis, upper duodenal stenosis, gastric volvulus, or annular pancreas.

Intestinal Obstruction

If intestinal obstruction is suspected, the specific diagnosis often can be suggested by

the patient's history and with appropriate radiologic imaging.

Plain radiographs of the abdomen generally provide a rapid assessment of possible

bowel obstruction with relatively little radiation exposure.

Abdominal ultrasound provides high sensitivity and specificity for detecting

intussusception.

Pyloric Stenosis

Infantile hypertrophic pyloric stenosis (IHPS) is a condition of hypertrophy of the

pylorus, with elongation and thickening, eventually progressing to near-complete
obstruction, of the gastric outlet.

It occurs in approximately 3 in 1,000 live births.

More commonly in males (4:1 to 6:1).

Approximately 30 percent of cases occur in firstborn children.

Pyloric Stenosis

The classic presentation of IHPS is the

three- to six-week-old baby who develops
immediate postprandial, non-bilious,
often projectile vomiting and demands to
be re-fed soon afterwards
(a "hungry vomiter").

In the past, patients were classically

described as being emaciated and
dehydrated with a palpable "olive-like"
mass at the lateral edge of the rectus
abdominus muscle in the right upper
quadrant of the abdomen.

Pyloric Stenosis

Laboratory evaluation classically showed

a hypochloremic, metabolic alkalosis
resulting from the loss of large amounts
of gastric hydrochloric acid, the severity
of which depended upon the duration of
symptoms prior to initial evaluation.

The diagnosis is made by ultrasound

examination of the abdomen.

Hirschsprung Disease

Usualy diagnosed in the neonatal

period.

Patients present with symptoms of

distal intestinal obstruction: bilious
emesis, abdominal distension, and
failure to pass stool.

Hirschsprung Disease

The diagnosis can be suggested by a

delay in passage of the first
meconium (greater than 48 hours of
age).

Affected children may also present

initially with enterocolitis, a
potentially life threatening illness in
which patients have a sepsis-like
picture with fever, vomiting,
diarrhea, and abdominal distension,
which can progress to toxic
megacolon.

Older Infants & Children

By far, the most common is gastroenteritis.

However, GERD, gastroparesis, mechanical obstruction, anaphylaxis, Munchausen

syndrome by proxy (factitious disorder by proxy), intracranial masses, peptic ulcer
disease, and cyclic vomiting also may be diagnostic considerations.

Adrenal crisis and anaphylaxis should be considered in children with

disproportionate hypotension and/or predisposing factors.

Older Infants & Children

Gasteroparesis

It is the condition of impaired emptying of gastric contents into the duodenum in the
absence of a mechanical obstruction; this may cause postprandial vomiting.

In gastroparesis the vomiting usually occurs many hours after ingestion of food, a
characteristic that differentiates this entity from GER or rumination syndrome, in
which the emesis is during or immediately after eating.

Gasteroparesis

The following conditions may cause gastroparesis:

Surgery with vagus nerve damage (eg, fundoplication)
Use of drugs such as opioids or anticholinergics
Metabolic disturbances such as hypokalemia, acidosis, or hypothyroidism
Eosinophilic gastroenteropathy
Neuromuscular disorders such as cerebral palsy, diabetes mellitus, pseudoobstruction and muscular dystrophy
Viral illness (postviral gastroparesis)

In most cases, the symptoms resolve spontaneously within 6 to 24 months.

Intussusception

It is the most common cause of intestinal obstruction in infants between 6 and 36

months of age.

typically patients develop the sudden onset of intermittent, severe, crampy,

progressive abdominal pain, accompanied by inconsolable crying and drawing up of
the legs toward the abdomen.

The episodes become more frequent and more severe over time.

Intussusception

Vomiting may follow episodes of

abdominal pain. Initially emesis is
non-bilious, but it may become
bilious as the obstruction progresses.

A sausage-shaped abdominal mass

may be felt in the right side of
abdomen. As symptoms progress,
increasing lethargy develops, which
can be mistaken for
meningoencephalitis.

Intussusception

In up to 70 percent of cases, the stool contains

gross or occult blood.

In infants, intussusception may present as

lethargy, with or without vomiting or rectal
bleeding.

In young infants, intussusception is more

often caused by a pathological lead point,
such as Meckel diverticulum or a duplication
cyst.

Infections

Pharyngitis (particularly streptococcal pharyngitis).

Urinary tract infections frequently present with nausea and/or vomiting.

Intracranial
Hypertension

Brain tumors and other intracranial masses can cause nausea, vomiting, or both, by
increasing the intracranial pressure at the area postrema of the medulla.

Several characteristics suggest tumor-associated emesis, such as triggering emesis by

an abrupt change in body position, neurogenic nausea and other neurologic
symptoms such as headache or focal neurologic deficit; these signs and symptoms
may be subtle.

Intracranial
Hypertension

Idiopathic intracranial hypertension refers to increased intracranial pressure (ICP)

with normal cerebrospinal fluid (CSF) content, normal neuroimaging, the absence of
neurologic signs except cranial nerve VI palsy, and no known cause.

The clinical manifestations of idiopathic intracranial hypertension vary with age.

Younger children, for example, who cannot complain of headache or visual

impairment, may present with irritability, sleep, or behavior disturbance.

In older children, headache is a more common chief complaint in older children and
frequently is described as being pulsatile, occasionally awakening the child from
sleep. Associated nausea or vomiting may be present, as may neck or retroocular
pain that is worse with eye movement.

Munchausen Syndrome
by Proxy

Also known as factitious disorder by proxy, Meadow syndrome, and proxy factitia

Its consists of fabricating or inducing illness in a child in order to get attention.

The patient may have a history of frequent recurrent illnesses without a clear etiology

Adolescents

In addition to the disorders affecting children

listed above, some of the more common causes
include gastroenteritis, appendicitis,
inflammatory bowel disease, pregnancy, and
toxic ingestions.

Clinical Approach

Clinical Approach

Clinical Approach

Clinical Approach

Clinical Approach

A detailed history and astute clinical acumen are necessary to narrow down the
diagnostic possibilities.

The appropriate urgency depends on duration of illness, overall clinical status of the
patient (especially hydration, circulatory, and neurologic status) and associated
findings on the physical examination and history.

Clinical Approach

Prolonged vomiting (>12 hours in a neonate, >24 hours in children younger than
two years of age, or >48 hours in older children) should not be ignored. Screening
laboratory tests should include: Additional testing should be based upon the
history and physical examination
complete blood count
electrolytes,
blood urea nitrogen,
amylase, lipase,
liver function tests,
urinalysis, urine culture, and stool studies for occult blood, leukocytes, and
parasites.

Clinical Approach
Clues on physical examinationCertain physical findings may offer diagnostic clues
that can aid in narrowing the differential diagnosis:
A tense, bulging fontanelle in a neonate or young infant should increase the
level of suspicion for meningitis.

Projectile vomiting in an infant three to six weeks of age suggests pyloric

stenosis as a diagnosis.
Ambiguous genitalia and/or hyperkalemia suggest the possibility of
adrenal crisis (usually due to congenital adrenal hyperplasia),.
Headache, positional triggers for vomiting, lack of nausea, and/or
vomiting on awakening should suggest the possibility of intracranial hypertension

Clinical Approach
An unusual odor emanating from the patient should prompt an
investigation for metabolic causes of vomiting.
Marked distension, visible bowel loops, absent bowel sounds, green or
yellow bile, or increased "rumbling" bowel sounds ("borborygmi") should raise
suspicion for intestinal obstruction.
Enlarged parotid glands in an adolescent should raise suspicion for bulimia

Vomiting in association with trauma should prompt imaging studies to rule

out intracranial or intraabdominal injury.

Hypotension disproportionate to the apparent illness and/or hyperkalemia

suggests the possibility of adrenal crisis

Laboratory
Investigations

Referrals
When to refer the patient?

Patients should be referred to a pediatric gastroenterologist or other appropriate

specialist (eg, pediatric surgeon, neurologist) when there are symptoms or physical
findings that are of particular concern.

These include an abnormal neurologic exam, peritoneal signs on abdominal

examination, severe abdominal pain, gastrointestinal bleeding, or significant weight
loss.

Immediate pediatric surgical consultation is warranted if appendicitis, bowel

obstruction, or bowel perforation are suspected.

Treatment

Treatment should be directed toward the underlying etiology.

Electrolyte abnormalities, metabolic abnormalities, or nutritional deficiencies should

be corrected.

Cognitive-behavioral interventions are useful for vomiting associated with functional

dyspepsia, adolescent rumination syndrome, and bulimia.

Prokinetic medications such as metoclopramide, domperidone (where available), and

erythromycin are beneficial when there are abnormalities in esophago-gastric
motility.

Antiemetics, which are useful in persistent vomiting to avoid electrolyte

abnormalities or nutritional sequelae, typically have not been recommended in the
case of vomiting of unknown etiology. These agents are contraindicated in infants .

Likewise, they are not indicated for anatomic abnormalities or surgical abdomen.

Treatment

Clinical Approach

Instead, antiemetics are most useful for motion sickness, postoperative vomiting,
cyclic vomiting syndrome, and gastrointestinal motility disorders .

In addition, a double-blind study suggests that single dose ondansetron may facilitate
oral rehydration in children with gastroenteritis who are unable to tolerate oral
intake.

During the last two decades, there have been considerable advances in the
development of antiemetics. These include the emergence of 5-hydroxytryptamine 3
receptor antagonists (Ondansetron, Granisetron), which have one primary site of
antagonism and have helped in the treatment of post-operative nausea and vomiting
and chemotherapy-associated emesis.

These include neurokinin 1 receptor antagonists that likely mediate nausea and
vomiting triggered by chemotherapeutic agents, motion, gastric irritants, and other
stimuli .

Alternative Medicine

There is some evidence for efficacy of some nutraceuticals, such as ginger for
functional dyspepsia and other motility disorders.

Hypnotherapy is often helpful for treatment of anticipatory nausea and vomiting (eg,
prior to chemotherapy).

THANKS A LOT!

DR. Ryan Al.Ghanemi