Vomiting resident survival guide (pediatrics)
Synonyms and keywords: Vomiting in childhood, Vomiting in children, An approach to vomiting in children

# Overview
Vomiting is a protective reflex mechanism that causes forceful reflux of stomach or esophageal contents outside the mouth. It is a common pediatric problem with varied etiology. It may be the presenting symptom of an underlying life-threatening illness. Management of vomiting in children usually involves treating dehydration, electrolyte imbalance, and the underlying cause. Antiemetic therapy is given in older children with persistent vomiting.

# Causes

## Life Threatening Causes
- Following is a list of life-threatening causes for vomiting in children. These etiologies include the conditions that may result in either death or permanent disability within 24 hours if left untreated:
Pyloric stenosis
Intestinal malrotation with volvulus
Congenital intestinal obstruction
Diabetic ketoacidosis
Intussusception
Necrotizing enterocolitis
Gastroenteritis
Meningitis
Sepsis
Shaken baby syndrome
Hydrocephalus
Congenital adrenal hyperplasia
Inborn errors of metabolism
Obstructive uropathy
- Pyloric stenosis
- Intestinal malrotation with volvulus
- Congenital intestinal obstruction
- Diabetic ketoacidosis
- Intussusception
- Necrotizing enterocolitis
- Gastroenteritis
- Meningitis
- Sepsis
- Shaken baby syndrome
- Hydrocephalus
- Congenital adrenal hyperplasia
- Inborn errors of metabolism
- Obstructive uropathy

## Common Causes
- Common causes of vomiting in the pediatric population varies with the age as elaborated in the following table:

# FIRE: Focused Initial Rapid Evaluation
- A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the patients in need of immediate intervention:

# Complete Diagnostic Approach
- Shown below is an algorithm summarizing the diagnosis of vomiting in children:

## Non-bilious, Non-bloody Vomiting

# Treatment
- The mainstay of therapy for vomiting in children is supportive care.
- Supportive therapy for vomiting in children include the following:
Treat dehydration
Correct electrolyte imbalance
Identify, address, and treat the underlying cause
- Treat dehydration
- Correct electrolyte imbalance
- Identify, address, and treat the underlying cause
- In bilious vomiting, do the following:
Avoid oral intake
Advice NPO
Decompress the stomach with nasogastric tube
Start IV fluids
Consult for surgical opinion
- Avoid oral intake
- Advice NPO
- Decompress the stomach with nasogastric tube
- Start IV fluids
- Consult for surgical opinion

## Antiemetics
- Antiemetics such as metoclopramide, promethazine, and prochlorperazine are not routinely indicated in children due to severe adverse effects like somnolence, nervousness, dystonia, and other extrapyramidal symptoms.
- Avoid antiemetics before ruling out any life-threatening illness and surgical emergency.
- Children with occasional episodes of vomiting can be managed with observation for worsening of symptoms.
- If the child is improving, reassure parents and discharge the child.
- Antiemetics should be given to:
Older children who are continuously vomiting and unable to take anything orally.
Cyclic vomiting syndrome
Post-operative vomiting
Chemotherapy induced vomiting
- Older children who are continuously vomiting and unable to take anything orally.
- Cyclic vomiting syndrome
- Post-operative vomiting
- Chemotherapy induced vomiting
- Preferred antiemetics are ondansetron (5-HT3 receptor blocker) and domeperidone (dopamine antagonist).
- Preferred dose of ondansetron is 2 mg thrice a day in children aged between 2-4 years and 4 mg thrice a day in children above 4 years.
- Preferred dose of domeperidone is 0.2-0.4 mg/kg/dose thrice daily.
- Antihistamines are used in motion sickness.

# Do's
- Start oral fluids 30-60 minutes after the vomiting has stopped. Give clear fluids like water and clear broth frequently in small quantities.
- Continue breastfeeding in small and frequent doses.
- Continue the regular and full-strength formula in small and frequent doses.
- Give 5-10 ml of oral rehydration solutions (ORS) such as Pedialyte every 15-20 minutes.
- Reintroduce solid food like rice, toast, applesauce, cereals, and crackers 8 hours after the vomiting has stopped in kids.
- Start the normal diet 24 hours after the vomiting has stopped.
- Wash hands before feeding, eating, and cooking.

# Don'ts
- Do not give milk or solid food if the child is vomiting continuously.
- Do not give any solid food until 24 hours of vomiting onset.
- Do not give foods with sugars such as juices and carbonated drinks.