Paediatrics: Vomiting

Vomiting

A common symptom in childhood.

Three clinical scenarios are recognized:

• Acute: discrete episode of moderate to high intensity. Most commonand usually associated with an acute illness.
• Chronic: low-grade daily pattern, frequently with mild illness.
• Cyclic: severe, discrete episodes associated with pallor, lethargy +/–abdominal pain. The child is well in between episodes. Often there is a family history of migraine or vomiting.

Causes

• Acute: GI infection; non-GI infection (e.g. urinary tract infection); GIobstruction (congenital or acquired e.g. pyloric stenosis); adverse food reaction; poisoning; raised intracranial pressure; endocrine/metabolic disease (e.g. diabetic ketoacidosis).
• Chronic (usually GI): peptic ulcer disease; gastro-oesophageal reflux;chronic infection; gastritis; gastroparesis; food allergy; psychogenic (see Psychogenic vomiting); bulimia; pregnancy.
• Cyclic (usually non-GI cause): idiopathic; CNS disease; abdominalmigraine; endocrine (e.g. Addison’s disease); metabolic (e.g. acute intermittent porphyria); intermittent GI obstruction; fabricated illness.

Management

• Full history: e.g. early morning vomiting with CNS tumour, or familymembers with similar illness.
• Full examination:including ear, nose, and throat (ENT) and growth.

Assess for dehydration.

Treatment

• Supportive treatment as needed: e.g. oral or IV fluids.
• Treat cause: e.g. pyloromyotomy for hypertrophic pyloric stenosis.
• Pharmacological: antihistamines; phenothiazines (side-effects:extrapyramidal reactions); prokinetic drugs, e.g. domperidone. 5-HT₃ antagonists, e.g. ondansetron, are increasingly being used for treating post-operative or chemotherapy induced vomiting. 5-HT_1D agonists, e.g. pizotifen, are useful as prophylaxis and treatment for cyclic vomiting syndrome.

Complications

Dehydration, plasma electrolyte disturbance (e.g. ‘fall’ K⁺, ‘fall’ Cl^–, alkalosis with pyloric stenosis), acute or chronic GI bleeding (e.g. Mallory–Weiss tear), esophageal stricture, Barrett’s metaplasia, broncho-pulmonary aspiration, faltering growth, iron deficiency anaemia.

Psychogenic vomiting

• Causes: anxiety; manipulative behaviour; disordered family dynamics. Afamily history of vomiting is common.
• Management: exclude organic disease. Refer to child psychologist.