Approach to the infant or child with nausea and vomiting
- Carlo Di Lorenzo, MD
Carlo Di Lorenzo, MD
- Professor of Clinical Pediatrics
- Ohio State University
Nausea and vomiting are common sequelae of a multitude of disorders that can range from mild, self-limited illnesses to severe, life-threatening conditions. Vomiting and nausea may or may not occur together, or may be perceived at the same level of intensity. As an example, vomiting can occur without preceding nausea in individuals with mass lesions in the brain or increased intracranial pressure (ICP). Furthermore, some medications may alleviate nausea but not vomiting, or vice versa.
The symptoms of nausea and vomiting may be caused by many pathologic states involving several systems (including gastrointestinal, neurologic, renal, and psychiatric). Younger children may not be able to describe nausea, which may further complicate diagnosis. The best course of action should be dictated by the medical history, taking into consideration clinical features of specific disorders and their relative frequency among children in different age groups. The most important consideration during the initial encounter is recognition of serious conditions, such as intestinal obstruction and increased ICP, for which immediate intervention is required. (See 'Concerning signs' below.)
This topic review will provide an overview of the neurophysiology and differential diagnosis of nausea and vomiting in children, while suggesting a general approach to specific testing. Individual disorders are discussed in further detail in linked topic reviews. Several gastrointestinal disorders present with abdominal pain in addition to nausea and vomiting, and these are discussed below. However, evaluation of the child in whom abdominal pain is the primary presenting complaint is discussed separately. (See "Emergent evaluation of the child with acute abdominal pain" and "Chronic abdominal pain in children and adolescents: Approach to the evaluation".)
●Vomiting (emesis) refers to the forceful oral expulsion of gastric contents associated with contraction of the abdominal and chest wall musculature. Vomitus often has a slight yellow tinge, which is caused by reflux of small amounts of bile into the stomach. Vomitus is considered bilious if it has a green or bright yellow color, indicating larger amounts of bile in the stomach; bilious vomiting is often associated with intestinal obstruction, as described below.
●Nausea generally refers to an unmistakable sensation of unpleasantness that may precede vomiting, but may be present even in a child who does not vomit. It is often associated with autonomic changes such as salivation, increased heart and respiratory rates, and a reduction in gastric tone and mucosal blood flow . Although there is no forceful expulsion of gastric contents with nausea, there may be retrograde reflux of fluids from the duodenum to the gastric antrum.
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- PHYSIOLOGY OF EMESIS
- Somatomotor events
- APPROACH TO MANAGEMENT
- Concerning signs
- Physical examination
- Laboratory testing
- DIFFERENTIAL DIAGNOSIS OF VOMITING BY AGE GROUP
- Neonates and young infants
- - Gastroesophageal reflux disease
- - Food protein-induced enteropathy
- - Food protein-induced enterocolitis syndrome
- - Pyloric stenosis
- - Adrenal insufficiency
- - Intestinal obstruction
- Malrotation with volvulus
- Hirschsprung disease
- - Inborn errors of metabolism
- Older infants and children
- - Gastroenteritis
- - Other infections
- - Gastroparesis
- - Intussusception
- - Anaphylaxis
- - Adrenal crisis
- - Intracranial hypertension
- - Cyclic vomiting syndrome
- - Migraine
- - Eosinophilic esophagitis or gastroenteritis
- - Medical child abuse
- - Functional dyspepsia
- - Functional nausea and functional vomiting
- - Appendicitis
- - Inflammatory bowel disease
- - Pregnancy
- - Bulimia or psychogenic vomiting
- - Rumination syndrome
- INFORMATION FOR PATIENTS