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.
- Hornby PJ. Central neurocircuitry associated with emesis. Am J Med 2001; 111 Suppl 8A:106S.
- Li B U.K.. Nausea, vomiting and pyloric stenosis. In: Pediatric Gastrointestinal Disease, 5th Ed, Kleinman RE, Goulet OJ. (Eds), BC Decker Inc, Ontario 2008. Vol 1, p.127.
- Mohinuddin S, Sakhuja P, Bermundo B, et al. Outcomes of full-term infants with bilious vomiting: observational study of a retrieved cohort. Arch Dis Child 2015; 100:14.
- Vandenplas Y, Rudolph CD, Di Lorenzo C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49:498.
- Niedzielski J, Kobielski A, Sokal J, Krakós M. Accuracy of sonographic criteria in the decision for surgical treatment in infantile hypertrophic pyloric stenosis. Arch Med Sci 2011; 7:508.
- McCollough M, Sharieff GQ. Abdominal surgical emergencies in infants and young children. Emerg Med Clin North Am 2003; 21:909.
- Cribbs RK, Gow KW, Wulkan ML. Gastric volvulus in infants and children. Pediatrics 2008; 122:e752.
- Rodriguez L, Irani K, Jiang H, Goldstein AM. Clinical presentation, response to therapy, and outcome of gastroparesis in children. J Pediatr Gastroenterol Nutr 2012; 55:185.
- Aceves SS, Newbury RO, Dohil MA, et al. A symptom scoring tool for identifying pediatric patients with eosinophilic esophagitis and correlating symptoms with inflammation. Ann Allergy Asthma Immunol 2009; 103:401.
- McClung HJ, Murray R, Braden NJ, et al. Intentional ipecac poisoning in children. Am J Dis Child 1988; 142:637.
- Carter KE, Izsak E, Marlow J. Munchausen syndrome by proxy caused by ipecac poisoning. Pediatr Emerg Care 2006; 22:655.
- Perez ME, Youssef NN. Dyspepsia in childhood and adolescence: insights and treatment considerations. Curr Gastroenterol Rep 2007; 9:447.
- Hyams JS, Di Lorenzo C, Saps M, et al. Functional Disorders: Children and Adolescents. Gastroenterology 2016.
- Kovacic K, Miranda A, Chelimsky G, et al. Chronic idiopathic nausea of childhood. J Pediatr 2014; 164:1104.
- Kovacic K, Di Lorenzo C. Functional Nausea in Children. J Pediatr Gastroenterol Nutr 2016; 62:365.
- Madani S, Cortes O, Thomas R. Cyproheptadine Use in Children With Functional Gastrointestinal Disorders. J Pediatr Gastroenterol Nutr 2016; 62:409.
- Chial HJ, Camilleri M, Williams DE, et al. Rumination syndrome in children and adolescents: diagnosis, treatment, and prognosis. Pediatrics 2003; 111:158.
- Loewen PS. Anti-emetics in development. Expert Opin Investig Drugs 2002; 11:801.
- Vlieger AM, Blink M, Tromp E, Benninga MA. Use of complementary and alternative medicine by pediatric patients with functional and organic gastrointestinal diseases: results from a multicenter survey. Pediatrics 2008; 122:e446.
- Ghayur MN, Gilani AH. Pharmacological basis for the medicinal use of ginger in gastrointestinal disorders. Dig Dis Sci 2005; 50:1889.
- von Arnim U, Peitz U, Vinson B, et al. STW 5, a phytopharmacon for patients with functional dyspepsia: results of a multicenter, placebo-controlled double-blind study. Am J Gastroenterol 2007; 102:1268.
- Marchioro G, Azzarello G, Viviani F, et al. Hypnosis in the treatment of anticipatory nausea and vomiting in patients receiving cancer chemotherapy. Oncology 2000; 59:100.
- Soo S, Moayyedi P, Deeks J, et al. Psychological interventions for non-ulcer dyspepsia. Cochrane Database Syst Rev 2005; :CD002301.
- Calvert EL, Houghton LA, Cooper P, et al. Long-term improvement in functional dyspepsia using hypnotherapy. Gastroenterology 2002; 123:1778.
- Chiarioni G, Vantini I, De Iorio F, Benini L. Prokinetic effect of gut-oriented hypnosis on gastric emptying. Aliment Pharmacol Ther 2006; 23:1241.
- 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
- - Munchausen syndrome by proxy
- - Functional dyspepsia
- - Functional nausea and functional vomiting
- - Appendicitis
- - Inflammatory bowel disease
- - Pregnancy
- - Bulimia or psychogenic vomiting
- - Rumination syndrome
- INFORMATION FOR PATIENTS