Patient information: Nausea and vomiting in infants and children

NAUSEA AND VOMITING OVERVIEW

Nausea and vomiting are common in children, and are usually part of a mild, short-lived illness. Rarely, the problem can be severe and life-threatening. Nausea and vomiting are usually caused by another condition (eg, gastroenteritis), although the list of possible causes changes as a child grows.

Although most children recover from nausea and vomiting without any treatment, it is important to recognize the signs and symptoms of a more serious condition that requires further evaluation with a healthcare provider.

This topic review discusses the symptoms, causes, evaluation, and treatment of infants and children with sudden cases of vomiting, usually caused by an infection. This topic does not discuss intentional vomiting (eg, as seen with bulimia) or other causes of chronic vomiting. Spitting up in infants (gastroesophageal reflux) is discussed separately. (See "Patient information: Gastroesophageal reflux in infants".)

WHY DOES VOMITING OCCUR?

Vomiting is defined as the forceful throwing up of the stomach contents. To vomit, the abdominal and chest wall muscles contract, forcing the contents of the stomach into the esophagus and then out of the mouth (figure 1). Vomiting occurs when nerves in the body or brain sense one or more of a number of possible triggers, such as food poisoning, certain gastrointestinal infections, some medications, or motion. Nausea sometimes, but not always, occurs before vomiting. Younger children may not be able to describe nausea, although they may complain of a stomach ache or have other general complaints.

Vomiting often has a benefit since it provides a way for the body to get rid of potentially harmful substances. However, medications and methods to induce vomiting (eg, syrup of ipecac, placing a finger in the throat) are no longer recommended, even if an infant or child has ingested a harmful substance. In this case, it is best to immediately call for emergency medical assistance, available in the United States by calling 911.

Vomit versus spit up — There is a difference between vomiting and spitting up, although the terms are often used interchangeably. Spitting up requires no forceful muscle contraction and often occurs with a burp after feeding. The medical term for this is gastroesophageal reflux (GER). Most infants spit up milk or formula through the mouth or nose. (See "Patient information: Gastroesophageal reflux in infants".)

Spitting up is most common in infants during the first few months of life and usually begins to improve by 7 months, although individual children may vary. Burping frequently during feeding and limiting activity after feeding may reduce the frequency of spitting up. Spitting up is not usually caused by an allergy to something in the breastfeeding mother's diet or to infant formula.

Spitting up does not usually require treatment, especially if a child is eating and growing normally. An infant who spits up more frequently than previously, refuses to eat, frequently cries or arches the back as if in pain, chokes while spitting up, has forceful or projectile vomiting, or is not gaining weight should be evaluated by a healthcare provider.

CAUSES OF VOMITING

Vomiting can be caused by a number of different problems. The possible causes of vomiting depend upon a child's age.

Newborns and young infants — It can be hard to tell if an infant is spitting up or vomiting because some infants reflux forcefully or in large amounts. In this case, an evaluation with a healthcare provider will help to determine the cause and whether treatment is needed.

Forceful vomiting in newborns can indicate a serious condition and always requires further evaluation. Potential causes of vomiting in newborns and young infants include a blockage or narrowing of the stomach (pyloric stenosis) or a blockage of the intestines (intestinal obstruction).

Infants may also vomit because of infections of the intestine or other parts of the body. Any young infant (newborn to 3 months) who develops a temperature of 100.4º F (38º C) or higher, with or without vomiting, should be evaluated by a healthcare provider.

Older infants and children — The most common cause of vomiting in older infants and children is infectious gastroenteritis (an infection of the stomach or intestines), usually caused by a virus. Gastroenteritis can develop when an infant or child consumes contaminated food or places a contaminated object (or hand) into their mouth. The viruses that commonly cause gastroenteritis are spread easily and are usually present in large numbers in the stools of infected individuals. Careful hygiene (especially hand washing) is crucial to prevent these infections from spreading. Less commonly, vomiting occurs after consuming improperly stored or prepared foods that contain bacteria or toxins made by bacteria; this is called food poisoning.

Vomiting caused by gastroenteritis usually begins suddenly and resolves quickly, often within 24 hours. Other signs of gastroenteritis can include nausea, diarrhea, fever, or abdominal pain. (See "Patient information: Acute diarrhea in children".)

Other illnesses can also cause vomiting in older infants and children, including gastroesophageal reflux, peptic ulcer disease, an intestinal blockage (obstruction), and others.

Adolescents — Similar to children, the most common cause of nausea and vomiting in adolescents is infectious gastroenteritis. Vomiting usually resolves within 24 to 28 hours in an adolescent with gastroenteritis.

Less common causes of vomiting in adolescents include appendicitis (infection of the appendix), induced vomiting (eg, as seen with bulimia), inflammatory bowel disease (eg, Crohn's disease), pregnancy, and consumption of toxic substances (eg, overdose).

NAUSEA AND VOMITING DIAGNOSIS

Most children with vomiting do not need to be seen by a healthcare provider. However, parents of a child who vomits should monitor for signs of worsening or failure to improve within 24 hours. If a child is having severe pain or has signs of dehydration, they should be seen sooner. Any parent who is concerned about his or her child should call the child's healthcare provider immediately (for a full description of worrisome signs or symptoms (see 'When to seek help' below.

For children who are seen by a healthcare provider, the evaluation of vomiting requires a careful review of the medical history, a physical examination, and on occasion, diagnostic testing.

Medical history — A medical history often suggests the underlying cause of vomiting. It is important for parents to mention if their child has had a fever (temperature greater than 101ºF or 38.4ºC) or abdominal pain. Table 1 describes how to take a child's temperature (table 1).

Tests — Tests are available to determine if a child is dehydrated, although not all children will require testing. The clinician will determine if tests are necessary based on the individual situation.

For those who do require testing, a few carefully chosen tests are usually sufficient. Testing may include blood, urine, and/or a stool test. Most children with vomiting do not require x-rays or other imaging tests.

HOME CARE OF NAUSEA AND VOMITING

The following are some simple recommendations to help care for children with nausea and vomiting at home.

Monitor for dehydration — Dehydration can develop in children with vomiting. Signs of mild dehydration include a slightly dry mouth and increased thirst. Children who are mildly dehydrated do not need immediate medical attention but should be monitored for signs of worsening dehydration.

Signs of moderate or severe dehydration include decreased urination (less than one wet diaper or void in six hours), lack of tears when crying, a dry mouth, or sunken eyes. A child who is moderately or severely dehydrated should be evaluated by a healthcare provider as soon as possible to determine if treatment with oral or intravenous rehydration solution is needed.

Dietary recommendations — Children who are vomiting but are not dehydrated can continue to eat a regular diet as tolerated. Dehydrated children require rehydration (replacement of lost fluid). (See 'Oral rehydration therapy' below.)

Infants — If a breastfeeding infant vomits, he or she should continue to breastfeed unless a healthcare provider instructs the parent(s) otherwise. Oral rehydration solutions (eg, Pedialyte®) are not usually needed for infants who exclusively breastfeed because breastmilk is more easily digested. If an infant vomits immediately after nursing, the mother may try to breastfeed more frequently and for a shorter time.

For example, breastfeed every 30 minutes for five to 10 minutes. If vomiting improves after two to three hours, resume the usual feeding schedule. If vomiting worsens or does not improve within 24 hours, the parent should call the child's healthcare provider (see 'When to seek help' below.

For infants who drink infant formula, initially offer one to two ounces of an oral rehydration solution (eg, Pedialyte®) every 30 minutes for two to three hours. If vomiting improves, resume feeding with full strength infant formula. If vomiting worsens or does not improve within 24 hours, the parent should call their child's healthcare provider (see 'When to seek help' below.

Older infants and children — Older infants and children who vomit can continue to eat, if desired. However, it is common for children to have little or no appetite during a vomiting illness.

• Parents should continue to monitor for signs of dehydration, and should not force the child to eat, especially during the first 24 hours. The infant or child should be encouraged to drink fluids. The best fluids are the commercially prepared oral rehydration solutions (eg, Pedialyte®) (see 'Oral rehydration therapy' below. Other fluids, including water, diluted juice, or soda can be given in small quantities.

Apple, pear, and cherry juice, and other beverages with high sugar content should be avoided. Sports drinks (eg, Gatorade) should also be avoided since they have too much sugar and have inappropriate electrolyte levels.

• Recommended foods include a combination of complex carbohydrates (rice, wheat, potatoes, bread), lean meats, yogurt, fruits, and vegetables. High fat foods are more difficult to digest, and should be avoided.
• It is not necessary to restrict a child's diet to clear liquids or the BRAT diet (bananas, rice, applesauce, toast). Although these and similar foods are sometimes recommended to decrease diarrhea, these foods do not contain enough nutrients for a child.

Oral rehydration therapy — Oral rehydration therapy (ORT) was developed as a safer, less-expensive, and easier alternative to intravenous fluids. Oral rehydration solution (ORS) is a liquid solution that contains glucose (a sugar) and electrolytes (sodium, potassium, chloride) that are lost with vomiting and diarrhea.

ORS does not cure vomiting, but helps to treat the dehydration that may accompany it. ORS can be purchased at most grocery stores and pharmacies in the United States without a prescription. A few widely available brands include Pedialyte®, Infalyte®, and ReVital®, although generic brands are equally effective (table 2). Gelatin, tea, fruit juice, rice water, and other beverages are not recommended in children who are dehydrated. Parents should not try to prepare ORS recipes at home because the formulas must be exact.

ORS may be given at home to a child who is mildly dehydrated, refusing to eat a normal diet, or has vomiting and/or diarrhea. If needed, ORS can be given in frequent, small sips or small amounts by spoon, bottle, or cup over three to four hours. A healthcare provider may give specific instructions for oral rehydration to their patients. One method is described below:

• Parents should first calculate the total amount to be given with a standardized medicine syringe, or measuring cup or spoon, rather than a regular cup or spoon.
• A total volume of 5 teaspoons per pound, or 50 milliliters per kilogram, should be administered (table 3). For a 20-pound child, this would equal 100 teaspoons; for a 9 kg child, this would equal 450 milliliters.
• The fluid can be administered by teaspoonfuls (approximately equal to 5 milliliters each) every one to two minutes or as tolerated.
• After the total amount has been given, a normal diet can be resumed.

Children who refuse to drink or who vomit immediately after drinking ORS should be monitored closely for worsening dehydration. Children who are not dehydrated may drink ORS after every episode of vomiting to prevent dehydration. (See 'Monitor for dehydration' above.)

Medications — Medications to reduce nausea and vomiting, called antiemetics, may be recommended in certain situations (eg, to reduce the risk of dehydration in children who vomit repeatedly or to prevent motion sickness). These medications require a prescription, and should not be given to an infant or child unless a healthcare provider has recommended their use. Over-the-counter treatments for nausea or vomiting are not recommended for infants or children.

Antibiotics are not recommended for the treatment of vomiting unless the specific cause of the vomiting has been determined or is strongly suspected by a clinician, particularly after recent travel. Inappropriate use of antibiotics will not improve vomiting. Furthermore, antibiotics can cause side effects and lead to the development of antibiotic resistance.

Preventing spread — Parents with children who are vomiting should be cautious to avoid spreading infection to themselves, their family, and friends. Care with hand washing, diapering, and keeping sick children out of school or daycare are a few ways to limit the number of persons exposed to the infection.

Hygiene measures — Hand washing is an essential and very effective way to prevent the spread of infection. Hands should ideally be wet with water and plain or antimicrobial soap, and rubbed together for 15 to 30 seconds. Special attention should be paid to the fingernails, between the fingers, and the wrists. Hands should be rinsed thoroughly, and dried with a paper towel that is thrown away after one use.

Alcohol-based hand rubs are a good alternative for disinfecting hands if a sink is not available. Hand rubs should be spread over the entire surface of hands, fingers, and wrists until dry, and may be used several times. Hand rubs are available as a liquid or wipe in small, portable sizes that are easy to carry in a pocket or handbag. When a sink is available, visibly soiled hands should be washed with soap and water.

Hands should be cleaned after changing a diaper or touching any soiled item. They should also be washed before and after preparing food and eating, after going to the bathroom, after handling garbage or dirty laundry, after touching animals or pets, and after blowing the nose or sneezing.

WHEN TO SEEK HELP

The following is a list of signs and symptoms that are worrisome and require immediate medical attention:

• Bile (green) or blood-tinged (red or brown) vomit
• Any episode of vomiting in a newborn, or vomiting that continues for more than 24 hours in an infant or child
• If an infant refuses to eat or drink anything for more than a few hours
• Moderate to severe dehydration (dry mouth, no tears when crying, not urinating or having a wet diaper in six hours)
• Abdominal pain that is severe, whether or not it comes in waves
• Fever greater than 102ºF (39ºC) once or fever over 101ºF (38.4ºC) for more than three days
• Behavior changes, including lethargy or decreased responsiveness

WHERE TO GET MORE INFORMATION

Your child's healthcare provider is the best source of information for questions and concerns related to your child's medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your child's situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Gastroesophageal reflux in infants
Patient information: Acute diarrhea in children

Professional Level Information:
Approach to the infant or child with nausea and vomiting
Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents
Cyclic vomiting syndrome
Gastroesophageal reflux in infants
Gastroesophageal reflux in premature infants
Infantile hypertrophic pyloric stenosis
Management of gastroesophageal reflux disease in children and adolescents
Oral rehydration therapy

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• The Centers for Disease Control and Prevention

      (www.cdc.gov/)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (www.niddk.nih.gov)

• The American Academy of Pediatrics

      (www.aap.org)

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