"Vomitting in The Young Child" from Pediatric Emergency Playbook

All that follows is from Vomiting in the Young Child: Nothing or Nightmare Podcast and show notes Updated on January 1, 2016 by Dr. Tim Horeczko of the Pediatric Emergency Playbook.

Be very uncomfortable about labeling pediatric vomitting without diarrhea as Acute Gastroenteritis. Maybe – but maybe it is something bad (a surgical abdomen, a metabolic problem, CNS infection or neoplasm, or an initial presentation of diabetic ketoacidosis).

Even after he has completed a thorough pediatric evaluation, Dr. Tim Horeczko of the Pediatric Emergency Playbook that he signs out apparently benign vomiting and diarrhea as “vomitting and diarrhea” to emphasize that ultimately acute gastroenteritis is a retrospective diagnosis.

In the post Dr. Horeczko goes through an age based review of pediatric vomitting.

A great point he makes is that one of the big pediatric diagnoses in school age children is appendicitis. And he points out that sometimes after your evaluation, you belief that the child is okay for discharge but you want to be double sure – give the parents instructions to return to the emergency department in eight hours or twelve hours for re-evaluation (give them a specific time, one or the other) along with a detailed list of instructions of when to return sooner than that if anything changes or gets worse.

What follows are excerpts from the show notes of the above podcast:

The Neonate: Malrotation with Volvulus
In children with malrotation, 50% present within the first month of life, with the majority occurring in the first week after birth. Approximately 90% of children with malrotation with volvulus will present by one year of age. This is a pre-verbal child’s disease – which makes it even more of a challenge to recognize quickly.
The sequence of events usually is fussiness, irritability, and forceful vomiting. The vomit quickly turns bilious.
Green vomit is a surgical emergency.
Babies may also present unwell, with bloating and abdominal tenderness to palpation. Be aware that later stages of malrotation may present as shock – they present in hypovolemic shock due to third-spacing from necrotic bowel and/or septic shock from translocation or perforation. In the undifferentiated sick neonate, always consider a surgical emergency such as malrotation with volvulus.
In the stable patient, get an upper GI contrast study.

Rapid-fire word association for other vomiting emergencies in a neonate:

Fever, irritability and vomiting? Think meningitis, UTI, or sepsis.

Premature, unwell, and vomiting? Think necrotizing enterocolitis. Remember, 10% of cases of NEC can be full-term. Look for pneumatosis intestinalis.

Systemically ill, afebrile, and vomiting for no other reason? Think inborn error of metabolism. Screen with a glucose, ammonia, lactate, and urine ketones.

Others include congenital intestinal atresia or webs, meconium ileus, or severe GERD

The Infant: Non-Accidental Trauma
All that vomits is not necessarily from the gut.
Abusive head injury is the most common cause of death from child abuse. Infants especially present with non-specific complaints like fussiness or vomiting. Up to 30% of infants with abusive head injury may be misdiagnosed on initial presentation.

The Toddler: Diabetic Ketoacidosis (DKA)
The important diagnosis not to miss in the vomiting toddler or early school age child is the initial presentation of diabetic ketoacidosis. Children under 5 (especially those under 2) and those from lower socioeconomic groups have a higher risk of DKA as their initial presentation of diabetes.
This is true for any child that isn’t quite acting right – check a finger stick blood sugar as a screen.
The International Society for Pediatric and Adolescent Diabetes (ISPAD) criteria for DKA:
Hyperglycemia, with a blood glucose of >200 mg/dL (11 mmol/L)
AND
Evidence of metabolic acidosis, with a venous pH of less than 7.3 or a bicarbonate level of < 15 mEq/L
AND
Ketosis, found either in the urine or if directly checked in the blood.
If you have access to checking a serum beta-hydroxybutryrate – the unsung ketone – it can help in diagnosis in unclear cases.

[See Cerebral Edema (a big danger in diabetic ketoacidosis) Criteria and Action Items in the show notes.]

As you can see, vomiting in the young child can be really anything! Keep your differential broad, and think by age and by system.
Differential Diagnosis of Vomiting in Children
The general approach to the child with chiefly vomiting starts with the decision: sick or not sick. If ill appearing, establish rapid IV access, or if needed IO. Rapid blood sugar and if available a point of care pH and electrolytes. Be the detective in your history and doggedly go after any red flags as you go methodically by organ system.
Do a careful physical exam. The general assessment is always helpful – is the child irritable, listless, agitated?
What is his work of breathing? Effortless tachypnea may be a sign of acidosis or sepsis.
Is the abdomen soft or is it tender or distended. Always look in the diaper area – is there a hernia, is there a high-riding, tender, discolored scrotum without cremasteric reflex? Ovarian torsion has been reported in infants as young as 7 months.
Any skin signs? Look for petechiae, urticaria, purpura.
In other words, use your best judgement, have the dangerous differentials in the back of your mind, and pull the trigger when red flags mount up. Otherwise, a good history and a good exam will get you where you need to be.

Take home points for the young child with vomiting:
1. Neonates are allowed to regurgitate (effortless reflux of stomach contents — the happy spitter-upper). They are not allowed to vomit (forceful, unpleasant contraction of abdominal muscles). Consider surgical causes of forceful vomiting, especially if the child does not look anything other than well.
2. Bilious is bad – green vomit is always a surgical emergency – get the surgeons involved early
3. Not all vomiting is GI related – if it is not obviously benign, think methodically by organ system and adjust your targeted history and physical to pick up any leads.
4. Match the tempo of your treatment to the tempo of the disease.