Links To PedsCases Approach to Pediatric Vomitting Part 1

Posted on May 11, 2020 by Tom Wade MD

Here is a list of all the types of resources available on PedsCases, Categories.

Today I reviewed PedsCases Approach to Pediatric Vomitting Part 1.  I’ll be reviewing Pediatric Vomitting Part 2 in an upcoming post. Here are the direct links:

Here are excerpts from Part 1:

Differential Diagnosis

Vomiting is a very common pediatric presentation, and the differential is extremely broad. While GI (gastrointestinal) causes tend to come to mind first, there are many non-GI causes for vomiting that have to be considered. The causes for pediatric
vomiting can be broken into categories including:

  • gastrointestinal
  • infectious
  • neurologic
  • metabolic/endocrine
  • respiratory
  • toxin or medication-related
  • psychogenic or behavioral.

Gastrointestinal Causes:

Important causes of vomiting in the newborn period include:

  • pyloric stenosis
  • duodenal atresia
  • intestinal malrotation
    • a congenital anomaly in rotation of the midgut as it forms, presents as intermittent bilious vomiting, usually with significant abdominal distension
    • It may be associated with severe abdominal pain if associated with midgut volvulus causing bowel ischemia.
    • Since the bowel obstruction is often intermittent, the timing of presentation can be variable.
    • Bilious or bile-stained vomiting should be treated as a potential surgical emergency [meaning get a stat pediatric surgery consult].
  • tracheo-esophageal fistula.
  • Necrotizing enterocolitis
    • [See Current status of laboratory and imaging diagnosis of neonatal necrotizing enterocolitis [PubMed Abstract] [Full Text HTML] Ital J Pediatr. 2018; 44: 84.]

After the newborn period, important gastrointestinal causes of vomiting include:

  • gastroesophageal reflux disease (GERD)
    • Gastroesophageal reflux disease (GERD) is associated with esophagitis, failure to
      thrive and recurrent aspiration.
    • Gastro-esophageal reflux (GER) is extremely common and typically presents in infants between 1-3 months of age. It is characterized by frequent small volume regurgitation of a milky substance, irritability with feeds orwhen lying supine, or back arching with feeds. Many infants are asymptomatic. Gastro-esophageal reflux is a normal physiologic process in infants and must be distinguished from gastro-esophageal reflux disease (GERD)
  • intussusception and other causes of bowel obstruction
    • intussusception involves invagination of a portion of the small bowel into another
      portion of bowel.

      • It is the most common cause of intestinal obstruction in children six to 36 months of age.
      • In addition to vomiting, the classic triad of features includes intermittent, progressive abdominal pain, red currant jelly stools and a palpable sausage-like abdominal mass.
  • Food allergies such as milk protein allergy in infants or celiac disease in older infants and children are other fairly common causes of vomiting.
  • Eosinophilic esophagitis, a disease characterized by eosinophilic infiltrates in the esophagus is another cause of vomiting often found in older children or adolescents with a history of asthma, atopy and eczema, who complain of food sticking in the
    esophagus
  • Appendicitis is a common GI cause of vomiting in children and adolescents that should not be missed. Usually, there will also be a history of fever and abdominal pain.

Non-Gastrointestinal Causes

Infectious Causes

  • Acute Gastroenteritis
  • UTI
  • Pyelonephritis
  • Meningitis
  • Sepsis
  • Meningitis and pyelonephritis classically present with vomiting and fever.

Neurologic Causes – Relate to Increased Intracranial Pressure

  • The history should be suggestive of other symptoms of increased intracranial pressure, such as morning headaches, focal neurological deficits or changes in vision.
  • Hydrocephalus
  • Intracranial neoplasms
  • Pseudo tumor cerebri in older children

Migraines can be another common cause for vomiting in children

Metabolic and Endocrine Causes

  • Diabetic Ketoacidosis
    • DKA can be the initial presentation of type 1 diabetes so always consider it as a cause of vomitting.
    • A child in DKA may also present with abdominal pain, changes in respiratory pattern, and confusion or lethargy.
  • Congential adrenal hyperplasia
  • Inborn errors of metabolism

Respiratory-Related Vomiting

  • Refers to post-tussive emesis, which is common in
    children with:

    • asthma
    • foreign body aspiration
    • respiratory infections following prolonged and forceful coughing episodes.

Ingestions

  • Iron poisoning
  • Lead poisoning
  • Medications
    • opiates
    • anticonvulsants
    • aspirin
    • other medications

Less common categories of pediatric vomiting include psychogenic and behavioral causes, which includes overfeeding in infants and bulimia nervosa in adolescents.

Pregnancy must also be considered in adolescents.

 

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