Links To PedsCases Approach to Pediatric Vomitting Part 2 With Additional Resources

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

Today I review PedsCases Approach to Pediatric Vomiting Part 2.  I’ve reviewed Approach to Pediatric Vomiting Part 1 previously. Here are the direct links:

Here are excerpts from Part 2 [Note: be sure and also review my post, Links To PedsCases Approach to Pediatric Vomitting Part 1]:



  • the onset,
  • frequency,
  • time frame,
  • provoking and alleviating factors should be explored.
  • The vomit should be characterized in detail
    including the amount, color, and consistency.

First, it should be categorized as bilious or non-bilious.

Second, it should be categorized as bloody or non-bloody.

Third, the vomit should be identified as projectile or non-projectile, as projectile vomiting may point to a specific diagnosis – namely, pyloric stenosis.

Fourth, the age of presentation should be considered.

  • In the neonatal period, consider:
    • Gastroenteritis
    • Malrotation
    • Pyloric stenosis
    • Tracheo-esophageal fistula
    • Necrotizing enterocholitis
  • In infancy, common causes to consider include:
    • GERD
    • Gastroenteritis
    • Bowel Obstruction
    • Milk protein allergy
    • UTI
  • In children, one must think of:
    • Gastroenteritis
    • UTI
    • DKA
    • Post-tussive vomiting
    • Increased intracranial pressure.
  • In adolescents, consider:
    • Gastroenteritis
    • Appendicitis
    • DKA
    • Increased intracranial pressure

Fifth, one should determine whether the child is febrile or afebrile. The presence of fever increases the likelihood of an infectious etiology.

[Sixth, determine] the presence of any associated GI symptoms

  • Nausea
  • Abdominal pain
  • [Abdominal] distension
  • Diarrhea
  • Obstipation

[Seventh,] infectious symptoms should be elicited, including:

  • Fever,
  • Dysuria,
  • Ear pain,
  • Cough,
  • Coryza,
  • Shortness of breath
  • Meningismus

[Eighth, consider the possibility of diabetic ketoacidosis, DKA:]

  • Source: PMID: PMID: 25941653  – The clinical signs of DKA include dehydration (may be difficult to detect), tachycardia, tachypnoea (may be mistaken for pneumonia or asthma), deep sighing (Kussmaul) respiration with a typical smell of ketones in the breath (variously described as the odor of nail polish remover or rotten fruit), nausea, vomiting (may be mistaken for gastroenteritis), abdominal pain (may mimic an acute abdominal condition), confusion, drowsiness, progressive reduction in level of consciousness, and eventually loss of consciousness.
  • Review also Diabetic Ketoacidosis – Outstanding Summary And Flow Chart From Emergency Medicine Cases
    Posted on April 24, 2020 by Tom Wade MD

[Ninth,] Red flag symptoms that you do not want to miss include meningismus, costovertebral tenderness, abdominal pain and any evidence of increased intracranial pressure. Do
not miss a child who is vomiting due to a life-threatening condition such as meningitis, DKA or pyelonephritis.

[Tenth,] Increased Intracranial Hypertension [Link is to Download PDF revised 1/15] from Nationwide Children’s Hospital:

Basically if the pediatric vomiting patient has any sign or symptom that could be neurologic, consider Increased Intracranial Pressure.

[This is from the above parent handout. The key is for the pediatrician to look for any of these behaviors in the patient with vomitting. And then to consider Increased Intracranial Pressure as a possible cause.]

  • Change in your child’s behavior such as extreme irritability (child is cranky, cannot
    be consoled or comforted)
  • Increased sleepiness (does not act as usual when
    you offer a favorite toy, or is difficult to wake up)
  • Shrill or high-pitched cry
  • Nausea (child feels like throwing up)
  • Vomiting (throwing up)
  • Complaint of a headache or stiff neck
    when waking up
  • Complaint of nausea or throwing up in
    the morning
  • Convulsions (seizures)
  • Weakness of one side of the body
  • Trouble walking or uncoordinated movement
    (staggering or swaying)
  • Eye changes (crossed eyes, droopy eyelids, blurred or double vision, trouble using eyes,
    unequal size of eye pupils, or continuous downward gaze)
  • Increased head size, if your child is younger than 18 months
  • Full or tight fontanel (soft spot), if your child is younger than 18 months
  • Loss of consciousness (does not awaken when you touch and talk to him)
  • Child just does not “look right” to you

[Eleventh,] assess the patient’s hydration status and ask about:

  • Oral intake
  • Urine output
  • Tear production
  • Weight changes.

Physical Exam

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