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Red flag symptoms: Vomiting in children, assessment and possible causes

Advice on taking a careful history, physical examination and possible causes in neonates, infants and older children.

Intussusception may present with vomiting and abdominal pain
Intussusception may present with vomiting and abdominal pain

Red flag symptoms

  • Bilious vomiting
  • Haematemesis
  • Recurrent vomiting
  • Projectile vomiting in the first few weeks of life
  • Early morning headache
  • Lethargy
  • Bulging fontanelle
  • Peritonism
  • Poor growth/abnormal development
  • Weight loss
  • Abdominal tenderness and/or abdominal mass

Vomiting is a common symptom in children, often associated with a self-limiting viral GI infection.

Vomiting may be preceded by the sensation of nausea, this may be associated with autonomic symptoms such as sweating and pallor. Nausea does not always precede vomiting, for example, in rumination syndrome where there is oral regurgitation of food. Moreover, vomiting does not necessarily follow nausea, for example, in functional dyspepsia where there is early satiety.

Careful history-taking and examination are needed to assess hydration status and whether urgent management is needed.

Vomiting may be defined as an autonomic response causing forceful expulsion of gastric or intestinal contents from the mouth. This forceful expulsion is accompanied by an increase in intra-abdominal pressure.

This should be differentiated from regurgitation - effortless return of contents. Posseting describes the small amount of milk that often accompanies the return of swallowed air, while regurgitation refers to larger, more frequent losses which may indicate gastro-oesophageal reflux.

Clinical assessment

Important questions include assessing how the vomiting started, whether it is related to eating, recurrence, frequency and duration.

The content of the vomitus is important to consider, for example, does it consist of undigested food or blood, or is it bilious?

If the vomiting is projectile in the first few weeks of life, pyloric stenosis should be excluded. Bile-stained vomitus may be associated with intestinal obstruction.

Systemic enquiry includes assessing for abdominal pain, headaches, bowel symptoms, fever, respiratory symptoms, neurological symptoms and weight loss. 

It is important to explore whether there is a possible relationship to foods, as this may be suggestive of a food allergy. A family history may be relevant, for example in the case of disorders of metabolism.

Assessing fluid status and carrying out observations are helpful.

Children are at an increased risk of dehydration and this may be significant in the context of poor oral intake and/or diarrhoea. After physical examination, assessing growth may be relevant.

Causes

Neonates

In neonates, bilious vomiting and abdominal distension may be caused by volvulus, Hirschsprung's disease and necrotising enterocolitis.

Volvulus is an important diagnosis as it may cause a rapid bowel ischaemia. Hirschsprung's disease tends to have vomiting as a later feature as it causes distal intestinal obstruction.

Necrotising enterocolitis tends to affect the terminal ileum and proximal ascending colon. It occurs in 1-3 per 1000 live births, usually affecting premature infants. It may present with bilious vomiting, abdominal distension and blood in the stools.

Vomiting may be an indication of systemic infection or may occur in the context of GI infection in all age groups. It may be accompanied by fever, irritability, respiratory signs or rash. UTIs may present with non-specific symptoms.

Infants

In infants, gastro-oesophageal reflux disease (GORD) may present with vomiting associated with feeding. Gastro-oesophageal reflux is physiological; pathological gastro-oesophageal reflux or GORD is associated with poor weight gain, oesophagitis or respiratory problems.

Reflux may develop at one to four months; most cases resolve by six to 18 months. Vomiting, bowel symptoms and atopic dermatitis may be suggestive of food intolerance.

Projectile progressive vomiting with metabolic disturbance may be diagnostic for pyloric stenosis. This is the most common cause of intestinal obstruction in infancy, with an incidence of two to four per 1,000 live births. It may present with poor weight gain and dehydration.

Intussusception may present with bilious vomiting, abdominal pain and redcurrant jelly stools. However, the latter is a late and rare sign. Intussusception occurs when one segment of bowel invaginates into another, usually proximal to the ileocaecal valve, compromising the blood supply to part of the bowel. It is most common in children aged five months to three years.

Bilious vomiting and abdominal pain may be present in the case of a strangulated hernia or bowel obstruction. A strangulated hernia may result from adhesions secondary to previous abdominal surgery.

Raised intracranial pressure may present with vomiting. It may be associated with headaches that wake a child at night; the headache may be worse lying down and may be exacerbated by coughing and micturition. Raised intracranial pressure may present with a bulging fontanelle on clinical examination.

Infants with recurrent vomiting may have an inherited metabolic disease. In these cases, vomiting may be associated with failure to thrive, lethargy and developmental delay. Diabetic ketoacidosis and adrenal insufficiency may cause vomiting.

Older children

In older children, bilious vomiting with abdominal pain may be a sign of a strangulated hernia or adhesions.

The presence of fever and pain localising from the central abdomen to the right iliac fossa may point to a diagnosis of acute appendicitis. Appendicitis may be more difficult to diagnose in younger children. Possible differential diagnoses include mesenteric adenitis, intussusception and ectopic pregnancy. 

It is important to consider the possibility of gonadal torsion. Renal causes include haemolytic uraemic syndrome which is often associated with E Coli 0157 and Shigella infections, and nephrolithiasis may cause vomiting.

Episodes of recurrent vomiting in an otherwise well child may be suggestive of cyclical vomiting syndrome. Vomiting may also be a feature in diabetic ketoacidosis. In older children, the history is key in identifying alcohol intake, drug use, eating disorder or pregnancy risk.

Possible causes

Neonates

  • Volvulus
  • Hirschsprung's disease
  • Necrotising enterocolitis

Infants

  • GORD
  • Pyloric stenosis
  • Intussusception
  • Strangulated hernia
  • Bowel obstruction
  • Raised intracranial pressure
  • Inherited metabolic disease

Older children

  • Strangulated hernia
  • Adhesions
  • Acute appendicitis
  • Cyclical vomiting syndrome
  • Diabetic ketoacidosis
  • Eating disorder
  • Pregnancy
  • Alcohol
  • Illicit drug intake

  • Dr Kochhar is a GP in East Sussex

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This is an updated version of an article that was first published in April 2014

Resources

  1. Chandran L, Chitkara M. Pediatric Review 2008; 29: 183-92 
  2. Scorza K, Williams A, Phillips JD et al. Am Fam Physician 2007; 76: 76-84
  3. Assessment of nausea and vomiting in children. BMJ Best Practice. Dec 2016. [Accessed 13 June 2017]

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