Vomiting in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Adenike Eketunde

Synonyms and keywords: Vomiting in kids

## Overview

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Vomiting in children is common and can range from a benign condition to a life-threatening condition. Most cases of vomiting are gastrointestinal in origin, most commonly gastroesophageal reflux disease and gastroenteritis. Vomiting, also known as emesis, is the oral expulsion of gastrointestinal content from the mouth due to the gut and thoracoabdominal wall muscles' contraction. At the same time, nausea refers to the need to vomit. Retching is used to describe the muscular event of vomiting with the expulsion of vomitus.

## Historical Perspective

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There is limited information about the historical perspective of vomiting in children.

## Classification

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Vomiting in children may be classified according to the content of vomitus, motion, and duration into:

* Bloody and non-bloody
* Bilious and non-bilious
* Projectile and non-projectile
* Acute and chronic [1][2][3]

## Pathophysiology

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* The vomiting center can be triggered by the gastrointestinal (GI) tract, the vestibular system, the chemoreceptor trigger zone, and higher centers in the cortex and thalamus.
* The vomiting center is found in the medulla oblongata's reticular formation with muscarinic type receptor, which activates the vomiting center. Signals are then sent out to the abdominal muscle via the efferent pathway with the trigeminal (CN V), facial (CN VII), glossopharyngeal (CN IX), vagus (CN X), and hypoglossal (CN XII) to the upper gastrointestinal tract, within vagal and sympathetic nerves to the lower tract, and within spinal nerves to the diaphragm and abdominal muscles causing vomiting.
* The chemoreceptor trigger zone (CTRZ), which contains the Dopamine 2 receptor, is located outside the blood-brain barrier and can be activated directly by an irritant.[4]

## Causes

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Common causes of vomiting in children include:

* Acute gastroenteritis
* Obstruction of the GI tracts
* Infantile hypertrophic pyloric stenosis
* Intussusception
* Indirect inguinal hernia
* Appendicitis
* Volvulus
* Inflammation of the GI tract including esophagitis, gastroenteritis, peptic ulcer disease, hepatitis, pancreatitis, cholecystitis or appendicitis may cause vomiting
* Hepatitis
* Gallbladder disease
* Pancreatitis
* CNS injury concussion/post-concussion syndrome, increased intracranial pressure (ICP), migraine headache and viral meningitis.
* Renal disease
* Drugs [5][6]

## Differentiating [disease name] from other Diseases

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Vomiting in children must be differentiated from other diseases that cause vomiting in children such as cyclic vomiting syndrome (CVS) [7], gastrointestinal disease (obstructive and inflammatory) [8], central nervous system (CNS) disease, pulmonary disease, renal disease, endocrine/metabolic disorders, drugs (either as side effects or in Overdose), or psychiatric disorders.

## Epidemiology and Demographics

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Vomiting in children is very common and there are no racial, gender, age, or race predispstions to vomiting in children.

## Risk Factors

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There are no established risk factors for vomiting in children.

## Natural History, Complications and Prognosis

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* The majority of children with vomiting is mostly due to gastroenteritis. Gastroenteritis ranges from asymptomatic to dehydration to death, and usually starts with mild fever and vomiting, followed by 1-4 days of non-bloody, watery diarrhea.[1]
* Common complications of vomiting in children is dehydration.
* Prognosis ranges from excellent to poor depending on the etiology of the vomiting (include gastroenteritis to meningitis respectively)

## Diagnosis

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### Diagnostic Criteria

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* The diagnosis of vomiting in children is made with both medical history and physical examination.

### Symptoms

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* Symptoms of vomiting in children include the following:

* Fever
* Lightheadedness
* Vertigo
* Rapid pulse
* Excessive sweating
* Dry mouth
* Decreased urination
* Chest pain
* Fainting
* Confusion
* Excessive sleepiness [9]

### Physical Examination

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* Physical examination may be remarkable for signs of dehydration:

* Dry skin
* Cracked lips
* Dark-Color urine
* Dizziness
* Fatigue
* Sweating
* Frequent urination. [10]

### Laboratory Findings

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* There are no specific laboratory findings associated with vomiting in children. However, blood and urine tests are helpful in diagnosis to check for infection and kidney function.

### Electrocardiogram

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There are no ECG findings associated with vomiting in children.

### X-ray

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There are no x-ray findings associated with vomiting in children.

### Echocardiography or Ultrasound

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There are no echocardiography/ultrasound findings associated with vomiting in children.

### CT scan

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There are no CT scan findings associated with vomiting in children.

### MRI

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There are no MRI findings associated with vomiting in children.

### Other Imaging Findings

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There are no other imaging findings associated with vomiting in children.

### Other Diagnostic Studies

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* There are no other imaging findings associated with vomiting in children.

## Treatment

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### Medical Therapy

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* The mainstay of therapy for vomiting in children is to treat underlying conditions and rehydration. Antiemetic can be used in the treatment of vomiting.[11]
* Hydration includes giving fluid in small amounts; electrolytes can be used in some situations as determined by the doctor to treat dehydration. Children with vomiting might stop oral intake and decompression of the stomach with a nasogastric tube necessary for a certain patient depending on the cause. Indications for nasogastric tube include duodenal atresia, midgut malrotation, volvulus, jejunoileal atresia, and meconium ileus, necrotizing enterocolitis, etc.[12]
* A study shows that Ondasteron reduces required intravenous hydration by 51% and increase oral rehydration therapy in children with acute gastritis and acute gastroenteritis.[13]
* Another antiemetic; metoclopramide, often used in adults with refractory chemotherapy-induced nausea and vomiting (CIN V), is also used for CINV prevention in children. Regulatory bodies advised against its use in children aged <1 years and to caution against its use in children aged <5 years and its duration of service beyond five days.[14]

### Surgery

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* Surgical intervention is not recommended for the management of vomiting in children.

### Prevention

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* There are no primary preventive measures available for vomiting in children.

## References

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1. ↑ 1.0 1.1 Andrade, Gabriela Bonente Herculano de; Marin, Barbara Said; Medeiros, Daniela Nasu Monteiro; Yamanari, Mauricio Gustavo Ieiri; Troster, Eduardo Juan (2020). "Vomiting in newborns as a result of a duodenal membrane: two case reports". Einstein (São Paulo). 18. doi:10.31744/einstein_journal/2020RC4641. ISSN 1679-4508.
2. ↑ Galea R, Said E (2018). "Infantile Hypertrophic Pyloric Stenosis: An Epidemiological Review". Neonatal Netw. 37 (4): 197–204. doi:10.1891/0730-0832.37.4.197. PMID 30567916.
3. ↑ Tomasik E, Ziółkowska E, Kołodziej M, Szajewska H (2016). "Systematic review with meta-analysis: ondansetron for vomiting in children with acute gastroenteritis". Aliment Pharmacol Ther. 44 (5): 438–46. doi:10.1111/apt.13728. PMID 27401959.CS1 maint: Multiple names: authors list (link)
4. ↑ Becker DE (2010). "Nausea, vomiting, and hiccups: a review of mechanisms and treatment". Anesth Prog. 57 (4): 150–6, quiz 157. doi:10.2344/0003-3006-57.4.150. PMC 3006663. PMID 21174569.
5. ↑ Andrade GBH, Marin BS, Medeiros DNM, Yamanari MGI, Troster EJ (2020). "Vomiting in newborns as a result of a duodenal membrane: two case reports". Einstein (Sao Paulo). 18: eRC4641. doi:10.31744/einstein_journal/2020RC4641. PMC 7687917 Check `|pmc=` value (help). PMID 33263676 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
6. ↑ https://www.merckmanuals.com/professional/pediatrics/symptoms-in-infants-and-children/nausea-and-vomiting-in-infants-and-children
7. ↑ Raucci U, Borrelli O, Di Nardo G, Tambucci R, Pavone P, Salvatore S; et al. (2020). "Cyclic Vomiting Syndrome in Children". Front Neurol. 11: 583425. doi:10.3389/fneur.2020.583425. PMC 7667239 Check `|pmc=` value (help). PMID 33224097 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
8. ↑ Sullivan PB (2008). "Gastrointestinal disorders in children with neurodevelopmental disabilities". Dev Disabil Res Rev. 14 (2): 128–36. doi:10.1002/ddrr.18. PMID 18646021.
9. ↑ Reust CE, Williams A (2016). "Acute Abdominal Pain in Children". Am Fam Physician. 93 (10): 830–6. PMID 27175718.
10. ↑ Hoxha T, Xhelili L, Azemi M, Avdiu M, Ismaili-Jaha V, Efendija-Beqa U; et al. (2015). "Performance of clinical signs in the diagnosis of dehydration in children with acute gastroenteritis". Med Arch. 69 (1): 10–2. doi:10.5455/medarh.2015.69.10-12. PMC 4384849. PMID 25870468.CS1 maint: Multiple names: authors list (link)
11. ↑ Carter B, Seupaul RA (2012). "Update: antiemetics for vomiting associated with acute gastroenteritis in children". Ann Emerg Med. 60 (3): e5–6. doi:10.1016/j.annemergmed.2012.01.031. PMID 22424648.
12. ↑ Singhi SC, Shah R, Bansal A, Jayashree M (2013). "Management of a child with vomiting". Indian J Pediatr. 80 (4): 318–25. doi:10.1007/s12098-012-0959-6. PMID 23340985.CS1 maint: Multiple names: authors list (link)
13. ↑ Roslund G, Hepps TS, McQuillen KK (2008). "The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial". Ann Emerg Med. 52 (1): 22–29.e6. doi:10.1016/j.annemergmed.2007.09.010. PMID 18006189.CS1 maint: Multiple names: authors list (link)  Review in: Evid Based Med. 2009 Apr;14(2):44
14. ↑ Lau Moon Lin M, Robinson PD, Flank J, Sung L, Dupuis LL (2016). "The Safety of Metoclopramide in Children: A Systematic Review and Meta-Analysis". Drug Saf. 39 (7): 675–87. doi:10.1007/s40264-016-0418-9. PMID 27003816.CS1 maint: Multiple names: authors list (link)