★ Must-know
📌 True vomiting is the forceful ejection of stomach or esophageal contents from the mouth, often with nausea and retching; regurgitation is effortless or nearly effortless and is not true emesis, while rumination is regurgitation with rechewing of food.
📌 Chronic recurrent vomiting generally occurs more than two episodes, with low-intensity vomiting in children who are generally not acutely ill, whereas cyclic recurrent vomiting has infrequent episodes (≤2/week) but acute severity and forceful vomiting more than 4 to 6 times/h.
Further detail
📌 Pregnancy should be excluded in a sexually active adolescent female with vomiting.
Effortless regurgitation contrasts with forceful emesis; rumination adds rechewing.
📌 Acute vomiting in the context of an acute abdomen requires immediate surgical consultation.
Signs of an acute abdomen include:
Findings suggesting increased intracranial pressure include:
★ Must-know
Many cases of intestinal malrotation present as volvulus in the newborn period with bilious vomiting and severe clinical toxicity, while other cases present years later as intermittent vomiting.
Congenital obstructive lesions include:
Further detail
Causes of acquired obstructive lesions include:
Plain abdominal x-rays are recommended initially for suspected obstruction; ultrasound, CT, or fluoroscopy may establish the diagnosis more definitively, but may be unnecessary or unrecommended once surgery is already indicated.
Abdominal trauma can cause an obstructive duodenal hematoma, with child abuse and seat belt injuries recognized as causes.
Bowel twisting on its mesentery can obstruct blood flow and present as severe neonatal illness.
★ Must-know
Superior mesenteric artery syndrome is transient duodenal obstruction caused by compression between the superior mesenteric artery anteriorly and the aorta posteriorly.
Superior mesenteric artery syndrome causes bilious vomiting and epigastric pain relieved by a prone or knee-chest position.
With rotavirus, vomiting often precedes diarrhea by 1 to 2 days.
Pyloric stenosis presents in the first few weeks of life with progressive nonbilious vomiting, often projectile, and may later cause coffee-ground emesis and poor weight gain.
Further detail
📌 A child with acute-onset, large-volume emesis and fever and/or diarrhea consistent with acute gastroenteritis may not need additional workup.
By presentation, pyloric stenosis often causes dehydration, metabolic alkalosis, and hypochloremia.
Pyloric stenosis is diagnosed by physical examination and ultrasound or an upper gastrointestinal study showing the string sign through the narrowed pylorus.
With rotavirus, vomiting often comes first; diarrhea follows 1 to 2 days later.
★ Must-know
📌 Mental status changes and abnormal respirations may indicate ingestion of a toxic drug or poison.
Further detail
Sinusitis can cause acute, chronic, or cyclic vomiting; nausea, congestion, postnasal drip, and early-morning vomiting often preceded by coughing suggest the diagnosis.
Ureteropelvic junction obstruction causes hydronephrosis during fluid loading and diuresis; congenital cases may present as an abdominal mass or urinary tract infection.
Spontaneous resolution of symptoms after several hours as dehydration relieves renal pelvic distention suggests ureteropelvic junction obstruction.
★ Must-know
Most inborn errors of metabolism present early in the newborn period with vomiting and failure to thrive, while some cause later chronic or cyclic vomiting after certain foods are introduced or during acute stress or illness.
Metabolic disorders may cause vomiting episodes accompanied by acidosis, mental deterioration, and coma, and the family history may include the disorder, unexplained intellectual disability, failure to thrive, or neonatal deaths.
📌 A metabolic workup should be considered when vomiting is accompanied by neurologic symptoms, hepatosplenomegaly, or unusual odors from the breath, urine, or ear wax.
Further detail
For suspected metabolic disease, blood and urine should be collected during episodes of suggestive symptoms.
The metabolic workup includes blood tests for:
★ Must-know
📌 When gastroesophageal reflux is suspected without life-threatening symptoms such as apnea, a trial of an H₂ blocker or proton pump inhibitor may be diagnostic; apnea often prompts additional study.
Further detail
📌 A family history of peptic ulcer disease or similar symptoms should prompt a urea breath test or stool antigen assay for Helicobacter pylori; antibody testing is less useful for diagnosis.
📌 Endoscopy should be considered for peptic ulcer symptoms that are atypical or do not respond to therapy.
★ Must-know
Vomiting may indicate food hypersensitivity, commonly to cow’s milk or soy protein, including food protein enterocolitis syndrome and food protein enteropathy; IgE-mediated food allergy may also cause vomiting.
Causes of gastric stasis and paralytic ileus include:
📌 Psychogenic vomiting should be diagnosed only after organic causes have been ruled out.
Further detail
Vomiting may reveal a specific food-related disorder such as hereditary fructose intolerance or celiac disease after certain foods are introduced.
Patients with psychogenic vomiting are often anxious, affected by familial conflict, and not bothered by the vomiting.
Vestibular disorders may feature:
Manometry and biopsy may be necessary to diagnose pseudo-obstruction definitively.
Take a 24-question practice quiz on Pediatric Vomiting, with every answer explained.
1. Which feature distinguishes true vomiting from regurgitation?
2. A child has infrequent episodes of vomiting but becomes acutely ill and vomits forcefully more than four times per hour during an episode. Which pattern best fits?
Memorize the key concepts of Pediatric Vomiting with 62 flashcards.
What defines true vomiting by its contents and manner of ejection?
Forceful ejection of stomach or esophageal contents from the mouth.
How does regurgitation differ from true vomiting?
It is effortless or nearly effortless and is not true emesis.
What distinguishes rumination from other regurgitation?
Rumination includes rechewing regurgitated food.
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