Paediatrics: Vomiting

Vomiting

A common symptom in childhood.

Three clinical scenarios are recognized:

·  Acute: discrete episode of moderate to high intensity. Most common and usually associated with an acute illness.

·  Chronic: low-grade daily pattern, frequently with mild illness.

·  Cyclic: severe, discrete episodes associated with pallor, lethargy +/– abdominal pain. The child is well in between episodes. Often there is a family history of migraine or vomiting.

Causes

·  Acute: GI infection; non-GI infection (e.g. urinary tract infection); GI obstruction (congenital or acquired e.g. pyloric stenosis); adverse food reaction; poisoning; raised intracranial pressure; endocrine/metabolic disease (e.g. diabetic ketoacidosis).

·  Chronic (usually GI): peptic ulcer disease; gastro-oesophageal reflux; chronic infection; gastritis; gastroparesis; food allergy; psychogenic (see Psychogenic vomiting); bulimia; pregnancy.

·  Cyclic (usually non-GI cause): idiopathic; CNS disease; abdominal migraine; endocrine (e.g. Addison’s disease); metabolic (e.g. acute intermittent porphyria); intermittent GI obstruction; fabricated illness.

Management

•   Full history: e.g. early morning vomiting with CNS tumour, or family members with similar illness.

•   Full examination: including ear, nose, and throat (ENT) and growth.

Assess for dehydration.

Treatment

•   Supportive treatment as needed: e.g. oral or IV fluids.

•   Treat cause: e.g. pyloromyotomy for hypertrophic pyloric stenosis.

•   Pharmacological: antihistamines; phenothiazines (side-effects: extrapyramidal reactions); prokinetic drugs, e.g. domperidone. 5-HT₃ antagonists, e.g. ondansetron, are increasingly being used for treating post-operative or chemotherapy induced vomiting. 5-HT_1D agonists, e.g. pizotifen, are useful as prophylaxis and treatment for cyclic vomiting syndrome.

Complications

Dehydration, plasma electrolyte disturbance (e.g. ‘fall’ K⁺, ‘fall’ Cl^–, alkalosis with pyloric stenosis), acute or chronic GI bleeding (e.g. Mallory–Weiss tear), oesophageal stricture, Barrett’s metaplasia, broncho-pulmonary as-piration, faltering growth, iron deficiency anaemia.

Psychogenic vomiting

•   Causes: anxiety; manipulative behaviour; disordered family dynamics. A family history of vomiting is common.

•   Management: exclude organic disease. Refer to child psychologist.