pediatrics
Nausea and Vomiting in Infants and Children
Evaluation
Evaluation includes assessment of severity (eg, presence of dehydration, surgical or other life-threatening disorder) and diagnosis of cause. History of present illnessshould determine when vomiting episodes started, frequency, and character of episodes (particularly whether vomiting is projectile, bilious, or small in amount and more consistent with spitting up). Any pattern to the vomiting (eg, after feeding, only with certain foods, primarily in the morning or in recurrent cyclic episodes) should be established. Important associated symptoms include diarrhea (with or without blood), fever, anorexia, and abdominal pain, distention, or both. Stool frequency and consistency and urinary output should be noted. A history of possible ingestions or drug use (particularly including use of cannabinoids) should be elicited. Review of systemsshould seek symptoms of causative disorders, including weakness, poor suck, and failure to thrive (metabolic disorders); delay in passage of meconium, abdominal distention, and lethargy (intestinal obstruction); headache, nuchal rigidity, and vision changes (intracranial disorders); food bingeing or signs of distorted body image (eating disorders); missed periods and breast swelling (pregnancy); rashes (eczema or urticaria in food allergies, petechiae in sepsis or meningitis); ear pain or sore throat (focal nongastrointestinal infection); and fever with headache, neck or back pain, or abdominal pain (meningitis, pyelonephritis, or appendicitis). Past medical historyshould note history of travel (possible infectious gastroenteritis), any recent head trauma, and unprotected sex (pregnancy). Vital signs are reviewed for indicators of infection (eg, fever) and volume depletion (eg, tachycardia, hypotension). During the general examination, signs of distress (eg, lethargy, irritability, inconsolable crying) and signs of weight loss (cachexia) or gain are noted. Because the abdominal examination may cause discomfort, the physical examination should begin with the head. The head and neck examination should focus on signs of infection (eg, red, bulging tympanic membrane; bulging anterior fontanelle; erythematous tonsils) and dehydration (eg, dry mucous membranes, lack of tears). The neck should be passively flexed to detect resistance or discomfort, suggesting meningeal irritation. Cardiac examination should note presence of tachycardia (eg, dehydration, fever, distress). Abdominal examination should note distention; presence and quality of bowel sounds (eg, high-pitched, normal, absent); tenderness and any associated guarding, rigidity, or rebound (peritoneal signs); and presence of organomegaly or mass. The skin and extremities are examined for petechiae or purpura (severe infection) or other rashes (possible viral infection or signs of atopy), jaundice (possible metabolic disorder), and signs of dehydration (eg, poor skin turgor, delayed capillary refill). Growth parameters and signs of developmental progress should be noted. The following findings are of particular concern: Bilious emesis Lethargy or listlessness Inconsolability and bulging fontanelle in infant Nuchal rigidity, photophobia, and fever in older child Peritoneal signs or abdominal distention (surgical abdomen) Persistent vomiting with poor growth or development Initial findings help determine severity of diagnosis and need for immediate intervention. Any neonate or infant with recurrent or bilious (yellow or green) emesis or projectile vomiting most likely has a Intestinal Obstruction and probably requires surgical intervention. An infant or young child with colicky abdominal pain, signs of intermittent pain or listlessness, and absent or bloody stools needs to be evaluated for an Intussusception . A child or adolescent with fever, nuchal rigidity, and photophobia should be evaluated for Overview of Meningitis . A child or adolescent with fever and abdominal pain followed by vomiting, anorexia, and decreased bowel sounds should be evaluated for Appendicitis . Recent history of head trauma or chronic progressive headaches with morning vomiting and vision changes indicate intracranial hypertension. Other findings can be interpreted primarily depending on age ( see Table: Some Causes of Vomiting in Infants, Children, and Adolescents ). irritability, choking, and respiratory signs (eg, stridor) may be manifestations of Gastroesophageal Reflux in Infants . A history of poor development or neurologic manifestations suggests a central nervous system or metabolic disorder. Delayed passage of meconium, later onset of vomiting, or both may indicate fever suggests infection; the combination of vomiting and diarrhea suggests acute Overview of Gastroenteritis . Lesions on fingers and erosion of tooth enamel or an adolescent unconcerned about weight loss or with distorted body image suggests an Testing should be directed by suspected causative disorders ( see Table: Some Causes of Vomiting in Infants, Children, and Adolescents ). Imaging studies are typically done to evaluate abdominal or central nervous system pathology. Various specific blood tests or cultures are done to diagnose inherited metabolic disorders or serious infection. If dehydration is suspected, or vomiting has been prolonged, serum electrolytes should be measured (See also Pathophysiology .) 