VOMITING IN CHILDREN

 Common cause is GERD

 Feed volumes should be calculated since overfeeding is common in bottle fed infants
 If transient, with other symptoms like fever, diarrhea or runny nose and cough, most likely
due to gastroenteritis or URTI, but also need to consider UTI, sepsis or meningitis.
 If projectile 2-8 weeks of age, exclude pyloric stenosis.
 If bile-stained, potential emergency – IO (intussusception, malrotation, strangulated inguinal
hernia).
GERD Clinical features
involuntary passage of gastric contents into the esophagus milky vomits after feeds
caused by functional immaturity of the lower esophageal crying / irritability
sphincter which is inappropriately relaxed arching of the back
common in the first year of life drawing up knees into the chest
resolve spontaneously by 12 months of age

Complication More common in

FTT CP/neurodevelopmental disorder
esophagitis - hematemesis, IDA, discomfort on feeding preterm
recurrent pulmonary aspiration - pneumonia, obesity
cough/wheeze, apnea hiatus hernia
dystonic neck posturing post op esophageal atresia/diaphragmatic hernia

Investigation Management
diagnosed clinically uncomplicated
atypical hx/complication, failure respond to rx - 24 hour parental reassurance
esophageal pH monitoring feeding assesment
smaller & frequent feeding
adding inert thickening agents (Carobel)
PPI
omeprazole
Surgery
fundoplication

PYLORIC STENOSIS CLinical features Diagnosis Management

hypertrophy of the non-bilious vomiting, Gastric peristalsis may rehydration

pyloric muslce causing increase in frequency be seen as a wave insert ryle tube
gastric outlet and forcefulness moving from left to definitive treatment -
obstruction overtime and right across the surgical
presents at 2-8 weeks ultimately projectile abdmomen (pyloromyotomy) after
of age feeds normally after confirmed by test feed electrolytes have been
strong familial pattern vomiting olive mass is palpable corrected
usually baby boy, first weight loss if late in the RUQ
born presentation diagnostic - USG
hypochloraemic shows hypertrophied
hypokalaemic pylorus
hyponatremia met barium meal -
alkalosis may
develops.
 INTUSSUSCEPTION
invagination of one
portion of the intestine
into another
most common IO in
infancy and early
childhood
Malrotation
congenital abnormality
of the midgut
failure of the intestine
to rotae into the correct
position during fetal life
uncommon but
important to diagnose
usually presents in the
first 1-3 days of life with
IO
Hirschprung disease
common cause of IO
absence of ganglion cells
from the myenteric and
submucosal plexus
causing absent peristalsis
and functional
obstruction of the distal
bowel
increased incidence in
siblings, Down Syndrome
Clinical features
previously healthy,
preceding viral illness
sudden onset, severe
intermittent cramping
pain
vomiting
stools - initially normal,
then become dark red
and mucoid (redcurrant
jelly)
PA - sausage shaped mass
palpable with abdominal
distention
Clinical features
bilious vomiting,
abdominal pain,
tenderness (peritonitis,
ischemic bowel)
Clinical features
delayed passage of
meconium
abdominal distention
vomiting - bilious or non
bilious
hirschprung associated
enterocolitis (HAEC) -
fever, foul smelling,
explosive diarrhea,
abdominal
distention,septic shock
FTT
recurrent enterocolitis
Investigation
abdominal xray -
distended small bowel,
absence of gas in distal
colon and rectum
diagnostic - USG - target
sign / doughnut sign
Investigation
abdominal xray - all the
small bowel to the right.
dilated stomach +/-
duodenum with rest of
abdomen being gasless.
USG - whirpool sign
Investigation
Abd xray - dilated loop of
bowel with absence of
gas in the rectum
contrast enema -
presence of a transition
zone with an abnormal
rectosigmoid index
diagnostic - rectal biopsy -
absence of ganglion cells
and calretinin and
presence of
acetylcholinesterase
positive hypertrophic
nerve bundles
Management
non operative reduction
success rate 80-90%
hydrostatic reduction with
saline / air reduction /
barium enema reduction
indication for surgery
failed non operative
reduction
bowel perforation
suspected lead point
small bowel
intussusception
Management
urgent surgical
correction
Management
IV resus
gastric decompression
rectal washout
once the diagnosis is
confirmed - definitive
surgery
VOMITING IN CHILDREN QUESTIONS

1. 2 months old baby who is seen in the paediatric outpatient, born term weighing 3.5kg and is
breastfed. Her mother is concerned as she has vomited some of the milk after most feeds
since birth. She cries when she vomits. She is continuing to grow along the 50 th centile. What
is the most likely diagnosis?

a. GERD
b. H. pylori infection
c. Infant colic
d. Overfeeding
e. Pyloric stenosis

2. An 8 months old infant, is brought to the ED by his parents. He is having episodes of

abdominal pain and is just recovering from URTI. He seems well in between, but then
suddenly seems to be in pain and looks pale. He has vomited several times. On questioning,
he has had no blood in his stool but has not opened his bowels for 24 hours. What is the
most likely diagnosis?

A. GERD
B. Intussusception
C. AGE
D. Appendicitis
E. Pyloric stenosis

3. An 8 year old girl presents to GP with vomiting and abdominal pain. Her vomiting just started
today and she has no diarrhea or fever. She looks unwell and has cilincal dehydration on
examination and has deep rapid breathing. She is thirsty and pale. She has lost weight over
the last few weeks. What is the most likely diagnosis?

a. GERD
b. AGE
c. DKA
d. UTI

4. 5 weeks old baby has been breastfeeding well and putting on weight. However, over the last
36 hours, he has been vomiting after almost every feed. The vomit goes everywhere and he
then wants to feed again. All the vomits are milky. He was born at term with birth weight of
3.8kg.

a. GERD
b. Infant colic
c. Pyloric stenosis
d. Intussusception

5. A 5 month old regularly regurgitate a large portion of her feeds. A pH probe study showed
significant periods of low esophageal pH. The child has normal growth and no other
significant past medical history. Which of the following is the best management at this point?
 a. Barium swallow
b. Proton pump inhibitor
c. Close monitoring
d. Surgical correction

6. 5 year old girl presented with vomiting 1 day ago. She is unable to tolerate food and drinks.
O/E she is crying with tears, good capillary refill time. Her temperature is 38c. what is the
most appropriate management at this stage?

a. Advice probiotic
b. Prescribe antibiotic
c. Prescribe ORS
d. Reassurance
e. Refer for admission

7. A 10 months old girl brought into ED. Mother reports the child pulls her legs up to her
abdomen and cries for 5-10mins followed by episode of relaxed silence. She also reports the
child is passing blood and mucus in her stools. O/E tubular mass is felt in the upper right
quadrant. The most likely diagnosis is

a. Intussusception
b. Volvulus
c. Pyloric stenosis
d. AGE

8. A 4 week old infant presents to your office with his parents. The parents note that he has had
vomiting everytime he eats. His vomitus is mostly formula and non bilious. He seems to be
hungry and is demanding to fed often. Except for the vomiting, he seems to be well without
diarrhea. Exam reveals an afebrile infant in no distress with normal cardiac and pulmonary
exams and relatively benign abdomen. There is no ‘olive’ palpable. Your working diagnosis is

a. AGE
b. Pyloric stenosis
c. Intussusception
d. Volvulus

9. A 3 week old baby boy presented with worsening projectile vomiting milk after feeding for 2
days. Noted feeding demand increased, mother noted fewer soiled diapers. O/E mild
dehydration, active on handling, not dysmorphic. Vital sign stable. PA – not distended, non
tender, palpable mass on RUQ 1.5cmx1.5cm. diapers – yellowish stool, no blood.

a. GERD
b. Pyloric stenosis
c. Intussusception
d. Hirschprung disease
10. 3 months old boy, full term baby. Complaint of irritability and vomiting for 1 month. Vomiting
during sleep for the past 3 weeks. O/E alert, well, PA soft not distended. Weight <10 th centile.
Length and head circumference >10th centile.

What is the most likely diagnosis?

a. GERD
b. Lactose intolerance
c. Pyloric stenosis
d. Intussusception

11. 8 week old baby boy is brought to the ED with projectile vomiting. His mother says he has
been vomiting after every feed for the last week. He has still been breastfeeding well and is
otherwise well. He has had no fever, diarrhea, rash. He was born term via SVD. He is the first
baby in the family.
O/E smiling, alert, pink and well perfused. On palpation, there is smooth olive sized mass in
the left epigastric region. In severe cases, which acid-base abnormality would be seen is this
condition?
a. Hypochloremic hyperkalamic met alkalosis
b. Respiratory acidosis
c. Hyperchloremic hypokalamic met acidosis
d. Hypochlorremic hypokalaemic met alkalosis

12. A young mother with her first born son presents to the ED. The child is six weeks old,
restless and appears dehydrated. The mother describes progressive vomiting immediately
after feeding. Initially low volume, it has increased to large volume and projectile. O/E the
child has sunken eyes, and fontanelle. On palpation, there is mass in the epigastric region.
Given the most likely diagnosis, what is the most appropriate management?

A. conservatively, IV fluids and NG tube

B. emergent surgery
C. reassurance and discharge
D. IV fluids and antibiotics
E. Correct electrolyte abnormalities before surgery