Alpha Fardah Athiyyah - Recurrent Vomiting in Children - Pegasus

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1 - 2 JUNE 2024
Recurrent Vomiting In Children:

How To Manage
Alpha Fardah Athiyyah
Departement of Child Health Faculty of Medicine
Dr Soetomo General Academic Hospital
Surabaya
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM
UKK
Gastrohepatologi
“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”

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OUTLINE
I • Definition
II • Pathophysiology
III • Differential Diagnosis
IV • Diagnosis Approach
V • Cyclic Vomiting Syndrome

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Definition
• Vomiting: forceful expulsion of gastric
contents through the mouth and/or nose
• Common symptom of numerous
underlying conditions, can originate from
the GI tract or systemic disorders
• Differs from:
• Reflux / regurgitation: effortless
retrograde flow of duodenal or gastric
fluids into the esophagus and oral
cavity
• Rumination: self-promote to electively
regurgitate, and often chew and
swallow their regurgitated food again
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM 3
“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE” Shields TM, Lightdale JR. Vomiting in Children. Pediatr Rev. 2018 Jul;39(7):342-358.
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• Acute vomiting: presents rapidly over 24 to 48 hours

and can be associated with severe symptoms and
dehydration.
• Recurrent vomiting: at least 3 episodes occurring
over 3 mo period
• Chronic vomiting: several days to weeks, tends to
be of low volume and infrequent (more than 2
times/week), and it is rarely associated with
dehydration
• Cyclic / episodic vomiting: discrete episodes of
Shields TM, Lightdale JR. Vomiting in Children. Pediatr Rev.
high intensity vomiting that occur sporadically in 2018 Jul;39(7):342-358.
Campbell C, Slater Y, Approach to the vomiting child,
between asymptomatic intervals Paediatrics and Child Health (2018), https://doi.org/

10.1016/j.paed.2018.09.001
• Temporal
Singhi SC, Shah R, Bansal A, Jayashree M. Management of a
pattern of vomiting is Important to make
child with vomiting. Indian J Pediatr. 2013 Apr;80(4):318-
4 25.
differential diagnosis
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Pathophysiology
• Three linked activities of vomiting:
1. Nausea: sensation of impending emesis and is frequently
accompanied by autonomic changes, such as increased
heart rate and salivation
2. Retching: strong, involuntary efforts to vomit but without
expelling material from the mouth, may be seen as
preparatory manoeuvres to vomiting
3. Vomiting: forceful ejection of stomach contents up to and
out of the mouth
• Vomiting can occur without preceding nausea, for e.g.,
projectile vomiting in individuals with increased intracranial
pressure
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM Singhi SC, Shah R, Bansal A, Jayashree M. Management of a child with vomiting. Indian J Pediatr. 2013 5
Apr;80(4):318-25.
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The
complex
pathways
leading to
vomiting
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM Campbell C, Slater Y, Approach to the vomiting child, Paediatrics and Child Health (2018), 6
https://doi.org/ 10.1016/j.paed.2018.09.001
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Harlos M. (2024, June 1) Management of nausea and vomiting

7
“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE” in palliative care.
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Causes of
Vomiting by
Age and
Temporal
Pattern
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM Shields TM, Lightdale JR. Vomiting in Children. Pediatr Rev. 2018 Jul;39(7):342-358. 8
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Temporal patterns of vomiting
Apr;80(4):318-25.
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Etiology and source of vomiting according to contents of vomitus
Apr;80(4):318-25.
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Diagnosis approach
• History taking:
• Age and gender • Is the time of vomiting related to
• Determine first what you are dealing with: eating/drinking?
vomiting/other • Does changing body position affect
• What is the child's nutritional status? vomiting
• Are there any predisposing factors? • Dietary information: quality, quantity
and frequency of meals (especially for
• Are there any diseases that attack the child young children)
intercurrently?
• What is the drinking technique?
• What is the shape (contents) of the vomit,
is it like milk/original food (a sign of • What are the psychosocial conditions
esophageal contents), or is it milk that has at home?
curdled (stomach contents) or contains
Hegar B. Muntah. Dalam: Buku Ajar Gastrohepatologi Anak, BP IDAI, Jakarta 2020
bile (duodenum contents), or is there
blood?
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... diagnosis approach

• Physical examination
• Vital signs, consciousness • Head/Neck: ears, pharynx,
tonsils, sinuses
• Anthropometry: BW, BL or BH, HC
according to WHO / CDC growth • Thorax
chart • Abdomen: tenderness, mass,
• Neurological examination: digital rectal examination,
meningeal stimulation, cranial genitalia
nerves, physiological/pathological • Extremities
reflexes
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM Hegar B. Muntah. Dalam: Buku Ajar Gastrohepatologi Anak, BP IDAI, Jakarta 2020 12
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Red flags signs & symptoms for urgent referral

evaluation:
• hematemesis (especially with the first episode of vomiting)
• hematochezia
• recurrent bilious emesis
• clinical dehydration
• evidence of shock
• focal neurologic changes
• abdominal distention, and absent or tympanic bowel sounds
• vomiting that wakes a child from sleep
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Supporting Examination: depending on suspicion

• Work up sepsis: blood, urine, CRP • Radiological examination, especially in
cultures, etc surgical cases:
• Metabolic disorder tracking: blood gas • Plain abdominal x-ray to see the
analysis, ammonia, etc appearance of intestinal air
• Serum electrolyte examination • Abdominal radiography with
• Bilirubin and hepatic transaminases in contrast as indicated
hepatitis • Ultrasound
• Urinalysis in urinary tract infections • CT or MRI in suspicion of elevated
• Serum amylase and lipase in intracranial pressure
pancreatitis • pHmetry & multiple intraluminal
• Cerebrospinal fluid examination in impedance for GERD suspicion
intracranial infections • Endoscopy: may be necessary for
gastritis or ulcers
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM Hegar B. Muntah. Dalam: Buku Ajar Gastrohepatologi Anak, BP IDAI, Jakarta 2020 14
Shields TM, Lightdale JR. Vomiting in Children. Pediatr Rev. 2018 Jul;39(7):342-358.
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Evaluation of
children with
cyclic
vomiting
pattern
Raucci U, Borrelli O, Di Nardo G,

Tambucci R, Pavone P, Salvatore
S, et al. Cyclic Vomiting Syndrome
in Children. Front Neurol. 2020
Nov 2;11:583425. doi:
10.3389/fneur.2020.583425.
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM PMID: 33224097; PMCID:
15
“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE” PMC7667239.
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Diagnosis approach:
• Detailed medical history, baseline testing
to identify organic causes, find alarm
symtoms & signs, comorbidities
• Diagnosis criteria:
• NASPGHAN
• Rome IV (DGBI)→ earlier diagnosis,
different criteria for neonate/toddlers
• ICHD-3
Raucci U, Borrelli O, Di Nardo G, Tambucci R, Pavone P, Salvatore S, et al. Cyclic Vomiting Syndrome in
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM Children. Front Neurol. 2020 Nov 2;11:583425. doi: 10.3389/fneur.2020.583425. PMID: 33224097; 16
PMCID: PMC7667239.
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Four
phases
scheme
for CVS
Raucci U, Borrelli O, Di Nardo G,

Tambucci R, Pavone P, Salvatore
S, et al. Cyclic Vomiting
Syndrome in Children. Front
Neurol. 2020 Nov 2;11:583425.
doi:
10.3389/fneur.2020.583425.
PMID: 33224097; PMCID:
PMC7667239. 17
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Treatment
Proton pump inhibitor

≠
obat muntah

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Treatment
• Emergency management:
• treat dehydration
• in bilious vomiting stop oral fluids/feeds and decompress the
stomach with nagogastric tube, start iv fluids, seek surgical consult
• antiemetics? not routinely indicated (especially due to concerns
about side effects), should be avoided prior to evaluation for
surgical abdomen. Acceptable indications:
• not able to take orally due to persistent vomiting
• post-operative vomiting
• chemotherapy induced vomiting
• cyclic vomiting syndrome
• acute motion sickness
“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE” Apr;80(4):318-25.
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• Treatment based on etiology, for examples: ... treatment

• Vestibular: antihistamines for motion sickness
• Obstruction: surgery for intestinal atresia
• Metabolic: rehydration and insulin for DKA,
• Infection: antimicrobial therapy for susceptible agents
• Toxin: ondancentron (serotonin receptor antagonist) for CINV
(chemotherapy induced nausea and vomiting)
• Nephrologic: surgery for UPJ obstruction
• Gastrointesinal: supportive, antiemetics on acute episode,
amitryptiline for prophylactic of CVS
• Genitalia: surgery for testicular/ovarial torsion
Shields TM, Lightdale JR. Vomiting in Children. Pediatr Rev. 2018 Jul;39(7):342-358.
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM Singhi SC, Shah R, Bansal A, Jayashree M. Management of a child with vomiting. Indian J Pediatr. 20
2013 Apr;80(4):318-25.
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Antiemetic
Medications
and Their
Dosages and
Target
Receptors
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... CVS
Medications available for pharmacological treatment of CVS in children

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM Raucci U, Borrelli O, Di Nardo G, Tambucci R, Pavone P, Salvatore S, et al. Cyclic Vomiting Syndrome in Children. Front Neurol. 22
2020 Nov 2;11:583425. doi: 10.3389/fneur.2020.583425. PMID: 33224097; PMCID: PMC7667239.
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Summary
• Vomiting is a common symptom of numerous underlying conditions, can originate
from the GI tract or systemic disorders
• Age and temporal pattern of vomiting is important to make the diagnosis in children
• Careful history taking, physical examination, recognize red flag signs and symptoms,
and supporting examination as indicated are important to make the diagnosis
• CVS is identified by acute, stereotyped and recurrent episodes of intense nausea and
incoercible vomiting with predictable periodicity and return to baseline health
between episodes with multifactorial pathophysiology
• Diagnosis established by Rome IV criteria based on detailed medical history; baseline
testing to identify organic causes, find alarm symtoms & signs, comorbidities are
recommended
• Treatment includes acute treatments during attack, lifestyle & dietary changes, and
prophylactic pharmacotherapy as needed.
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TERIMA
KASIH
감사합니다 UKK
Gastrohepatologi
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Cyclic vomiting syndrome (CVS)

• Acute, stereotyped and recurrent episodes of intense nausea and incoercible
vomiting with predictable periodicity and return to baseline health between
episodes
• Pathophysiology: multifactorial: aberrant brain-gut pathways, mitochondrial
enzymopathies, gastrointestinal motility disorders, calcium channel abnormalities,
and hyperactivity of the hypothalamic-pituitary-adrenal axis in response to a
triggering environmental stimulus
• Children: prevalence 1.9%, incidence 3.15 per 100.000 /year, mean age at onset
5.7±0.3 year, mean age diagnosis 8.0±0.3 year
• 50-70% resolves in late childhood or early adolescence, evolves into migraine later in
life
Raucci U, Borrelli O, Di Nardo G, Tambucci R, Pavone P, Salvatore S, et al. Cyclic Vomiting Syndrome in Children. Front Neurol. 2020 Nov
2;11:583425. doi: 10.3389/fneur.2020.583425. PMID: 33224097; PMCID: PMC7667239.
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... CVS
Differential diagnosis:
• “URGENTIME”
• URologic
• Gastrointestinal
• Endocrine
• Neurologic disorders
• Toxins/medication
• (recurren) Infections
• MEtabolic diseases
• Perform diagnostic tests to rule out
differential diagnosis

Raucci U, Borrelli O, Di Nardo G, Tambucci R, Pavone P, Salvatore S, et al. Cyclic Vomiting Syndrome in
“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE” Children. Front Neurol. 2020 Nov 2;11:583425. doi: 10.3389/fneur.2020.583425. PMID: 33224097;
PMCID: PMC7667239.
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... CVS
Treatment
• Acute treatment (during attack): supportive, symptomatic care, fluid & electrolyte
correction, antiemetics, analgesics, sedation, abortive agents
• Lifestyle changes & dietary restrictions (non-pharmacologic):
• vomiting diaries: frequency, type of meal before episodes, potential aggravating
life events
• avoidance of excessive excitement, triggering foods (e.g. foods that aggravate
migraines: cheese, chocolate, hot dogs, aspartame, MSG, alcohol) &
documented food sensitivities
• good sleep hygiene, regular aerobic exercise, meal schedules, mood hydration,
moderation/avoidance of caffeine
• Prophylactic pharmacotherapy during interictal period: depends on attack intensity
(more than 1-2 months) and severity (exceeding 2 days or hospitalization),
impairment of QoL, attack treatments ineffective
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM Raucci U, Borrelli O, Di Nardo G, Tambucci R, Pavone P, Salvatore S, et al. Cyclic Vomiting Syndrome in Children. Front Neurol. 2020 28
Nov 2;11:583425. doi: 10.3389/fneur.2020.583425. PMID: 33224097; PMCID: PMC7667239.
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Differential diagnosis
• Mnemonic ‘VOMITINGs’
• Vestibular: otitis media
• Obstruction: pyloric stenosis,
malrotation, volvulus,
intussusception, incarcerated hernia
• Metabolic: diabetic ketoacidosis,
inborn errors of metabolism,
congenital adrenal hyperplasia,
Reye’s syndrome
• Infections:
• Gastrointestinal – gastritis, gastroenteritis, NEC,
appendicitis, hepatitis, pancreatitis, cholecystitis
• Other systems – upper respiratory infections,
pharyngitis, sinusitis, pneumonia, sepsis
Apr;80(4):318-25.
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... Differential diagnosis

... ‘VOMITINGs’
• Toxins and drugs: various poisons,
chemotherapeutic agents, iron,
organophosphates, theophylline, salicylates,
alcohol, lead and other heavy metals
• Increased intracranial pressure from any
etiology
• Nephrologic disease: acute renal failure,
chronic renal failure, pyelonephritis, RTA,
obstructive uropathy
• Gastrointestinal: GER, formula intolerance,
peptic ulcer disease, CVS
• Genital system: testicular torsion,
epididymitis, dysmenorrhea, ovarian torsion,
pelvic inflammatory disease
Apr;80(4):318-25.
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... pathophysiology
• Starts with salivation and sensation of nausea
• Reverse peristalsis empties material from the
upper part of the small intestine into the
stomach
• The glottis closes, preventing aspiration of
vomitus into the trachea
• The breath is held in mid inspiration
• The muscles of the abdominal wall contract, and
because the chest is held in a fixed position, the
contraction increases intra-abdominal pressure
• The LES and the esophagus relax, and the gastric
contents are ejected
Vomiting process
Barrett KE, Barman SM, Brooks HL, Yuan J. Ganong’s Review of Medical Physiology 26th ed. 32
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM McGraw-Hill Education, New York 2019
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... pathophysiology
Neural pathways leading to

the initiation of vomiting in
response to various stimuli
Barrett KE, Barman SM, Brooks HL, Yuan J. Ganong’s Review of Medical Physiology 26th ed. McGraw-Hill 33
PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM Education, New York 2019
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... pathophysiology
• Four main stimulating pathway of emetic
reflex:
1. mechanical
2. blood-borne toxins
3. motion
4. emotional response
• Each pathway includes 1 or multiple
receptors activated by various specific
neurotransmitters and can occur either
in isolation or in combination
Shields TM, Lightdale JR. Vomiting in Children. Pediatr Rev. 2018 Jul;39(7):342-358. 34

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1 PEG SU

Recurrent Vomiting In Children:

“UPDATES ON PEDIATRIC GASTROHEPATOLOGY MANAGEMENT IN DAILY PRACTICE”

III • Differential Diagnosis

V • Cyclic Vomiting Syndrome

• Acute vomiting: presents rapidly over 24 to 48 hours

between asymptomatic intervals Paediatrics and Child Health (2018), https://doi.org/

Harlos M. (2024, June 1) Management of nausea and vomiting

Temporal patterns of vomiting

Etiology and source of vomiting according to contents of vomitus

... diagnosis approach

Red flags signs & symptoms for urgent referral

Supporting Examination: depending on suspicion

Raucci U, Borrelli O, Di Nardo G,

Raucci U, Borrelli O, Di Nardo G,

Proton pump inhibitor

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM 18

• Treatment based on etiology, for examples: ... treatment

Medications available for pharmacological treatment of CVS in children

Cyclic vomiting syndrome (CVS)

PEDIATRIC GASTROHEPATOLOGY UPDATE SYMPOSIUM 27

... Differential diagnosis

Neural pathways leading to

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