Nausea and Vomiting in Infants and Children

Infants normally spit up small amounts (usually < 5 to 10 mL) during or soon after feedings, often when being burped. Rapid feeding, air swallowing, and overfeeding may be causes, although spitting up occurs even without these factors. Occasional vomiting may also be normal, but repeated vomiting is abnormal.

The most common causes of vomiting in infants and neonates include the following:

Other important causes in infants and neonates include the following:

Less common causes of recurrent vomiting include sepsis Neonatal Sepsis Neonatal sepsis is invasive infection, usually bacterial, occurring during the neonatal period. Signs are multiple, nonspecific, and include diminished spontaneous activity, less vigorous sucking... read more and food intolerance. Metabolic disorders Introduction to Inherited Disorders of Metabolism Most inherited disorders of metabolism (also called inborn errors of metabolism) are caused by mutations in genes that code for enzymes; enzyme deficiency or inactivity leads to Accumulation... read more (eg, urea cycle disorders Urea Cycle Disorders Urea cycle disorders are characterized by hyperammonemia under catabolic or protein-loading conditions. There are many types of urea cycle and related disorders (see the table) as well as many... read more , organic acidemias) are uncommon but can manifest with vomiting.

History of present illness should 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 systems should 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 history should 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:

Initial findings help determine severity of diagnosis and need for immediate intervention.

Other findings can be interpreted primarily depending on age ( see Table: Some Causes of Vomiting in Infants, Children, and Adolescents Some Causes of Vomiting in Infants, Children, and Adolescents ).

In infants, irritability, choking, and respiratory signs (eg, stridor) may be manifestations of gastroesophageal reflux Gastroesophageal Reflux in Infants Gastroesophageal reflux is the movement of gastric contents into the esophagus. It may be physiologic or pathologic. When pathologic, it is also known as gastroesophageal reflux disease (GERD)... read more . 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 Hirschsprung disease Hirschsprung Disease Hirschsprung disease is a congenital anomaly consisting of a failure of neuronal colonization (and thus a failure of innervation) of the lower intestine, usually limited to the colon, resulting... read more or intestinal stenosis.

In children and adolescents, fever suggests infection; the combination of vomiting and diarrhea suggests acute gastroenteritis Overview of Gastroenteritis Gastroenteritis is inflammation of the lining of the stomach and small and large intestines. Most cases are infectious, although gastroenteritis may occur after ingestion of drugs, medications... read more . Lesions on fingers and erosion of tooth enamel or an adolescent unconcerned about weight loss or with distorted body image suggests an eating disorder Introduction to Eating Disorders Eating disorders involve a persistent disturbance of eating or of behavior related to eating that Alters consumption or absorption of food Significantly impairs physical health and/or psychosocial... read more . Morning nausea and vomiting, amenorrhea, and possibly weight gain suggest pregnancy Contraception and Adolescent Pregnancy Many adolescents engage in sexual activity but may not be fully informed about contraception, pregnancy, and sexually transmitted infections, including hepatitis C and HIV infection. Impulsivity... read more . Vomiting that has occurred in the past and is episodic, short-lived, and has no other accompanying symptoms suggests cyclic vomiting Etiology Nausea, the unpleasant feeling of needing to vomit, represents awareness of afferent stimuli (including increased parasympathetic tone) to the medullary vomiting center. Vomiting is the forceful... read more .

Testing should be directed by suspected causative disorders ( see Table: Some Causes of Vomiting in Infants, Children, and Adolescents 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 of Dehydration in Children Pathophysiology Dehydration is significant depletion of body water and, to varying degrees, electrolytes. Symptoms and signs include thirst, lethargy, dry mucosa, decreased urine output, and, as the degree... read more .)