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Emergency and Acute Medicine: Vomiting (Pediatric)
Pediatric vomiting is a forceful, coordinated expulsion of gastric contents through the mouth, involving the phases of nausea, retching, and emesis. During vomiting, there is sustained contraction of the abdominal muscles and diaphragm, while the pylorus and antrum contract simultaneously. Unlike adults, vomiting in children—especially neonates and infants—requires a high index of suspicion for serious pathology, as it may be the first sign of life-threatening disease.
The etiology of pediatric vomiting is broad and age-dependent, encompassing gastrointestinal, metabolic, neurologic, infectious, and feeding-related causes. Gastrointestinal causes include conditions such as Hypertrophic pyloric stenosis, Intussusception, and Midgut volvulus, all of which may lead to obstruction and require urgent intervention. Metabolic causes include inborn errors of metabolism and diabetic ketoacidosis, while neurologic causes include intracranial hemorrhage, tumors, or hydrocephalus. Infectious etiologies such as gastroenteritis, urinary tract infections, pneumonia, and sepsis are also common. Feeding-related issues, including overfeeding or milk allergy, are particularly relevant in infants.
Clinical presentation varies depending on the underlying cause, but assessment of vomiting characteristics is critical. Nonbilious vomiting suggests obstruction proximal to the pylorus, whereas bilious (green) vomiting indicates obstruction distal to the ampulla of Vater and is a surgical emergency until proven otherwise. Bloody vomiting may indicate upper gastrointestinal bleeding, while “coffee-ground” emesis reflects digested blood. A feculent odor suggests distal bowel obstruction or peritonitis. Projectile vomiting in a 2–6 week old infant is classic for hypertrophic pyloric stenosis, while sudden onset vomiting with abdominal distention and systemic illness may suggest volvulus or intussusception.
On physical examination, clinicians should assess hydration status, vital signs, and overall appearance, as children can deteriorate rapidly. Signs such as tachycardia, poor perfusion, altered mental status, or shock indicate severe illness. Abdominal examination may reveal distention, tenderness, masses, or peritoneal signs suggesting obstruction or perforation. Additional examination should include evaluation of the genitourinary system (e.g., testicular torsion) and neurologic status.
The diagnostic workup is guided by clinical suspicion and aimed at excluding life-threatening causes. Laboratory studies may include glucose, electrolytes, and infection markers (CBC, cultures). Imaging plays a key role: abdominal radiographs can identify obstruction or perforation, while ultrasound is particularly useful for diagnosing pyloric stenosis and intussusception. CT scans may be required for complex cases such as appendicitis or masses. In some cases, nasogastric tube placement can aid in diagnosis and management by assessing gastric contents.
Management begins with initial stabilization, including airway, breathing, and circulation assessment. Fluid resuscitation with isotonic saline (0.9% NS) is essential, especially in dehydrated or hypovolemic children, while cautiously considering conditions such as increased intracranial pressure. Bedside glucose testing is important to detect hypoglycemia. Gastric decompression with a nasogastric or orogastric tube may be required in cases of obstruction or persistent vomiting. Treatment then focuses on identifying and addressing the underlying cause, with early surgical consultation when an acute abdomen is suspected. Antibiotics should be initiated if infection or peritonitis is present.
Antiemetic therapy may be used once serious causes have been excluded or addressed. First-line therapy includes Ondansetron, given at 0.1 mg/kg per dose (typically 4–8 mg) IV or PO every 6 hours. Second-line options include Metoclopramide at 0.1 mg/kg per dose PO every 6 hours, Prochlorperazine at 0.1 mg/kg per dose IV, IM, or PR every 6 hours, and Promethazine at 0.25 mg/kg per dose PO, PR, or IM every 6 hours. These medications should be used cautiously due to potential side effects, especially in younger children.
Disposition depends on the child’s clinical status and underlying cause. Admission is required for unstable vital signs, dehydration, inability to tolerate oral intake, or suspected serious pathology. Children may be discharged if they are stable, able to tolerate fluids, and serious causes have been excluded, with clear instructions given to caregivers regarding warning signs such as persistent vomiting, abdominal distention, decreased urine output, fever, lethargy, or behavioral changes.
A critical clinical pearl is that bilious vomiting in neonates is an emergency and should be assumed to represent intestinal obstruction (e.g., malrotation with volvulus) until proven otherwise. Additionally, clinicians must always consider non-gastrointestinal causes of vomiting, including neurologic, metabolic, and toxicologic etiologies, to avoid missing potentially life-threatening conditions.
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