Chapter 9: Vomiting and Nausea. From Pediatric Gastrointestinal and Liver Disease , 4th ed. (2011)

“It is accepted that the ability to vomit developed as a protective mechanism to rid the body of ingested toxins. Unfortunately, vomiting also frequently occurs unrelated to the ingestion of noxious agents, a circumstance that produces several clinical challenges. First, vomiting is a sign of many diseases that affect different organ systems. Therefore, determining the cause of a vomiting episode can be difficult. Second, vomiting can produce several complications (e.g., electrolyte derangement, prolapse gastropathy, Mallory-Weiss syndrome) that demand diagnosis and treatment. Third, vomiting is a frequent complication of medical therapy (surgical procedures, cancer chemotherapy). Fourth, selection of appropriate therapy for this distressing problem is essential to improve patient comfort and avoid additional medical complications of the vomiting.”

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Vomiting in children: reassurance, red flag, or referral?

Pediatr Rev. 2008 Jun;29(6):183-92. PMID: 18515335

“Vomiting is a nonspecific symptom that may accompany a wide variety of GI and extraintestinal disorders. Serious extraintestinal causes of vomiting include brain tumor and meningitis; congenital or acquired intestinal obstructive syndromes are the most serious intestinal causes. Associated fluid and electrolyte imbalances always must be considered when assessing a child who has a history of vomiting. Conditions such as mild GER may only necessitate reassurance, but symptoms of bilious vomiting should prompt immediate referral to a pediatric surgeon. Results of the history and physical examination, keeping in mind the nature of the vomiting and age of the child, may help the clinician determine the likely cause and the need for emergent treatment.”

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Chapter 8: Nausea, Vomiting, and Pyloric Stenosis. From Walker’s Pediatric Gastrointestinal Disease, 5th ed. (2008)

“The clinical approach to vomiting begins by distinguishing it from regurgitation and recognizing the temporal (acute, recurrent–chronic, recurrent–cyclic, or episodic) pattern of vomiting. Other variables that help narrow down the diagnostic possibilities include the age of the patient, time of day and proximate events, contents of vomitus, presence or absence of nausea, associated systemic symptoms, and family history. Although one can typically treat empirically, the presence of specific alarm symptoms indicates the need of a more thorough diagnostic evaluation.”

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Evaluation of nausea and vomiting.

Am Fam Physician. 2007 Jul 1;76(1):76-84. PMID: 17668843

“A comprehensive history and physical examination can often reveal the cause of nausea and vomiting, making further evaluation unnecessary. Acute symptoms generally are the result of infectious, inflammatory, or iatrogenic causes. Most infections are self-limiting and require minimal intervention; iatrogenic causes can be resolved by removing the offending agent. Chronic symptoms are usually a pathologic response to any of a variety of conditions. Gastrointestinal etiologies include obstruction, functional disorders, and organic diseases. Central nervous system etiologies are primarily related to conditions that increase intracranial pressure, and typically cause other neurologic signs. Pregnancy is the most common endocrinologic cause of nausea and must be considered in any woman of childbearing age. Numerous metabolic abnormalities and psychiatric diagnoses also may cause nausea and vomiting. Evaluation should first focus on detecting any emergencies or complications that require hospitalization. Attention should then turn to identifying the underlying cause and providing specific therapies. When the cause cannot be determined, empiric therapy with an antiemetic is appropriate. Initial diagnostic testing should generally be limited to basic laboratory tests and plain radiography. Further testing, such as upper endoscopy or computed tomography of the abdomen, should be determined by clinical suspicion based on a complete history and physical examination.”

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The vomiting child–what to do and when to consult.

Aust Fam Physician. 2007 Sep;36(9):684-7. PMID: 17885698

“Viral gastroenteritis is the most common cause of acute vomiting but should only be made after careful consideration of other causes. Management of hydration status in a child with a self limiting case of vomiting is vital. Regular review in the early phases of an undifferentiated vomiting illness will ensure that more fulminant illnesses are not overlooked and that secondary complications of dehydration do not arise. Chronic regurgitation and gastro-oesophageal reflux in infancy are common presentations that require considered management and may be a presenting symptom of food allergy. Other chronic presentations of nausea and vomiting in the older child may require referral for specialist assessment.”

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