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Originally published at on January 1, 2016. Reposted with permission.

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In the young child, vomiting is the great imitator:

Gastrointestinal, Neurologic, Metabolic, Respiratory, Renal, Infectious, Endocrine, Toxin-related, even Behavioral.

To help us organize, below is a review of can’t-miss diagnoses by age.

The Neonate: Malrotation with Volvulus

In children with malrotation, 50% present within the first month of life, with the majority occurring in the first week after birth. Approximately 90% of children with malrotation with volvulus will present by one year of age.   This is a pre-verbal child’s disease – which makes it even more of a challenge to recognize quickly.

The sequence of events usually is fussiness, irritability, and forceful vomiting.  The vomit quickly turns bilious.

Green vomit is a surgical emergency.

Babies may also present unwell, with bloating and abdominal tenderness to palpation.  Be aware thatlater stages of malrotation may present as shock – they present in hypovolemic shock due to third-spacing from necrotic bowel and/or septic shock from translocation or perforation.   In the , always consider a surgical emergency such as malrotation with volvulus.

In the stable patient, get an upper GI contrast study.

Rapid-fire word association for other vomiting emergencies in a neonate:

• Fever, irritability and vomiting?  Think meningitis, UTI, or sepsis.
• Premature, unwell, and vomiting?  Think necrotizing enterocolitis.  Remember, 10% of cases of NEC can be full-term. Look for pneumatosis intestinalis.
• Systemically ill, afebrile, and vomiting for no other reason?  Think inborn error of metabolism.  Screen with a glucose, ammonia, lactate, and urine ketones.
• Others include congenital intestinal atresia or webs, meconium ileus, or severe GERD

On multivariable analysis, if at least one of the questions was positive, there was an OR of 189 for abuse (CI 97 – 300).  In other words, if any of those six questions are problematic, get your child protective team involved.

Other important diagnoses in the infant: intussusception and pyloric stenosis (rapid review in audio).

The Toddler: Diabetic Ketoacidosis (DKA)

The important diagnosis not to miss in the vomiting toddler or early school age child is the initial presentation of diabetic ketoacidosis.  Children under 5 (especially those under 2) and those from lower socioeconomic groups have a higher risk of DKA as their initial presentation of diabetes.

This is true for any child that isn’t quite acting right – check a finger stick blood sugar as a screen.

Hyperglycemia, with a blood glucose of >200 mg/dL (11 mmol/L) AND Evidence of metabolic acidosis, with a venous pH of less than 7.3 or a bicarbonate level of < 15 mEq/L AND Ketosis, found either in the urine or if directly checked in the blood.

If you have access to checking a serum beta-hydroxybutryrate – the unsung ketone – it can help in diagnosis in unclear cases.

Cerebral Edema Criteria:

• Minor criteria: headache, vomiting, irritability or lethargy; hypertension in the face of hypovolemia.
• Major criteria: change in mental status, including agitation or delirium; incontinence (especially if inappropriate for the child’s age); sluggish pupils and cranial nerve palsies; relative bradycardia(Cushing’s triad).

Cerebral Edema Action Items:

• Immediately give mannitol, 1 g/kg over 15-20 minutes.  May repeat it in 2 hours if needed.  Hypertonic saline (3% NaCl) is second-line therapy.
• Put the head of the bed up 30 degrees.
• Alert your colleagues and counsel your parents.  Make sure everyone knows what to watch out for.

As you can see, vomiting in the young child can be really anything!  Keep your differential broad, and think by age and by system.

The general approach to the child with chiefly vomiting starts with the decision: sick or not sick.  If ill appearing, establish rapid IV access, or if needed IO.  Rapid blood sugar and if available a point of care pH and electrolytes.  Be the detective in your history and doggedly go after any red flags as you gomethodically by organ system.

• Do a careful physical exam. The general assessment is always helpful – is the child irritable, listless, agitated?
• What is his work of breathing?  Effortless tachypnea may be a sign of acidosis or sepsis.
• Is the abdomen soft or is it tender or distended.  Always look in the diaper area – is there a hernia, is there a high-riding, tender, discolored scrotum without cremasteric reflex?  Ovarian torsion has been reported in infants as young as 7 months.
• Any skin signs?  Look for petechiae, urticaria, purpura.

In other words, use your best judgement, have the dangerous differentials in the back of your mind, and pull the trigger when red flags mount up.  Otherwise, a good history and a good exam will get you where you need to be.

Take home points for the young child with vomiting:

Wolfsdorf JI, Allgrove J, Craig ME et al. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2014 Sep;15 Suppl 20:154-79.

This post and podcast are dedicated to , for his fervor in the care of children and his dedication to .

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