What is it ?
Vomiting represents the expulsion of the stomach contents, forcibly. Apart from during the infant period, vomiting usually indicates there is some irritation of the stomach, or some sort of generalised illness. It can occur with any illness and some children will vomit quite regularly when they are unwell. Rarely vomiting can be due to a surgical cause such as an obstructed bowel. In this case the vomiting will be unrelenting, bile stained and will child will need prompt evaluation.
What are the causes ?
Infancy - the first 12 months
Vomiting is very common during the infant period. It is easiest to divide it into two groups. Those that vomit all the time, and those where vomiting is a new symptom.
Vomiting all the time.
- Reflux – regurgitation during infancy is so common it can classified as a normal variant. Sometimes the reflux is enough to be called vomiting. If the infant is feeding, growing and developing well and does not appear distressed there is little that needs to be done. Sometimes as the infant becomes more mobile this can actually worsen. There is little place for medications and most parents will elevate the head of the cot for a period. Usually this improves by around 12 months.
- Food Protein Intolerance – Some infants will have more severe vomiting and reflux associated with difficulty feeding, irritability, explosive uncomfortable bowel actions and weight gain that is ‘just ok’. This condition probably was misdiagnosed as severe reflux in the past. The most likely protein is cow’s milk that is passed through the breast milk or from a cow’s milk based formula. The diagnosis of this simply involves removing dairy from the Mother’s diet if breastfed and noticing a dramatic improvement in symptoms within 48 hours. Current recommendations for those under 6 months who are not breastfed is to trial a hypoallergenic formula such as Allerpro. For those older than 6 months a soy based protein formula can be used. The good news is that this is not an allergy and infants will ‘grow out of this’. For more information see infant feeding problems.
- Other causes – There are rare conditions that can present as persistent vomiting, and these are generally more serious. There will be poor weight gain, lethargy, pallor and these infants will need a careful assessment that may involve blood tests.
The Infant who suddenly starts vomiting.
Infection represents the most common cause. This age group will need a medical assessment to establish where the infection is. Sometimes it can be a simple virus, but more invasive bacterial infections can present as vomiting and fever. This is a situation, particularly in those under 3 months, where an urgent assessment is needed, preferably at a hospital.
Gastroenteritis – the most common cause of sudden (acute) vomiting. The infant will have profuse diarrhoea, and sometimes a temperature. This age group is susceptible to dehydration and so needs earlier assessment.
Surgical causes – this means there is some sort of bowel abnormality, and the infant will present with ‘green vomitus’ (bile stained) without any infectious cause. Other symptoms include lethargy, listlessness, and will require urgent hospital assessment.
Pyloric stenosis – this results in projectile vomiting around 4 weeks of age. This is a rare condition due to swelling of a muscle (the pylorus) at the stomach outlet. The infant will projectile vomit with every feed, which differentiates this from reflux which has intermittent projectile vomiting. There is sudden cessation of weight gain, and the diagnosis is by ultrasound. It is easily fixed by paediatric surgeons at a tertiary hospital.
The toddler and young child
- Infections – again this by far is the most common cause of vomiting. The older the child the more obvious the source. Gastroenteritis will involve vomiting, diarrhoea and sometimes fever and abdominal pain. Other infections can also present with vomiting, and it is common for children with a hacking cough to also vomit.
Other causes –
Surgical – one of the most common surgical causes of sudden vomiting during this period is intussusception. This part of the bowel telescoping into another part. This leads to severe episodes of abdominal pain 15 – 20 minutes apart, with vomiting, and paleness. Diarrhoea is sometimes present and can look like red currant jam. This is a surgical emergency and requires urgent hospitalisation.
Food allergies – will sometimes cause vomiting. This will usually be within seconds to minutes of ingesting a particular food such as peanuts, tree nuts, egg, etc.
Cyclic vomiting – some young children will present with episodes of vomiting, for which there is no obvious cause. Initially they will be diagnosed with ‘gastro’ but after repeated episodes of vomiting, with no features to suggest infection or any other cause cyclic vomiting maybe the cause. Between the episodes the child is perfectly healthy. It is best to be thought of as a form of migraine. Sometimes the vomiting is so severe rehydration is needed in hospital.
Infections – Older children do not vomit nearly as much as the infants or toddlers and usually the cause is obvious, such as gastroenteritis, or a flu like illness. Other infections can cause vomiting but there will be other obvious symptoms
Surgical – the most common surgical cause is appendicitis. Abdominal pain, loss of appetite, fever and persistent constant pain that localises to the right lower abdomen is the classic presentation.
Other causes – there are a host of other causes where vomiting maybe a sign of a significant illness. Usually there will be other symptoms to suggest the diagnosis. For example childhood migraine will often have vomiting as a part of this syndrome, but headache is the main symptom.
What’s the treatment ?
In most cases vomiting will settle as the illness abates. For example the child with a viral infection will slowly improve and the vomiting will subside. Occasionally doctors use a medication called ondansetron to help with vomiting. This suppresses the feeling of vomiting and has been used extensively to help with nausea and vomiting in adults and children. It can be administered as a wafer. Otherwise ensuring the child is well hydrated is the most important aspect of vomiting once the cause is established.
What Do the Doctor’s do ?
Vomiting is a common cause to make an appointment and the doctor will take a history and perform an examination. The main concern is finding a cause for the vomiting and assessing for dehydration. In infants this can be difficult as vomiting can be such as common symptom for a whole host of problems, and often it is better to be admitted to hospital in this age group. As the usual diagnosis is infectious, such as gastroenteritis, assessing hydration and managing this is important. See article on gastroenteritis.
Frequently Asked Questions.
- How do I know when to take my child to hospital ? An infant who develops sudden vomiting should be seen quickly to rule out a more sinister cause. For toddlers and children this depends on the causes as outlined above. Under any circumstances if your child appears unwell, listless, and is unable to tolerate fluids then medical assessment is urgently needed.
- What about Panadol and or nurofen ? These medications are not particularly useful or recommended in vomiting children. They do not help with vomiting, abdominal discomfort and may cause the child to vomit more.
- What about giving an injection to stop the vomiting ? In adults sometimes a drug called maxalon is given as an injection. It should never be used in children as it can have a very nasty side effect and its effectiveness is negligible. The only medication tolerated under certain diagnostic considerations is ondansetron as mentioned above.
- Should i give my child fluids whilst they vomit ? Keeping a child hydrated is the most important part of any cause of vomiting, particularly if the cause is not going to require surgery. Small frequent sips of fluids given every few minutes, or in the form of iceblocks is encouraged. See gastroenteritis handout.
- What about food ? Usually solid food will worsen vomiting, and is not necessary. We can cope for several days without eating food, so fluids are the priority. When vomiting appears to be improving gently restarting solids is acceptable.