Vomiting in the Young Child: Nothing or Nightmare

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.

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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. 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 that later 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 undifferentiated sick neonate, 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

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The Infant: Non-Accidental Trauma

All that vomits is not necessarily from the gut.

Abusive head injury is the most common cause of death from child abuse.   Infants especially present with non-specific complaints like fussiness or vomiting.   Up to 30% of infants with abusive head injury may be misdiagnosed on initial presentation.

Louwers et al. in Child Abuse and Neglect developed and validated a six-question screening tool for use the in ED.  The power of this tool was that it was validated for any chief complaint – it is not an injury evaluation checklist – it is a screen for potential abuse in the undifferentiated child:

1. Is the history consistent?
2. Was seeking medical help unnecessarily delayed?
3. Does the onset of injury fit with the developmental level of the child?
4. Is the behavior of the child and his interaction with his care-givers appropriate?
5. Do the findings of the head-to-toe examination match the history?
6. Are there any other red flags or signals that make you doubt the safety of the child or other family members?

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).

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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.

The International Society for Pediatric and Adolescent Diabetes (ISPAD) criteria for DKA:

1. Hyperglycemia, with a blood glucose of >200 mg/dL (11 mmol/L)
   AND
2. Evidence of metabolic acidosis, with a venous pH of less than 7.3 or a bicarbonate level of < 15 mEq/L
   AND
3. 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.

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

Differential Diagnosis of Vomiting in Children

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 go methodically 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.

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Take home points for the young child with vomiting:

1. Neonates are allowed to regurgitate (effortless reflux of stomach contents -- the happy spitter-upper).  They are not allowed to vomit (forceful, unpleasant contraction of abdominal muscles).  Consider surgical causes of forceful vomiting, especially if the child does not look anything other than well.
2. Bilious is bad – green vomit is always a surgical emergency – do not pass go – get the surgeons involved early
3. Not all vomiting is GI related – if it is not obviously benign, think methodically by organ system and adjust your targeted history and physical to pick up any leads.
4. Match the tempo of your treatment to the tempo of the disease.

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References

Applegate KE, Anderson JM, Klatte EC. Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. Radiographics. 2006; 26(5):1485-500.

Glaser NS, Wootton-Gorges SL, Buonocore MH et al. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes. 2006 Apr;7(2):75-80.

Louwers ECFM, Korfage IJ, Affourtit MJ et al. Accuracy of a screening instrument to identify potential child abuse in emergency departments. Child Abuse & Neglect. 2014; (38): 1275–1281.

Lee HC, Pickard SS, Sridhar S et al. Intestinal Malrotation and Catastrophic Volvulus in Infancy. J Emerg Med. 2012; 43(1): e49–e51.

Marcin JP, Glaser N, Barnett P et al. Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema. J Pediatr. 2002; 141(6):793-7.

Parashette KR, Croffie J. Intestinal Malrotation in Children: A Problem-solving Approach to the Upper Gastrointestinal. Pediatrics in Review. 2013; (34)7: 307-321.

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.

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This post and podcast are dedicated to Damian Roland, BMedSci (Hons), MB BS, MRCPCH, for his fervor in the care of children and his dedication to quality medical education.

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Nausea and Vomiting | Non-Accidental Trauma | DKA

 

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