Management of Pediatric Nausea and Vomiting

Emergency Evaluation

• Any bilious (green) vomiting in a child is a surgical emergency and requires immediate abdominal imaging and surgical consultation – the presence of bile indicates obstruction distal to the ampulla of Vater and mandates prompt evaluation to rule out conditions such as malrotation/volvulus or intestinal atresia. 1
• Plain abdominal radiographs should be obtained first for bilious vomiting; a normal film does not exclude malrotation or volvulus, so an upper‑GI contrast study must follow if clinical suspicion persists. 1
• Upper‑GI contrast series has a sensitivity of approximately 96 % for detecting malrotation and should be performed when bilious vomiting is present despite a normal radiograph. 1

Age‑Specific Common Causes

Neonates & Young Infants (< 3 months)

• Gastro‑esophageal reflux disease (GERD) is the most frequent cause of recurrent non‑bilious vomiting in infants; it occurs daily in about 50 % of healthy infants and is especially common in preterm infants with immature lower esophageal sphincter function. 4
• Hypertrophic pyloric stenosis (HPS) presents with non‑bilious projectile vomiting in infants 2–12 weeks old; a palpable epigastric “olive” mass is found in 60–80 % of cases and metabolic alkalosis is typical on laboratory testing. 2

Older Infants (3–12 months)

• Intussusception often presents with intermittent crampy abdominal pain, “currant‑jelly” stools, and progression from non‑bilious to bilious vomiting; it is a surgical emergency requiring prompt ultrasound diagnosis. 2

Children > 1 year

• Bacterial gastroenteritis pathogens such as Campylobacter, Salmonella, and Shigella are common causes of vomiting in this age group; targeted antibiotic therapy is reserved for severe disease. 5
• Gastroparesis can present with chronic nausea, vomiting, and post‑prandial fullness, and may be seen in children with diabetes. 6

Diagnostic Approach

• History should distinguish true vomiting from regurgitation, rumination, or bulimia, and document frequency, forcefulness, bile content, and presence of blood. 6
• Physical examination should assess hydration (capillary refill, urine output ≥ 4 wet diapers/24 h, mucous membrane moisture) and weight trajectory; poor weight gain helps differentiate pathologic GERD from benign reflux. 4
• Stool evaluation for pathogens (e.g., Campylobacter, E. coli O157, Salmonella, Shigella, Vibrio, Yersinia, norovirus, rotavirus) is indicated when vomiting is accompanied by diarrhea. 5

Initial Management

Acute Viral Gastroenteritis (No Red Flags)

• Oral rehydration therapy (ORT) is the cornerstone; give small, frequent volumes (~5 mL · min⁻¹) to children with dehydration. 5
• Ondansetron may be administered to children ≥ 4 years with acute gastroenteritis to facilitate ORT and reduce the need for intravenous fluids or hospitalization. 5
• Antimotility agents (e.g., loperamide) are contraindicated in children < 18 years; deaths have occurred in 0.54 % of children, all < 3 years old. 5
• Early re‑feeding with full‑strength formula or breast milk is recommended; a lactose‑free diet shortens diarrhea duration by approximately 18 hours. 5

Benign GERD (No Red Flags)

• A 2–4‑week trial of smaller, more frequent feeds combined with upright positioning after feeds is advised; continue full‑strength formula or breast milk without dilution. 3
• Monitor weight gain and symptom progression; reassess if vomiting persists or worsens. 4

Surgical Emergencies (e.g., NEC, obstruction, intussusception)

• Place the infant nil per os (NPO) and initiate nasogastric/orogastric decompression while arranging immediate surgical consultation. 3

Safety Considerations

• Antiemetics should generally be avoided in preterm infants because they may mask clinical deterioration. 3

All citations are provided in brackets after each statement.