Recurrent Vomiting in Children

Diagnosis

The American Academy of Pediatrics recommends that gastroesophageal reflux disease (GERD) is the most common cause of recurrent vomiting in a 3-year-old child, though acute viral gastroenteritis should be considered if symptoms are recent in onset 1, 2
Bilious vomiting indicates obstruction distal to the ampulla of Vater and represents a surgical emergency until proven otherwise, particularly concerning for malrotation with volvulus 3, 4
Projectile vomiting raises concern for pyloric stenosis or increased intracranial pressure 3, 5
Blood in vomit or stool suggests mucosal injury, intussusception, or other serious pathology 3, 4

For non-bilious recurrent vomiting without red flags, a conservative management trial (2-4 weeks) is recommended, including dietary protein elimination and lifestyle modifications 1, 2
Empirical PPI trial for 2 weeks is recommended if symptoms persist, with continuation for 8-12 weeks total if symptoms improve 2
Specialist referral is recommended if treatment fails 2

Oral rehydration therapy (ORT) is the first-line treatment for mild-to-moderate dehydration, with administration of small, frequent volumes (5 mL every minute initially) 3
Replace ongoing losses with 10 mL/kg ORS for each vomiting episode 3
Continue breastfeeding or full-strength formula throughout rehydration 3
IV fluids are reserved for severe dehydration (≥10% deficit) or failure of oral rehydration 3

Abdominal distension indicates possible intestinal obstruction 1
Weight loss or poor weight gain distinguishes GERD disease from benign reflux and warrants aggressive intervention 1, 3
Altered mental status or lethargy is concerning for metabolic disorder, intracranial pathology, or severe dehydration 3, 4