Eponymous fractures of Lower limb

VOMITING IN CHILDREN

When we say vomiting in children, we usually have parents who would come and tell us that “my child is vomiting”. We need to spend little more time to ask few more questions – can it be vomiting or retching or nausea? After you ask these questions, you’ll realize that in most condition our patient may have all three of them. But it will help us to differentiate one over the other, in some of the rare cases.

In vomiting, we’ve forceful expulsion of gastric contents due to abdominal and diaphragmatic contraction. In case of nausea, vomitus doesn’t come out and there’s an unpleasant feeling and autonomic changes which precede vomiting and the patients complaints of excessive salivation and difficulty in breathing just prior to nausea feeling.

In pediatrics, we need to differentiate between vomiting and regurgitation. We should understand that if the child throws up without or minimal effort then its always Regurgitation; but if its forceful then it is vomiting. Keep in mind that forceful doesn’t mean projectile, it just mean that the child has to do an effort to expel the contents out.

Mostly vomiting subsides on its own as soon as the irritating content is removed and thus its self-limiting. Then how to know when do we need to worry about vomiting? Remember that any vomiting in neonates lasting >12 hours, in children under 2 years lasting >24 hours and in children above 2 years lasting >48 hours (provided there are no red flags).

Nature of vomiting could be – bilious, projectile, periodic and early morning. Bilious vomiting suggests obstruction to intestinal contents and bile is regurgitating in stomach; sometimes because of persistent vomiting in a very short period of time, the bile regurgitates into the stomach. In pediatrics, the only cause of projectile vomiting is pyloric stenosis. Keep in mind that increased intracranial tension leading to vomiting is almost never projectile. In periodic vomiting we look at different causes like abdominal migraine and cyclical vomiting. Pain is more important symptom than vomiting in abdominal migraine whereas in cyclical vomiting its vice-versa. Early vomiting is considered as a red flag which may indicate an increased intracranial pressure; also sometimes cyclical vomiting may also be there as an early vomiting.

We always ask for associated symptoms when a child comes to us with vomiting. Fever is an important symptom about which I’ll mention in the upcoming article. Remember that whenever there’s a combination of headache and vomiting, the physician would look at 2 possibilities, one being intra-cranial tension (due to various causes including SOL, hydrocephalous, idiopathic intra-cranial hypertension); but the most important diagnosis would be to rule out Migraine. If you get a child who has rectal blood per rectum alongwith vomiting and is a young child, we must think in terms of interssusception (it would be better to diagnose interssusception much before rectal bleeding); and that could be done by knowing how well the child is when the child has vomiting or crampy abdominal pain. If there’s unusual smell and color of urine, it may suggest inborn error of metabolism. If you’ve a child who has vomiting along with breathlessness, rule out Ketoacidosis. Keep a note that usually a patient won’t come with symptoms of breathlessness (as in dyspnea); it would rather be an effortless increase in the respiratory rate of the children, which many a times may be go unnoticed by the parents.

Whenever a patient approaches a physician, they won’t come with only one symptom, but rather with few symptoms together. So its important to decide the chief complaint along with the sequence in which the symptoms appear. If a child comes with fever and vomiting (since 1-2 days); and presently the vomiting has been reduced but the child has started with loose motions, we need to think in terms of Acute Gastroenteritis. But if the child approaches you with complaints of fever and diarrhea in first couple of days; diarrhea appears to be less or same and the vomiting has now started, we should think about parental diarrhea due to urinary tract infection. Hence, though the 2 patients came with almost same symptoms but the correct diagnosis was made according to the sequence in which the symptoms appeared. But what if the patient comes with all the three complaints(fever, vomiting and abdominal pain) together? Now it’s the duty of the physician to think which is the chief complaint. For example, if the child has fever as the dominant complaint then think in terms of Dysentry as well as Upper Urinary tract infection(Pyelonephritis); instead if vomiting is considered as dominant complaint, then think in terms of Gastro-enteritis or Hepatitis; and if abdominal pain is the chief complaint, then we need to suspect Appendicitis (in elder children) and Interssusception (in young children).  Note that in pediatrics, diarrhea is not only caused consequent to GI problems but also due to systemic infection.  

Now lets take a case of 5 month old child, who comes with a complaint of persistent vomiting since last 1 month and has no other symptoms(not even GERD); so we are suppose to proceed? Now with the personal history – irritable, not eating properly, constipation and baby is passing extra urine; we should think about idiopathic hypercalcemia without even wasting time on investigations. Also with feeding history – we know that the child is on breast feed, happy, gaining weight and vomits little; then consider him to be “happy spitter”, observe him and leave him without any medication. Ask for family history – for consanguinity (in order to check for any inborn metabolic errors).

Lets quickly go through the other age groups because pediatrics being a dynamic field and we always have different diagnosis and thinking processes as per the age of the child. If a new born comes in his 1^st week with vomiting, we need to think about Intestinal obstruction which could occur due to sepsis. And if a child who is around one week, comes with vomiting and is looking dehydrated, dull and not feeding well; check for genitals, because it could be possible that he would be having Congenital Adrenal hypoplasia leading to Adrenal deficiency (which is potentially lethal condition), which can otherwise be treated normally.  Now if 6-8 weeks child comes with vomiting(projectile), looks dehydrated and not gaining weight; think in terms of Pyloric stenosis. If a child older than 10 weeks who is irritable, arching his back, not a “happy spitter”, throwing up and not putting weight; think in terms of Gastro-esophageal Reflux Disease, which needs treatment because it might be present with cough or apnea. If an adolescent comes with vomiting, think in terms of Appendicitis (if pain being prominent symptom than vomiting) and we can see tachycardia out of proportion to the respiratory rate. Now consider an adolescent coming with persistent vomiting, presence of blood and mucus in stool and he or she is not growing well, we should ask for any “arthalgia” or “joint symptom”; the child might be suffering from Inflammatory Bowel Disease and if we see any faltering in their growth charts then it would suggest the chronicity of the disease.

Red Flags in Vomiting In Children

·         Prolonged duration (in neonates >12 hours; in kids less than 2years >24 hours; in kids more than 2years >48 hours)

·         Bilious vomiting

·         The child is vomiting but without loose motions (because it could be something more than just gastro-enteritis)

·         Abdominal distension or blood in the stool, may suggest intestinal obstruction

·         Most importantly CNS symptoms – on awakening (progressive vomiting); if the child is vomiting, dehydrated but passing enough or more urine, it may suggest Diabetes Ketoacidosis.

Dealing with children is not easy many a times because they won’t be able to explain their discomfort to us properly, so we must evaluate the seriousness of the disease and check for any behavioral change. Try to make provisional diagnosis and if you aren’t able to make diagnosis then ask yourself whether the child has to go to – ICU or ward or he can go home; if you are sending home and not admitting then ask – do I need to start the treatment urgently? Or I can wait for the evolution of the disease so that we can diagnose it better without risking the patient’s life? Don’t forget to take a full history of personal diet, development and growth of the child.