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Persistent Vomiting

Vomiting is defined as the forceful expulsion of gastric contents through the mouth. Vomiting can be caused by a benign, self-limited process or it may be indicative of a serious underlying disorder persistent vomiting, spitting up, throwing up.

Vomiting is usually preceded by nausea, increased salivation, and retching. It is distinct from regurgitation, which is characterized by passive movement of gastric contents into the

Projectile vomiting results from intense gastric peristaltic waves, usually secondary to gastric outlet obstruction caused by hypertrophic pyloric stenosis or pylorospasm.

Retching often precedes vomiting, and it is characterized by spasmodic contraction of the expiratory muscles with simultaneous abdominal contraction.

Nausea is an imminent desire to vomit, usually induced by visceral stimuli.

Clinical Evaluation of Vomiting in the Neonate

Bilious Vomiting

Bilious vomiting, at any age, suggests intestinal obstruction or systemic infection.

Anatomic abnormalities of the gastrointestinal tract that may present in the first week of life with bilious vomiting and abdominal distention include malrotation, volvulus, duplications of the bowel, bowel atresia, meconium plug, meconium ileus, incarcerated hernia, and aganglionosis (Hirschsprung disease).

Necrotizing Enterocolitis

NEC is the most common inflammatory condition of the intestinal tract in the neonate. Symptoms of NEC include abdominal distention, bilious vomiting, and blood in the stool.

Metabolic Disorders

Inborn errors of metabolism should be considered in any acute neonatal illness, including persistent vomiting. Factors that suggest a metabolic disorder include early or unexplained death of a sibling, multiple spontaneous maternal abortions, or history of consanguinity.

Neurologic Disorders. Central nervous system abnormalities, such as intracranial hemorrhage, hydrocephalus and cerebral edema, should be suspected in the neonate who has

Clinical Evaluation of Vomiting in Infancy

Pyloric Stenosis

Pyloric stenosis is a major consideration in infants. Hypertrophy of the pylorus causes gastric

Gastroesophageal Reflux

Gastroesophageal reflux (GER) is defined as retrograde movement of gastric contents into the esophagus. GER occurs in 65% of infants and is caused by inappropriate relaxation of the

Gastrointestinal Allergy

Cow milk allergy is rare in infancy and early childhood and generally resolves by 2 to 3 years

Clinical Evaluation of Vomiting in Childhood

Peptic Ulcer

Peptic ulcer disease in early childhood is often associated with vomiting. Primary ulcer disease more often presents with epigastric pain in children by 11 years of age. Peptic ulcer

Pancreatitis

Pancreatitis is a relatively rare cause of vomiting, but should be considered in the child who has sustained abdominal trauma. Patients usually complain of epigastric pain, which may

Central Nervous System Disorders

Persistent vomiting without other gastrointestinal or systemic complaints suggests an intracranial tumor or other lesions that increase intracranial pressure.

Subtle neurologic findings (eg, ataxia, head tilt) should be assessed and a

Physical Examination of the Child with Persistent Vomiting

Volume depletion often results from vomiting, manifesting as sunken fontanelles, decreased skin turgor, dry mouth, absence of tears, and decreased urine output.

Peritoneal irritation often causes the child to keep his knees drawn up or to bend over. Abdominal distension, visible peristalsis, and increased bowel sounds are consistent with 

Abnormal masses, enlarged organs, guarding, or tenderness should be sought. A hypertrophic pylorus

Intussusception is often associated with a tender, sausage-shaped mass in the right upper quadrant and

Digital Rectal Exam. Decreased anal sphincter tone and large amounts of hard fecal material in the ampulla suggests fecal impaction. Constipation, increased rectal sphincter tone, and an empty rectal

Treatment

Initial therapy should correct hypovolemia and electrolyte abnormalities. In acute diarrheal illnesses

Bilious vomiting and suspected intestinal obstruction is managing by giving nothing by mouth, 

Pharmacologic Therapy

Antiemetic agents usually are not required because most instances of acute vomiting are caused by self-limited, infectious gastrointestinal illnesses. Conditions where effective

Diphenhydramine and dimenhydrinate are useful in treating the symptoms of motion sickness or vestibulitis. Anticholinergics, such as the scopolamine patch, also are 

Prochlorperazine and chlorpromazine have anticholinergic and antihistaminic properties. These drugs also decrease dopamine transmission in the