Vomiting in children

Vomiting in infants under the age of two months

This is not very common. Learn how to distinguish between the common spit ups/regurgitation (read more about reflux and spit ups in young infants here), and real vomiting.
How can one differentiate between the two?
When a child throws up it happens in a projectile manner, while spit ups, no matter how big, drip from the sides of the child’s mouth onto his/her clothes.
An infant who has thrown up more than once, or even if it happened only once but they are ill-appearing, must be evaluated by a physician.
Here are a couple of other points that I would like to remind you of:
– Fever at this age requires an urgent evaluation by a physician. So both fever and vomiting? Definitely require an evaluation (read more about this here).
– Recurrent episodes of vomiting in an infant around the age of 3 weeks, that are increasing in volume, require a pyloric stenosis workup (read more about this here).

Vomiting in older infants and children

I think it is best to divide this section into vomiting with and without fever.

Vomiting with fever

This indicates a likely infectious cause. What is a type of infection you don’t want to miss? Bacterial meningitis or a significant abdominal infection.

Bacterial meningitis

I apologize for starting my post with this but this really is the first diagnosis that a good pediatrician will think of and will want to rule out, despite it not being a common diagnosis.
What should raise concern for meningitis? Fever (usually high), an ill-appearing child, headache, and vomiting. Therefore, all cases of fever and vomiting require a paediatrician’s assessment, so they can state whether or not meningitis is suspected.

Some people will say that their child is vaccinated for meningitis. It is true that there are several routine vaccinations that cover different bacteria that can cause meningitis such as Hemophilus as part of the pentavalent vaccine, pneumococcal vaccination and the meningococcal vaccine (read more about it here).
But there is no single vaccine out there that is perfect, and these are certainly not the only bacteria out there that can cause severe infection in children.
But let it be clear that also in children who present with fever and vomiting, meningitis is not a common diagnosis. Then what else could be a possible cause?

Severe abdominal infection

Again, for this I would need a pediatrician to examine the child’s abdomen and rule out a severe abdominal infection that is causing the fever and vomits. An example of such an infection would be appendicitis. Children suffering from a severe abdominal infection are ill-appearing and present with severe abdominal pain.

Other infections

In practice, all febrile illnesses in pediatrics can lead to vomiting. Anything from a viral or bacterial throat infection to an ear infection (read about this here), pneumonia (more about this here), and certainly gastroenteritis as you will learn below.
Some children present with nausea every time they have fever and sometimes, they vomit as well. Nonetheless, these children still need to see a physician every time this happens.

Gastroenteritis

What about gastroenteritis? It is obvious to all of us that a child who has vomiting and diarrhea, whether it is with or without fever, has gastroenteritis. Vomiting is due to involvement of the upper gastrointestinal system while the diarrhea is due to involvement of the lower gastrointestinal system.
Where is the problem?
The problem lies in those children that present during their fever and vomiting phase, before their diarrhea has begun. This is why pediatricians prefer seeing children who are suffering from both vomiting and diarrhea rather than those with vomiting alone.
So, if your child is vomiting and has fever (or even without fever, as you will see below) and diarrhea – he most probably has acute gastroenteritis. In such cases I place emphasis on questioning the parents regarding the diarrhea. If the diarrhea is watery – this is usually an indication of a viral infection. If it contains mucous or blood, this may indicate dysentery, i.e bacterial infection. So just bear in mind that if there is fever, especially if it is high, viruses will cause watery diarrhea and bacterial infections will lead to mucous diarrhea that may or may not be bloody.
So, if your kid has fever and diarrhea and is also vomiting, go see your doctor after you’ve read the chapter about diarrhea on this website (link here).

Vomiting without fever

Recurrent vomiting without fever, especially if there is no diarrhea, is something that needs to be evaluated.
What could be the cause behind such symptoms?

A head injury

If your child suffered from a head injury before the vomiting started, his symptoms could be related to the injury. It could be the result of anything from a mild concussion to intracranial bleeding. If that is the case, I suggest you read more about head injuries in children here.

Any other brain issue

I know this is something that crosses many parents’ minds.
Their child could have started vomiting two hours ago and their mind will go off to think about the worst possible scenario. It doesn’t really work that way.
Intracranial lesions will present as a combination of symptoms – headaches that may awaken a child from their sleep, nausea or vomiting that occur mainly in the morning, and sometimes some neurological symptoms too. So, if this is the case and it has been going on for a while, see your pediatrician and consider performing workup including an eye check-up for papilledema and brain imaging, if need be (preferably an MRI).

Intestinal obstruction (intussusception)

Again, this isn’t a common occurrence, but it is a diagnosis you don’t want to miss.
Intussusception is a type of intestinal obstruction that is common between the ages of 5 months and 3 years. Usually, the child will present with vomiting without stools. At first, the child will be well-appearing between the vomiting episodes but the frequency of vomiting gradually increases and the amount of time during which the child is well-appearing decreases. The child will tend to alternate between intervals of irritability and lethargy.
When the symptoms first appear, the child could still be passing stool, but later on there are no stools passed at all. Most children are ill-appearing and pale.
The diagnosis can be carried out following an abdominal and rectal examination performed by a pediatrician after the symptoms raise suspicion.
The final diagnosis is carried out with the help of an X-ray or abdominal ultrasound. So as soon as there is a concern for intussusception and the primary physician has carried out their examination, the child should be referred to the emergency room for further workup.

Gastroenteritis

Okay, so I remember mentioning gastroenteritis in the section about the febrile child. However, I’d like to emphasize that gastroenteritis can also present without fever.

How should one manage a child who is vomiting?

Was it a single episode? Allow them to rest and continue the day as per usual.
Were there several episodes? First of all, consider all the possible diagnoses I mentioned and see a doctor as soon as possible for an evaluation.
In the meantime, what do I suggest you do with regards to eating and drinking?
If your child is vomiting, he needs to be fed something sweet.
I often see children who are vomiting walk into my clinic with a bottle of water. That’s great, really, but in order to relieve or even stop the vomiting the child needs sugar, in its simplest form. So, for these cases I suggest giving the child sugary drinks including juice or soda, sweetened ice tea, etc.
Ice cream or candy/lollipops (if the child is the right age for it) may also be a good option.
If the vomiting is accompanied by diarrhea, give the child a salty snack, such as salty pretzels or chips, in addition to the sweet drink.
In younger infants, give them formula, of course.

How much fluids does a child who is vomiting need?

There are no rules. Obviously, if you give a child who has been vomiting 250 ml in one go, they will throw it all up at once. So be patient and do it slowly.
I suggest you use small syringes and give small amounts of fluids every few minutes so as not to trigger further vomiting.
Remember the rule is that a child who has been vomiting needs sugar.
A child who has diarrhea needs salts.
A child who is suffering from both, needs a combo. And a doctor’s check-up.

Are there any other treatment options for a child who has been vomiting?

We all know that there are medicinal options out there that may relieve a child from vomiting or even bring them to a halt. To be honest, their use in children is very limited and pediatricians tend not to prescribe them for children who are throwing up.
The most important issue in my opinion is to reach the correct diagnosis and move forward from there. I haven’t come across any safe and efficient anti-emetics in children.

When can a child who has been vomiting return to day care?

Obviously, this is related to the underlying cause and how the child is feeling. Throwing up is not a pleasant thing and children need time to recuperate.
What is my opinion specifically about returning to day care?
A child who has thrown up twice within 24 hours can’t return to day care unless a pediatrician has determined that the underlying cause is non-infectious and the child’s condition allows for them to return to the educational institution.
Remember that a child has to be fever-free for 24 hours and all the other restrictions that I discuss here.

How shall we summarize this chapter?

Pediatricians prefer seeing children who are both vomiting and have diarrhea because then the diagnosis is easier and the cause is usually a viral infection that is self-resolving with the help of some supportive treatment.

In most cases., pediatricians also prefer seeing children with low-grade fever, with no meningeal signs over children without fever where the reason behind the vomiting is unclear.

Therefore, I think there are two take-home messages for parents here:
A. The red flags that require an immediate doctor’s assessment are high grade fever, abdominal pain, ill-appearance, signs of dehydration, young age, and more.
B. Ways to relieve the vomiting and good management options include sweetened drinks in those who are vomitin and salty food in those with diarrhea.

May we all be healthy and safe, always.