Vomiting in infants

Viral gastroenteritis

Usually with diarrhea

Sometimes fever and/or contact with a person who has similar symptoms

Clinical evaluation

Sometimes rapid immunoassays for viral antigens or PCR testing for enteric pathogens (eg, rotavirus, adenovirus)

Gastroesophageal reflux disease

Recurrent fussiness during or after feedings

Possibly poor weight gain, arching of the back, recurrent respiratory symptoms (eg, cough, stridor, wheezing)

Empiric trial of acid suppression

Sometimes upper GI contrast study, a milk scan, esophageal pH monitoring and/or impedance study, or endoscopy

Bacterial enteritis or colitis

Usually with diarrhea (often bloody), fever, crampy abdominal pain, distention

Often contact with a person who has similar symptoms

Clinical evaluation

Sometimes stool examination for white blood cell count and culture or PCR testing for enteric pathogens

Pyloric stenosis

Recurrent projectile vomiting immediately after feeding in neonates aged 2–12 weeks, infrequent stools

May be emaciated and dehydrated

Sometimes palpable “olive” in right upper quadrant

Ultrasonography of pylorus

Upper GI contrast study if ultrasonography is unavailable or uncertain

Congenital atresias or stenoses

Abdominal distention

Bilious emesis in first 24–48 hours of life (with lesser degrees of stenosis, vomiting can be delayed)

Sometimes polyhydramnios during pregnancy, Down syndrome, jaundice

Abdominal x-ray

Upper GI series or contrast enema depending on findings

Intussusception

Colicky abdominal pain, inconsolable crying, lethargy, drawing of legs up to chest

Later, bloody ("currant jelly") stool

Typically age 3–36 months, but can be outside this range

Abdominal ultrasonography

If ultrasonography is positive or nondiagnostic, air or contrast enema (unless patient has signs of peritonitis or perforation)

Hirschsprung disease

In neonates, delayed passage of meconium, abdominal distention, bilious emesis

Abdominal x-ray

Contrast enema

Rectal biopsy

Malrotation with volvulus

In neonates, bilious emesis, abdominal distention and pain

Bloody stool

Abdominal x-ray

Contrast enema or upper GI series

Sepsis

Fever, lethargy, tachycardia, tachypnea

Widened pulse pressure, hypotension

Cell counts and cultures (blood, urine, cerebrospinal fluid)

Chest x-ray if pulmonary symptoms are present

Food intolerance

Abdominal pain, diarrhea

Possibly eczematous rash or urticaria

Elimination diet

Sometimes skin testing and/or radioallergosorbent testing (RAST)

Metabolic disorders

Poor feeding, failure to thrive, lethargy, hepatosplenomegaly, jaundice

Sometimes unusual odor, cataracts

Neonatal metabolic screening

Further specific tests based on findings

Vomiting in children and adolescents

Viral gastroenteritis

Usually with diarrhea

Sometimes fever, contact with a person who has similar symptoms, or history of travel

Clinical evaluation

Sometimes rapid immunoassays for viral antigens or PCR testing for enteric pathogens (eg, rotavirus, adenovirus)

Bacterial enteritis or colitis

Usually with diarrhea (often bloody), fever, crampy abdominal pain, distention, fecal urgency

Often contact with a person who has similar symptoms or history of travel

Clinical evaluation

Sometimes stool for white blood cell count and culture or PCR testing for enteric pathogens

Cannabinoid hyperemesis syndrome

Cyclic episodes of nausea and vomiting in frequent cannabis users

Clinical evaluation

Non-GI infection

Fever

Often localizing findings (eg, headache, ear pain, sore throat, cervical adenopathy, dysuria, flank pain, nasal discharge) depending on cause

Clinical evaluation

Testing as needed for suspected cause

Appendicitis

Initial general malaise and periumbilical discomfort followed by pain localizing to right lower quadrant, vomiting after pain manifestation, anorexia, fever, tenderness at McBurney point, decreased bowel sounds

Ultrasonography (preferred over CT to limit radiation exposure)

Serious infection

Fever, toxic appearance, back pain, dysuria (pyelonephritis)

Nuchal rigidity, photophobia (meningitis)

Listlessness, hypotension, tachycardia (sepsis)

Cell counts and cultures (blood, urine, cerebrospinal fluid) as indicated by findings

Cyclic vomiting

≥ 3 episodes of intense acute nausea and unremitting vomiting and sometimes abdominal pain or headache lasting hours to days

Intervening symptom-free intervals lasting weeks to months

Exclusion of metabolic, GI (eg, malrotation), or central nervous system (eg, brain tumor) disorders

Intracranial hypertension (caused by tumor or trauma)

Chronic, progressive headache; nocturnal awakenings; morning vomiting; headache worsened by coughing or Valsalva maneuver; vision changes

Brain CT (without contrast)

Eating disorders

Binge and purge cycles, erosion of tooth enamel, weight loss or gain

Sometimes skin lesions on hand from inducing vomiting (Russell sign)

Clinical evaluation

Pregnancy

Amenorrhea, morning sickness, bloating, breast tenderness

History of unprotected sexual activity†

Urine pregnancy test

Toxic ingestions (eg, , iron, )

Often history of ingestion

Various findings depending on ingested substance

Qualitative and sometimes quantitative serum drug levels (depending on substance)

Adverse drug reaction (eg, to chemotherapeutic drugs)

Exposure to a specific drug

Clinical evaluation