Vomiting in Children: Causes, Diagnosis, and Treatment
Vomiting in children is the active expulsion of gastric or intestinal contents, a frequent symptom in pediatrics that requires careful etiological diagnosis. While often benign, it carries risks of severe complications like dehydration and metabolic disturbances. Effective management involves treating the underlying cause, providing symptomatic relief, and correcting fluid and electrolyte imbalances promptly.
Key Takeaways
Vomiting is frequent in pediatrics but requires rigorous etiological analysis.
Active rejection distinguishes vomiting from passive regurgitation or rumination.
Immediate risks include severe dehydration and hypovolemic shock.
Diagnosis relies heavily on clinical examination and detailed patient history.
Treatment focuses on rehydration, antiemetics, and addressing the root cause.
What defines vomiting in children and why is it important to diagnose?
Vomiting is defined as the active expulsion of gastric or intestinal contents through the mouth, typically affecting children aged 29 days to 15 years. This symptom holds quadruple importance in pediatrics: epidemiologically, it is very frequent; diagnostically, while easy to identify, determining the cause is often challenging; therapeutically, it requires logical treatment while avoiding excessive antiemetics; and prognostically, although usually benign, serious complications like severe dehydration must be carefully monitored. Understanding the anatomy, including the anti-reflux system elements like the lower esophageal sphincter, is crucial for proper assessment.
- Vomiting is the active rejection of stomach or intestinal contents.
- It is epidemiologically frequent but etiologically difficult to diagnose.
- The anti-reflux system includes the lower esophageal sphincter and the angle of His.
- The stomach's roles are food storage, acid/enzyme secretion, and food mixing/crushing.
What factors increase the risk of vomiting in pediatric patients?
Several factors related to the child and their environment can predispose them to vomiting. Factors intrinsic to the child include young age, pre-existing malformations of the digestive tract, and the presence of other illnesses. Additionally, simple actions like swallowing air during feeding can contribute. Environmental factors often relate to feeding techniques and psychological stress. Identifying these factors is key to prevention and management, especially in chronic or recurrent cases, ensuring that both physiological and external influences are addressed during the initial assessment.
- Child-related factors include young age, digestive tract malformations, and general illnesses.
- Swallowing air during feeding can trigger vomiting.
- Environmental factors involve poor feeding technique (e.g., improper latch or bottle feeding).
- Psycho-affective elements like parental conflict, lack of affection, or stress are contributing factors.
How does vomiting occur and what are the potential severe consequences?
Vomiting is triggered when stimuli activate the vomiting center, often originating from gastric irritation, toxins, or neurological factors like increased cerebral pressure or motion. The process involves a prodromal phase of nausea, pallor, and hypersalivation, followed by the active vomiting phase characterized by cessation of respiration, increased abdominal pressure, and duodenal contraction. The most dangerous consequences are systemic, including severe dehydration, hypovolemic shock, and metabolic disturbances such as hypochloremic/hypokalemic alkalosis. Repeated vomiting can also lead to respiratory issues like aspiration pneumonia (Mendelson's syndrome) and digestive damage like peptic esophagitis.
- Stimuli activating the vomiting center include toxins, medications, and cerebral pressure.
- The physical act involves respiratory arrest, abdominal pressure, and duodenal contraction.
- Severe metabolic consequences include dehydration, hypovolemic shock, and severe malnutrition.
- Respiratory complications involve apneas, recurrent acute respiratory infections, and Mendelson's syndrome.
- Digestive consequences include peptic esophagitis, esophageal stenosis, and Mallory-Weiss syndrome.
What steps are involved in diagnosing the cause and severity of vomiting?
The diagnostic process begins with confirming the positive diagnosis—active rejection—and assessing associated signs like diaphragmatic and abdominal contractions, preceded by prodromes such as nausea and sweating. Crucially, the severity must be determined clinically (dehydration, malnutrition) and biologically (electrolyte disturbances, alkalosis). The etiological diagnosis requires a triple inquiry: anamnesis (detailed history of the vomiting characteristics, associated signs, and diet), clinical examination (physical signs, neurological status, digestive findings), and paraclinical investigations tailored to suspected causes (surgical, infectious, neurological, or metabolic).
- Positive diagnosis relies on clinical signs of active rejection and prodromes (nausea, pallor).
- Severity assessment checks for dehydration, malnutrition, and electrolyte imbalances.
- Differential diagnosis excludes passive regurgitation, voluntary rumination (merycism), and expectoration of pus (vomica).
- Anamnesis details the timing, aspect (bilious, bloody), volume, frequency, and associated functional signs.
- Paraclinical tests include abdominal X-rays (ASP), ultrasound, and specific tests for infection (ECBU, lumbar puncture) or neurological issues (CT, MRI).
How are the causes of vomiting classified into acute and chronic categories?
Vomiting causes are broadly classified into occasional/acute and habitual/chronic types, often dictating the urgency of intervention. Acute causes include surgical emergencies like obstructive syndromes (e.g., intussusception, strangulated hernia) and peritonitis, as well as acute medical issues such as infections (gastroenteritis, meningitis) or neurological conditions causing intracranial hypertension (HTIC). Chronic causes frequently involve congenital digestive malformations like Gastroesophageal Reflux Disease (GERD) or Hypertrophic Pyloric Stenosis (HPS), metabolic disorders (e.g., protein intolerance), or functional/psycho-affective issues where no physical etiology is found.
- Acute surgical causes include obstructive syndrome (pain, stopped gas/stool) and peritonitis (fever, abdominal defense).
- Acute medical causes involve infections and neurological syndromes of HTIC (jet vomiting, headache).
- Chronic causes include congenital malformations like GERD and Hypertrophic Pyloric Stenosis (SHP).
- Metabolic chronic causes involve intolerances (cow's milk protein, gluten) or congenital metabolic blocks.
- Functional vomiting is often linked to psycho-affective causes or dietary errors.
What are the primary goals and methods for treating vomiting in children?
The primary goals of curative treatment are to stop the vomiting, prevent or manage complications, and treat the underlying cause. Symptomatic methods focus on postural changes (sitting upright or dorsal position > 60 degrees) and dietary adjustments, such as frequent, small, thickened meals. Pharmacological intervention includes antiemetics like Metopimazine or Domperidone, used cautiously due to potential extrapyramidal side effects, and antispasmodics. Crucially, treatment involves correcting consequences through oral or intravenous rehydration and nutritional rehabilitation. Specific treatments range from antibiotics for infections to surgical procedures like pyloromyotomy for HPS or fundoplication for severe GERD.
- Treatment goals are to stop vomiting, treat the cause, manage complications, and ensure communication.
- Non-pharmacological methods include orthostatic positioning and dietary thickening/fractionation.
- Antiemetics used include Metopimazine (Vogalène®) and Domperidone (Motilium®).
- Consequences are corrected via rehydration (oral/IV), nutritional rehabilitation, and mucosal protectors.
- Surgical interventions include Fredet-Ramsted pylorotomy for SHP and Nissen fundoplication for RGO.
- Preventive measures focus on promoting breastfeeding, good nutrition, and timely consultations.
Frequently Asked Questions
What is the key difference between vomiting and regurgitation in children?
Vomiting is characterized by the active, forceful rejection of contents, often preceded by nausea and abdominal contraction. Regurgitation, conversely, is a passive process that occurs without effort, typically following an eructation or burp.
What are the most serious metabolic complications of persistent vomiting?
Persistent vomiting can lead to severe dehydration and hypovolemic shock. Metabolically, it often results in acid-base disturbances, specifically hypochloremic/hypokalemic alkalosis, and can cause severe malnutrition if prolonged.
When should acute vomiting be considered a surgical emergency?
Acute vomiting requires urgent surgical evaluation if signs of obstructive syndrome (abdominal pain, stopped gas/stool, bilious vomit) or peritonitis (fever, abdominal defense) are present, indicating conditions like intussusception or appendicitis.
What are common chronic causes of vomiting related to digestive malformations?
Chronic vomiting is often linked to congenital issues. Key examples include Gastroesophageal Reflux Disease (GERD), which causes easy, positional vomiting, and Hypertrophic Pyloric Stenosis (SHP), characterized by early postprandial, projectile vomiting.
What are the principles of symptomatic treatment for pediatric vomiting?
Symptomatic treatment involves postural management (keeping the child upright), dietary modification (small, frequent, thickened meals), and cautious use of antiemetics like Domperidone or Metopimazine to stop the active expulsion reflex.
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