Managing vomiting

Treating a vomiting child is a challenge, especially when the cause is unknown. Not only is the child suffering , but the parents are afraid that their child is seriously ill. Oral rehydration is the mainstay of treatment to avoid dehydration, but is it ever appropriate to consider antiemetic medications?

Grappling with a vomiting child is a routine but serious challenge for pediatric health care providers. Vomiting distresses children, parents, and pediatricians alike. Not only do parents find vomiting problematic in and of itself, vomiting also makes parents think that their child is severely ill.¹ Parents' concerns may multiply if their child's vomiting leads to invasive testing or procedures such as intravenous (IV) line placement.

Children with vomiting are miserable, and they and their parents just want the vomiting to stop. At the same time, pediatricians wrestle with deciding what is causing the vomiting and choosing the appropriate interventions for management that may prevent children from needing IV fluids or even hospitalization.

Whereas regurgitation typically involves effortless expulsion of mouthfuls of food or stomach contents, vomiting results in more forceful expulsion of larger amounts of the stomach's contents.^2,3 The actual act of vomiting involves a coordinated process of reflexes under the coordination of the medullary vomiting center.

Before one vomits, the salivary rate increases and there may be involuntary retching. Then, the diaphragm descends suddenly, the abdominal muscles constrict, the gastric cardia relaxes, and the gastric contents are forced back up the esophagus. The medullary vomiting center has direct afferent innervation, but it also is indirectly influenced by chemoreceptors and higher central nervous system centers.

Differential diagnosis

Many disorders of childhood present with vomiting, and differentiating among the causes of vomiting can be a challenge. Infectious causes are the most common in children, and children often vomit as the body's defense against ingested toxins. A history of fever and/or diarrhea is a key indicator of an infectious cause.

Vomiting can be caused by disorders of the gastrointestinal tract that are anatomic, motile, inflammatory, or infectious (Table 1).^2,4 Vomiting also can be the result of other infectious, neurologic, renal, metabolic, endocrine, or immunologic causes. Increases in intracranial pressure can affect the vomiting center. Intestinal obstruction or anatomic or mucosal abnormalities also can result in vomiting.