Nausea and vomiting are very common symptoms in the pediatric population. Whether presenting in the emergency department or in an outpatient clinic, they are a frequent reason for parents and caregivers to seek medical attention.
Summary
Definitions
Nausea is the subjective unpleasant sensation of imminent vomiting. It is frequently accompanied by autonomic symptoms such as dizziness, pallor, and sweating.
According to the Rome foundation, chronic nausea is defined as bothersome nausea occurring several times per week, not usually associated with vomiting, in the absence of endoscopic or metabolic disease. These criteria must be fulfilled for the last 3 months, with the symptom onset at least 6 months prior to diagnosis.[1] In the latest Rome IV consensus, a specific definition of chronic nausea for young children or adolescents was not included.[2] [1]
Nausea is not always followed by vomiting, as in conditions such as chronic functional nausea, postural nausea, and functional dyspepsia.
Vomiting is defined as the vigorous oral expulsion of the gastric or intestinal contents associated with increased intra-abdominal pressure. Oral regurgitation refers to the effortless, usually postprandial, emesis of food content.
Vomiting is usually preceded by nausea; the only exceptions are rumination syndrome, in which oral regurgitation is not preceded by nausea, and possibly gastroesophageal reflux disease.
Etiology
There are various established mechanisms that are known to cause nausea and vomiting, including:[3]
- Stimulation of chemoreceptors situated in the area postrema (medullary structure located in the fourth ventricle of the brain)
- Movement-induced stimulation of the labyrinth
- Irritation or over-distension of the mechanically sensitive vagal afferents in the gastrointestinal tract.
The etiology of nausea and vomiting is often age-dependent, with a wide spectrum of gastrointestinal, nongastrointestinal, and environmental causes, including:
- Inflammatory changes causing infection of the gastrointestinal system or other body systems
- Anatomical abnormalities resulting in bowel obstruction
- Functional disorders or malignancy of the gastrointestinal tract
- Neurologic causes, which can be one of the most ominous causes, particularly in the presence of increased intracranial hypertension or central nervous system infection
- Metabolic or endocrine abnormalities such as diabetic ketoacidosis, adrenal insufficiency, and protein or carbohydrate metabolism disorders
- Urologic/gynecologic or renal causes such as gonadal torsion
- Renal causes such as hemolytic uremic syndrome and nephrolithiasis
- Psychiatric causes such as eating disorders, rumination, or factitious disorder
- Environmental causes such as toxic ingestions and adverse effects associated with the use of medications or illicit drugs.
Diagnosis
A complete history and meticulous physical examination is essential and provides the clues for appropriate diagnosis and management. Diagnostic testing should be directed by the clinical picture.[4]
Urgent considerations, particularly neurologic compromise, need to be addressed first and may prompt more immediate therapeutic management. Red-flag symptoms that may require urgent management include: lethargy, fever, volume depletion, weight loss, bilious vomiting, hematemesis, papilledema, abdominal tenderness, or the presence of a mass.
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Etiology of nausea and vomiting in children and adolescents grouped according to age
Abdominal x-ray showing fecal impaction in a patient with constipation
Abdominal x-ray showing filled right colon and empty left colon and rectum in a patient with intussusception
Abdominal x-ray showing intestinal malrotation; note the small bowel is located to the right side of the midline
Abdominal x-ray showing small bowel volvulus, a common cause of bilious vomiting
CT abdomen showing small calcification in area of the left ureteral space, which corresponds to the presence of a kidney stone
CT showing increased volume of lateral ventricles secondary to noncommunicating hydrocephalus
CT head showing right parietotemporal brain tumor
Barium enema showing transition zones in patient with Hirschsprung disease
Sitz marker test showing retention of ingested markers in the rectosigmoid region in a patient with constipation
CT head showing right parietotemporal brain tumor
CT showing increased volume of lateral ventricles secondary to noncommunicating hydrocephalus
Abdominal x-ray showing filled right colon and empty left colon and rectum in a patient with intussusception
Abdominal x-ray showing small bowel volvulus, a common cause of bilious vomiting
Abdominal x-ray showing intestinal malrotation; note the small bowel is located to the right side of the midline
Abdominal x-ray showing fecal impaction in a patient with constipation
Sitz marker test showing retention of ingested markers in the rectosigmoid region in a patient with constipation
CT abdomen showing small calcification in area of the left ureteral space, which corresponds to the presence of a kidney stone
Barium enema showing transition zones in patient with Hirschsprung disease
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