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Management of a Child with Vomiting

Article  in  The Indian Journal of Pediatrics · January 2013

DOI: 10.1007/s12098-012-0959-6 · Source: PubMed

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Indian J Pediatr (April 2013) 80(4):318–325
DOI 10.1007/s12098-012-0959-6

SYMPOSIUM ON PGIMER MANAGEMENT PROTOCOLS IN GASTROINTESTINAL EMERGENCIES

Management of a Child with Vomiting

Sunit C. Singhi & Ravi Shah & Arun Bansal &
M. Jayashree

Received: 10 August 2012 / Accepted: 28 December 2012 / Published online: 23 January 2013
# Dr. K C Chaudhuri Foundation 2013

Abstract Vomiting is a protective reflex that results in force- 0.15 mg/kg; maximum 4 mg) is indicated in children unable
ful ejection of stomach contents up to and out of the mouth. It to take orally due to persistent vomiting, post-operative vom-
is a common complaint and may be the presenting symptom iting, chemotherapy induced vomiting, cyclic vomiting syn-
of several life-threatening conditions. It can be caused by a drome and acute mountain sickness.
variety of organic and nonorganic disorders; gastrointestinal
(GI) or outside of GI. Acute gastritis and gastroenteritis (AGE) Keywords Children . Vomiting . Antiemetic
are the leading cause of acute vomiting in children. Important
life threatening causes in infancy include congenital intestinal
obstruction, atresia, malrotation with volvulus, necrotizing Introduction
enterocolitis, pyloric stenosis, intussusception, shaken baby
syndrome, hydrocephalus, inborn errors of metabolism, con- Vomiting is a very common complaint in infants and chil-
genital adrenal hypoplasia, obstructive uropathy, sepsis, men- dren who present to the emergency department (ED). A
ingitis and encephalitis, and severe gastroenteritis, and in large percentage of infants and children with vomiting have
older children appendicitis, intracranial mass lesion, diabetic a non-serious etiology for their symptoms and have a self-
ketoacidosis, Reye’s syndrome, toxic ingestions, uremia, and limiting illness. However, vomiting may be the presenting
meningitis. Initial evaluation is directed at assessment of symptom in several life-threatening conditions. The ED
airway, breathing and circulation, assessment of hydration management is primarily tailored to identify and manage
status and red flag signs (bilious or bloody vomiting, altered those with a serious underlying cause, and provide symp-
sensorium, toxic/septic/apprehensive look, inconsolable cry tomatic relief to others.
or excessive irritability, severe dehydration, concern for symp-
tomatic hypoglycemia, severe wasting, Bent-over posture).
The history and physical examination guides the approach in Terminology
an individual patient. The diverse nature of causes of vomiting
makes a “routine” laboratory or radiologic screen impossible. Vomiting is a complex behavior. It is usually composed of
Investigations (Serum electrolytes and blood gases,renal and three linked activities: nausea, retching and expulsion of
liver functions and radiological studies) are required in any stomach contents.
child with dehydration or red flag signs, to diagnose surgical Nausea is a sensation of impending emesis and is fre-
causes. Management priorities include treatment of dehydra- quently accompanied by autonomic changes, such as in-
tion, stoppage of oral fluids/feeds and decompression of the creased heart rate and salivation. Vomiting can occur
stomach with nasogastric tube in patients with bilious vomit- without preceding nausea, for e.g., projectile vomiting in
ing. Antiemetic ondansetron(0.2 mg/kg oral; parenteral individuals with increased intracranial pressure.
Retching is defined as strong, involuntary efforts to vomit
but without expelling material from the mouth, which may
S. C. Singhi (*) : R. Shah : A. Bansal : M. Jayashree
be seen as preparatory manoeuvres to vomiting.
Department of Pediatrics, Advanced Pediatrics Centre, PGIMER,
Chandigarh 160012, India Vomiting is a protective reflex and is defined as forceful
e-mail: [email protected] ejection of stomach contents up to and out of the mouth [1].
Indian J Pediatr (April 2013) 80(4):318–325 319

It is caused by violent co-ordinated contraction of the dia- identify and often are viewed as diagnoses of exclusion.
phragm and abdominal muscles accompanied by pyloric con- Examples of non-organic causes are psychogenic vomiting,
striction and gastroesophageal relaxation in response to cyclic vomiting syndrome, abdominal migraine, and bulim-
stimulation of the medullary vomiting centre. This stimulation ia. Mnemonic ‘VOMITINGs’ can help to remember wide
may occur from a variety of impulses -from pelvic and ab- ranging causes of vomiting:
dominal viscera, the heart, the peritoneum, the inner ear, and
the chemoreceptor trigger zone (caused by circulating drugs, & Vestibular: Otitis media
toxins, and metabolic derangements). Vomiting is complete & Obstruction: Pyloric stenosis, malrotation, volvulus, in-
emptying of the stomach as compared to regurgitation, which tussusception, incarcerated hernia
is nearly effortless return of short amount of food during or & Metabolic: Diabetic ketoacidosis, inborn errors of metab-
shortly after eating. When regurgitation occurs in a baby at or olism, congenital adrenal hyperplasia, Reye’s syndrome
after milk feed, it is known as posseting. & Infections:

– Gastrointestinal- Gastritis, gastroenteritis, necrotiz-

ing enterocolitis, appendicitis, hepatitis, pancreati-
Causes
tis, cholecystitis.
– Other systems- Upper respiratory infections, phar-
Vomiting does not always localize the problem to the GI
yngitis, sinusitis, pneumonia, sepsis
system. A variety of organic and non-organic disorders,
gastrointestinal (GI) or outside of GI, can be associated with & Toxins and drugs: Various poisons, chemotherapeutic
vomiting. Acute gastritis and gastroenteritis (AGE) are the agents, iron, organophosphates, theophylline, salicy-
leading causes of acute vomiting in children. Although lates, alcohol, lead and other heavy metals.
vomiting is a fairly frequent occurrence in a younger child, & Increased intracranial pressure from any etiology.
it tends to be less prevalent in older children [2]. The & Nephrologic disease : Acute renal failure, chronic renal
differential diagnosis of isolated vomiting is broad and age failure, pyelonephritis, renal tubular acidosis, obstruc-
specific (Table 1). Non-organic causes are difficult to tive uropathy.

Table 1 Illnesses presenting with vomiting according to the age group

Neonate Infant Toddler/older child Adolescent

Common Reflux Food poisoning Gastroenteritis/Gastritis Gastroenteritis/Gastritis

Pyloric stenosis Gastroenteritis Nonspecific (Otitis, GERD
sore throat, sinusitis)
Sepsis GE Reflux Post tussive Appendicitis
UTI Post tussive UTI Ingestion (toxic, bacillus cereus)
Malrotation Overfeeding Meningitis Migraine
Esophageal atresia Feed intolerance Toxic/Poisoning/Drugs Inflammatory bowel disease
Inborn error of metabolism (IEM) UTI GERD Toxic/Poisoning/Drugs
Hydrocephalus Nonspecific (otitis Obstruction
Milk allergy media, pneumonia)
Uncommon Congenital Adrenal Hyperplasia IEM DKA Hepatitis
Incarcerated hernia Renal Tubular Acidosis IEM DKA
Ileus Obstruction Hepatitis Peptic ulcer
Hirschprung disease Malrotation Migraine Psychological
Intracranial bleed Intussusception Peptic ulcer Pancreatitis
Milk allergy Pancreatitis Cholelithiasis
Renal insufficiency Raised ICP (Brain Tumor) Renal colic
Raised ICP Reye’s syndrome Raised ICP (Brain tumor)
Cyclic vomiting syndrome Middle ear disease
Cyclic vomiting

IEM Inborn error of metabolism; DKA Diabetic Ketoacidosis ; GE Gastro esophagial; UTI Urinary tract infection; ICP Intracranial pressure; GERD
Gastroesophageal reflux diseases
320 Indian J Pediatr (April 2013) 80(4):318–325

& Gastrointestinal: Gastro -Esophagial reflux (GER), for- Initial Evaluation

mula intolerance, peptic ulcer disease, cyclic vomiting
syndrome. Initial evaluation is directed at assessment of airway, breathing
& Genital system: Testicular torsion, epididymitis, dysmen- and circulation i.e., checking the vitals (heart rate, respiratory
orrhea, ovarian torsion, pelvic inflammatory disease. rate, blood pressure, capillary refill time and SpO2), assess-
ment of hydration status and Red flag signs (Table 2). If red
flag signs, seek gastroenterologist and surgical consult.
Evaluation If vomiting is non-bloody and non-bilious, the important
diagnostic variables in history which help in making diag-
Evaluation of a child with vomiting in ED comprises as- nosis are described below.
sessment of severity (e.g., presence of dehydration, surgical
or other life-threatening disorders) and diagnostic search for Age
a cause. This is achieved through focussed history (includ-
ing characteristics of vomiting and associated symptoms) Causes of vomiting vary with the age of the child (Table 1).
and physical examination, and consideration of possibilities However, some overlap across the age groups can occur. For
according to the age (Fig. 1). e.g., congenital anomalies of the GI tract present commonly in
The initial diagnostic focus is on likely acute GI or the neonatal period; yet webs and duplications can be discov-
systemic infections and exclusion of surgical causes. In ered throughout childhood. Malrotation or non-fixation of the
infancy, the life threatening causes include congenital intes- small intestine complicated by intermittent volvulus can cause
tinal obstruction, atresia, malrotation with volvulus, necro- episodic vomiting at any age. Duodenal hematoma typically
tizing enterocolitis, pyloric stenosis, intussusception, shaken follows accidental trauma to the abdomen in bicycling chil-
baby syndrome, hydrocephalus, inborn errors of metabo- dren but can result from abuse of toddlers. [3]
lism, congenital adrenal hyperplasia, obstructive uropathy,
sepsis, meningitis and encephalitis, and severe gastroenter- Temporal Pattern of Vomiting (Table 3)
itis. In older children, life threatening causes that need
attention are appendicitis, intracranial mass lesion, diabetic Acute vomiting episode, which is abrupt onset of vomiting
ketoacidosis, Reye’s syndrome, toxic ingestions, uremia, in previously well child, is the most common presentation in
and meningitis. children. Episodes separated by not more than 2 min are

Fig. 1 Algorithm for Patient having

evaluation of a child with dehydration?
vomiting in emergency room – Yes No
based on presence of other
symptoms, type of vomitus,
age, and physical signs Refer to protocol Characterization of
on diarrhea vomiting

Bloody Bilious Non bloody and non Regurgitant

bilious

Refer to protocol on Rule out

upper GI bleed obstruction
Neonate/ Child/
Infant Adolescent

Evidence of Lethargy/Altered
sepsis/meningitis? mental status?
No Yes No Yes

Evidence of Antibiotics, Diarrhea/Fever?

Metabolic,
obstruction? Evaluate Neurologic
No Yes
No Yes or
Peptic Endocrine
Metabolic/ Infectious
Surgical causes
disease/ causes
Endocrine
Toxins
Indian J Pediatr (April 2013) 80(4):318–325 321

Table 2 Red flag signs in a child presenting with vomiting fructose intolerance. History of binge eating should be asked
• Altered sensorium (cause or effect) when behavioral cause is suspected.
• Toxic/ septic /apprehensive look
• Bilious or bloody vomiting
Associated Symptoms
• Presence of inconsolable cry or excessive irritability
(meningitis, intussusception) GI Symptoms
• Signs of severe dehydration or concern for & Diarrhea: Gastroenteritis (diagnosis is made if vomiting
symptomatic hypoglycemia
and diarrhea both are present), bacterial colitis, inborn
• Visible severe wasting
error of metabolism and partial intestinal obstruction.
• Bent-over posture (drawing of legs up to the chest), and pained
avoidance of unnecessary movement typical of peritoneal
& Abdominal pain and its location
irritation (peritonitis, intussusception)
– Generalized : [peritonitis, abdominal migraine
(recurrent)]
– Substernal : Esophagitis
counted as a single episode. Recurrent vomiting is defined – Epigastric: Gastritis, pancreatitis
as at least 3 episodes occurring over 3 mo period. Recurrent – Right upper quadrant : Cholelithiasis, pneumonia
vomiting is further subdivided into chronic vomiting, which – Right lower quadrant : Appendicitis (vomiting after
is low grade frequent (>2/wk) vomiting episodes, and epi- pain)
sodic or cyclic vomiting, which is discrete episodes of high – Lower abdominal or suprapubic- UTI
intensity vomiting that occur sporadically in between
asymptomatic intervals. Cyclic vomiting syndrome is dis-
tinct clinical entity.It is important to elicit temporal pattern Extra Intestinal Symptoms
of vomiting because any single attack of episode or cyclic & Sore throat, ear pain: Sinusitis, otitis media
vomiting may resemble an acute vomiting attack. & Urinary retention, dysuria: Urinary tract infection,
Time of day vomiting occurs can give some clue to pyelonephritis
diagnosis. Vomiting consistently in early morning is com- & Jaundice: Hepatitis, biliary disorders
mon with increased intracranial pressure from various & Headache: Allergy, chronic sinusitis, migraine
causes and cyclic vomiting syndrome.
– Nocturnal or early morning worsened by coughing or
Contents of Vomiting valsalva manoeuvre
& Vertigo: Migraine, Meniere disease
Contents of vomiting gives important clue to diagnosis and
& Rash or urticaria: Food allergy, Henoch Schonlein purpura
sometimes helps in identifying serious illness. These are
& Back pain- Pyelonephritis
given in Table 4.
History of Toxic Ingestions: Food, iron, alcohol,
Relationship with Diet organophosphates
History of Drug Intake: digoxin (vomiting is first sign
Vomiting is aggravated by food in patients with gastritis, of toxicity), theophylline, salicylates, chemotherapeutic
cholecystitis, pancreatitis, protein allergy, and hereditary drugs, acetaminophen

Table 3 Temporal patterns of vomiting

Acute pattern Recurrent: chronic Recurrent: cyclic/episodic

Epidemiology Most common 2/3 of those with recurrent vomiting 1/3 of those with recurrent vomiting
Etiology See Table 1 Gastrointestinal (GI) more common Extra-intestinal causes outnumber
than extra-intestinal ones (7:1) GI ones (5:1)
Acid peptic disease, H. pylori Cyclic vomiting syndrome (88 %), DKA,
Addison disease, metabolic disorders,
malrotation, hydronephrosis
Vomiting severity Moderate to severe ± dehydration Mild (1–2 emeses/h at peak). Moderate to severe (6 emeses/h at peak),
Rarely dehydrated >50 % require IV hydration
Migraine family history Up to 14 % positive Up to 82 % positive
322 Indian J Pediatr (April 2013) 80(4):318–325

History of recent head trauma, similar symptoms in family life (2–4 wk commonly) in an otherwise healthy infant [5].
or neighbourhood (gastroenteritis, food poisoning, Affected children may appear irritable during or after the
hepatitis) feedings and stereotypic opisthotonic movements with exten-
sion and stiffening of arms and legs and extension of the head
Physical Examination (Sandifer syndrome) occasionally may be observed. Infants
who have the classic history of recurrent emesis but who are
The physical examination is directed towards evaluation of thriving and have normal physical examination findings do
degree of toxicity and dehydration and then focused according not need specific treatment; up to 95 % of them have resolu-
to possible clinical etiology. tion of symptoms by 12 mo (majority by 6 mo). Thickening
the formula or human milk by adding cereal may help reduce
Abdominal Examination vomiting in such infants, but elevating the head in the supine
position has no proven beneficial effect [6].
& Look for signs of obstruction such as distension, tender-
Infants with severe GER can have recurrent microaspira-
ness, high-pitched bowel sounds (or absent sounds in
tion into their lungs resulting in chronic wheezing, respira-
ileus), or visible peristalsis
tory symptoms, and even failure to thrive. This is known as
& Look for organomegaly
GER Disease. Basic reflux precautions such as smaller,
& Genitalia and hernia sites for ovarian/testicular torsion,
more frequent feeds and allowing the infant to remain up-
strangulated hernia
right for 30 min after feeds can be helpful. Reassuring the
& Per rectal examination: especially when intussusception
family that most children spontaneously outgrow GER by
is suspected.
the age of 1 usually helps alleviate parental anxiety.
Clinical features of some common surgical causes of
vomiting are given in Table 5. Minor Head Injury Minor head injury can present as vomit-
ing in children, especially toddlers [7]. There is evidence to
Extra Abdominal Examination suggest that vomiting after a minor head injury may be
related to intrinsic patient factors rather than the severity
& Look for icterus (hepatitis, biliary disease), pallor (intra-
of the injury [8]. Vomiting that is persistent or latent in onset
cranial bleed), rash or petechiae (CNS infection or bleed)
may more likely to signify head injury.
& Ear examination- Bulging red tympanic membrane (otitis
media)
Rumination Syndrome Rumination syndrome, an under-
& Abnormal muscle tone : Cerebral palsy (GER), metabolic
recognised condition, is characterised by effortless, often
disorder, mitochondriopathy
repetitive, regurgitation of recently ingested food into the
& Abnormal fundoscopic exam or bulging fontanelle: In-
mouth. It was originally described in children and in the
creased intracranial pressure, pseudotumorcerebri
developmentally disabled but it is now well -recognised that
& Neck stiffness, Kernig’s and Brudzinski’s sign: Meningitis
the condition occurs in patients of all ages and cognitive
[Sensitivity and specificity of vomiting is 71 % and 62 %
abilities [9]. The pathophysiology is incompletely under-
respectively for diagnosis of meningitis in a child with
stood, but involves a rise in intra-gastric pressure, generated
clinically suspected meningitis [4]].
by a voluntary, but often unintentional, contraction of the
Infant Regurgitation is defined as vomiting occurring two abdominal wall musculature, at a time of low pressure in the
or more times per day for 3 or more wk in the first 1–12 mo of lower oesophageal sphincter, causing retrograde movement

Table 4 Etiology and source of vomiting according to contents of vomitus

Material Source Examples

Undigested food Esophageal Esophageal stricture, achalasia

Bile: green/yellow Post-ampullary Small bowel obstruction (e.g., malrotation),
Distal to ampulla of vater prolonged vomiting of any cause
Digested food, milk curds Stomach proximal to pylorus Pyloric stenosis
Blood: red (fresh blood)/brown (old blood) Lesion above ligament of Treitz: Gastritis, esophagitis, bleeding diathesis
Stomach, esophagus
Clear large volume Increased gastric secretions Peritonitis, Zollinger-Ellison syndrome
Malodorous/ feculent Distal or Colonic obstruction Malrotation, appendicitis, stasis syndrome
Mucus Respiratory mucus, gastric URI, sinusitis, eosinophilic esophagitis
Indian J Pediatr (April 2013) 80(4):318–325 323

Table 5 Typical clinical pre-

sentation of some surgical Appendicitis Pre-adolescent child with periumbillical crampy pain and anorexia followed by
illnesses which may present vomiting. Pain shifts to right lower quadrant and fever may develop. Abdominal
with vomiting pain preceded by vomiting can be helpful in distinguishing appendicitis from
acute gastroenteritis
Intussusception 3 mo to 5 y-old (peak 6–11 mo) with intermittent colicky abdominal pain, vomiting,
and bloody mucous stools (triad in 20 % to 40 % of cases, and at least two findings
in 60 %), appears ill, quiet, or exhausted. Uncommonly classic tender sausage shaped
mass on right side of the abdomen and occult blood or frankly bloody, foul-smelling
“currant jelly” stool on rectal examination (absence of these does not rule out diagnosis).
Pyloric stenosis 3 wk-3 mo- old infant, with progressively worsening non-bilious vomiting, may
appear quite well early in the illness, but often seem frustrated and hungry. As the
obstruction increases, the vomiting becomes projectile.

of gastric contents into the oesophagus [9]. A typical history (acidosis with elevated anion gap), renal tubular acidosis
can be highly suggestive but oesophageal manometry may (metabolic acidosis with a normal anion gap) and renal
help to distinguish rumination syndrome from other belching/ or prerenal failure (elevated creatinine).
regurgitation disorders [9].
Hepatic or pancreatic enzymes may be elevated in the
setting of liver or pancreatic disease.
Laboratory Investigations
Radiographic Tests
The diverse nature of causes of vomiting makes a “routine”
laboratory or radiologic screen impossible. The history and
Radiographic tests are needed to differentiate surgical
physical examination must guide the approach in individual
causes from nonsurgical etiologies.
patients. Investigations are not required in following conditions
and a therapeutic trial of medications should be given if required. & Plain Radiograph Abdomen: Abdominal X ray (erect
& Well appearing infant with typical regurgitant reflex (no preferably) should be done in any child with suspected
diarrhea, fever, nausea and forceful abdominal contractions) intestinal obstruction. Upright or cross-table lateral view
& Well child with suspected gastritis or gastroesophagial reflux. can reveal distended bowel loops and/or air-fluid levels
& Brief episode of vomiting with no dehydration and clear consistent with intestinal obstruction(in a child with
etiology like gastroenteritis bilious vomiting, abdominal pain and distension); dilat-
& Chronic vomiting where acid peptic disease is suspected ed stomach in pyloric stenosis; free air under diaphragm
in case of a hollow viscus perforation; abnormal calcifi-
Selected tests can give useful clues to diagnosis.
cations like renal or biliary stones or fecoliths; and
basilar infiltrates caused by lower lobe pneumonias.
Urinalysis
& Ultrasound: Uitrasonography of abdomen should be
obtained according to the clinical possibility. Abdominal
Presence of glucose and ketones suggest diabetic ketoaci-
ultrasound can be helpful in diagnosis of appendicitis,
dosis; red blood cells suggest a renal cause (nephritis, UTI,
pyloric stenosis, and intussusceptions. Pelvic ultrasound
renal calculi or trauma); and leukocytes or nitrites suggest a
is the test of choice for renal, ovarian or uterine pathol-
urinary tract infection.
ogy in children.
& An Upper GI Series best demonstrates malrotation and
Blood Investigations
upper gastrointestinal tract obstructions and may some-
times be needed for diagnosis of pyloric stenosis.
In any child with dehydration or red flag signs (Table 2),
& CT Scan: A limited CT with rectal contrast can be
total blood counts, blood sugar, serum electrolytes, blood
helpful in diagnosis of appendicitis. An abdominal CT
gases, Liver enzymes, and renal function tests should be
is most useful in imaging the liver and pancreas, and for
obtained according to the clinical possibility.
evaluating mass lesions in the abdomen.
& Serum Electrolytes and Blood Gases: Typical abnormal-
ities occur in an infant with projectile vomiting from Upper GI Endoscopy
pyloric stenosis (hypochloremic, hypokalemic metabolic
alkalosis), congenital adrenal hypoplasia (hyperkalemia Upper GI endoscopy is useful for defining upper GI muco-
and hyponatremia), increased lactate production caused sal pathology such as acute gastritis, gastric erosions, esoph-
by alcohols, salicylates, uremia, and metabolic defects agitis, acute duodenitis, duodenal ulcers, stricture, varices,
324 Indian J Pediatr (April 2013) 80(4):318–325

mass (polyp, lymphoma), and foreign body impaction. The 5. Acute motion sickness
diagnostic yield of upper gastrointestinal endoscopy in chil-
dren up to 18 y of age with vomiting in one study from Dose of Ondansetron Oral: 0.2 mg/kg and Parenteral
Saudi Arabia was 67 %. [10] 0.15 mg/kg (maximum 4 mg); range 0.13–0.26 mg/kg. Higher
doses are not beneficial nor do they have more side effects [14].
Metabolic Work Up While there are existing older studies evaluating domper-
idone, dexamethasone and promethazine, these studies have
In a child with episodic vomiting or suspected metabolic small sample sizes, low methodological quality and reveal
disorders, blood and urine screening are positive only dur- inconsistent results and their use is not recommended, par-
ing actual vomiting episode. Therefore, attempt should be ticularly in the light of increased concerns regarding the
made to obtain samples (blood pH, ammonia, lactate, safety of these medications for children.
ketones, urine ketones and electrolytes, porphyrins and re-
& Drugs for acid peptic disease: can be given empirically
ducing substances) during acute episode only.
for 2 wk to 4 wk. H2 receptor antagonist or proton pump
In chronic vomiting if therapeutic drug trial fails to im-
inhibitor can be used.
prove symptoms, screening laboratory tests (complete blood
& Cyclic vomiting syndrome is an idiopathic disorder that
count, ESR, celiac screening, liver enzymes) and abdominal
usually begins in early childhood and is characterised by
ultrasound can be obtained along with pediatric gastroenter-
repeated, discrete attacks of vomiting to the point of
ology consultation.
dehydration, (on average 12 episodes/d, typically lasting
for 2–3 d) and intervening periods of normal health.
Relatively little is known about its’ pathogenesis or
Emergency Management
cause [15]. Episodes usually occur in morning hours,
and may have associated prodrome of nausea, pallor and
& Treat dehydration (refer to protocol for diarrhea)
headache. Treatment is supportive, focused on fluid
& If bilious vomiting, stop oral fluids/feeds (nil per oss –
management in cases where dehydration and electrolyte
NPO) and decompress the stomach with nasogastric
imbalance occur. Amitriptyline and propranolol have
tube. Start intravenous fluids. Seek surgical consult.
been described as effective for prophylactic therapy
& Antiemetics: Antimetics are not routinely indicated due to
(antiemetics may be of benefit during an acute episode).
concerns about side effects of earlier generation of antie-
& The mainstay of treatment for rumination syndrome is
metics (promethazine, prochlorperazine, and metoclopra-
explanation and behavioral treatment which consists of
mide) which cause somnolence, nervousness, irritability,
habit reversal techniques that compete with the urge to
dystonic reactions and other extrapyramidal symptoms.
regurgitate [9].
Newer antiemetics such as ondansetron have far fewer
side effects [11]. Evidence based on a limited number of
Conflict of Interest None.
studies evaluating the role of ondansetron in the treatment
of acute gastroenteritis complicated by vomiting, favour
the use of ondansetron and metoclopramide to reduce the Role of Funding Source Used available resources of Department of
number of episodes of vomiting. However, diarrhea Pediatrics
increases with both ondansetron and metoclopramide,
which is thought to be as a result of retention of fluids
and toxins that would otherwise have been eliminated References
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