Vomiting in Children Under 5

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Background
Presentation & Differentials
Management
Guidelines
References

Background

Vomiting in a child is a very common presentation with a range of differentials that vary according to age.

It also commonly presents with diarrhoea.

First, it is important to define vomiting in a child…

Posseting = non-forceful return of small amounts of milk (normal).

Regurgitation = non-forceful larger amounts of milk (more suggestive of reflux).

Vomiting = forceful return of milk.

Vomiting can be further sub-divided, according to the timeframe, into:

Acute (1-3 days)
Chronic (daily, weeks-months)
Cyclical / Episodic (discrete bouts, weekly or monthly, return to normal health in-between)

Presentation & Differentials

The presentation of vomiting can be varied, the following tables provide a brief overview of red flag symptoms and the differential diagnoses that should be considered, age dependant and grouped by mechanism to help remember them all (adapted from(1,2)).

Red Flag Symptoms	Differential Diagnoses of Concern
Failure to thrive	GORD / Coeliac / early-onset-IBD
Bile-stained / Abdo Distention	Intestinal Obstruction / Acute Surgical Abdo
Projectile Vomit	Pyloric Stenosis
Haematemesis	Peptic Ulcer / Oesophagitis
Blood in Stool	Intussusception / Gastroenteritis
Early Morning Vomiting / Bulging Fontanelle	Raised ICP
Severe dehydration / Shock	Sepsis / DKA / Severe Gastroenteritis
Onset of regurgitation after 6 months old	Late onset suggests a cause other than reflux
Alerted responsiveness / Irritability	Meningitis / Sepsis

Neonates (<1 month) indicates most common causes
GI Causes		Non-GI Causes
Mechanical	Mucosal / Metabolic	Infectious	Neurological
Overfeeding	Cow’s milk protein allergy	Neonatal sepsis	Hydrocephalus
GORD	Formula protein intolerance		Haemorrhage
Pyloric Stenosis
Hirschsprung’s
Malrotation with/without volvulus.
Meconium ileus
Obstruction (atresias, strictures)

Infants (1-12months) indicates most common causes
GI Causes			Non-GI Causes
Mechanical	Mucosal / Metabolic	Infectious	Infectious	Neurological
Overfeeding	Cow’s milk protein allergy	Gastroenteritis	Acute otitis media	Hydrocephalus
GORD	Formula protein intolerance		Pharyngitis	Brain tumours
Pyloric Stenosis	Haemorrhage		Urinary tract infection
Hirschsprung’s			Sepsis
Malrotation with/without volvulus.			Meningitis
			Pyelonephritis

Toddlers (12months-5yrs) indicates most common causes
GI Causes			Non-GI Causes
Mechanical	Mucosal / Metabolic	Infectious	Mechanical	Metabolic	Infectious	Neurological
Malrotation with/without volvulus	Oesophagitis	Gastroenteritis	Testicular / Ovarian Torsion	DKA	Acute otitis media	Brain Tumours
Intussusception	Coeliac			Adrenal Insufficiency	Pharyngitis
	Early onset IBD				Urinary tract infection
					Sepsis
					Meningitis
					Pyelonephritis
					Appendicitis

Management

If there are any red flag symptoms, signs of dehydration or shock, an unknown cause for the vomiting, these should prompt urgent specialist review (2).

Management is focused on treating the underlying cause.

PO / IV Ondansetron can be used in paediatric setting to alleviate symptoms in the short term and help with oral rehydration, preventing the need for IV fluid resuscitation (3).

The following table provides an overview of some diagnostic tests for some of the potential causes of vomiting (adapted from (1)).

Timeframe	Differential	Diagnostic Test
Acute	Malrotation with or without volvulus / Intestinal obstruction	X-ray abdomen; upper GI contrast study
	Oesophageal obstructions (atresias, strictures)	Oesophogram
	Pyloric stenosis / Intussusception	U&Es, abdominal ultrasound
	Hirschsprung’s disease	Contrast enema; anorectal manometry; rectal biopsy (gold standard)
	Gastroenteritis	Infectious stool studies (viral, bacterial)
Chronic	GORD	Clinical Dx, pH impedance
	Cow’s milk protein allergy	Hydrolysed formula trial
	Coeliac disease	Anti-TTG (IgA), Total IgA; endoscopy with biopsy
	Signs of increased intracranial pressure	MRI brain or CT head
Cyclical	Intussusception	Abdominal ultrasound
	Adrenal insufficiency	Morning serum cortisol, ACTH stimulation test
	Cyclic vomiting syndrome	Rome IV criteria, NASPGHAN

Guidelines

Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management
Clinical guideline [CG84]Published: 22 April 2009
https://www.nice.org.uk/guidance/cg84/chapter/Recommendations

Gastro-oesophageal reflux in children and young people
Quality standard [QS112]Published: 28 January 2016
https://www.nice.org.uk/guidance/qs112

Gastro-oesophageal reflux disease in children and young people: diagnosis and management
NICE guideline [NG1]Published: 14 January 2015 Last updated: 09 October 2019
https://www.nice.org.uk/guidance/ng1/chapter/Recommendations

Health protection in children and young people settings, including education
https://www.gov.uk/government/publications/health-protection-in-schools-and-other-childcare-facilities

Food allergy in under 19s: assessment and diagnosis
Clinical guideline [CG116]Published: 23 February 2011
https://www.nice.org.uk/guidance/cg116

References

1. Siegel BL, Li BUK. Vomiting in Children: Clinical Scenarios. Curr Treat Options Peds. 2023 Dec 1;9(4):199–223.

2. Recommendations | Gastro-oesophageal reflux disease in children and young people: diagnosis and management | Guidance | NICE [Internet]. NICE; 2015 [cited 2024 May 23]. Available from: https://www.nice.org.uk/guidance/ng1/chapter/Recommendations

3. Key points from the evidence | Management of vomiting in children and young people with gastroenteritis: ondansetron | Advice | NICE [Internet]. NICE; 2014 [cited 2024 May 23]. Available from: https://www.nice.org.uk/advice/esuom34/chapter/Key-points-from-the-evidence