What is the clinical approach to evaluating and managing vomiting in children?

From the Guidelines

Vomiting in children should be evaluated based on the presence of red flags, such as dehydration, bilious vomit, projectile vomiting, blood in vomit, severe abdominal pain, altered mental status, or vomiting that persists beyond 24-48 hours, and managed accordingly with oral rehydration therapy and gradual return to a normal diet, while seeking medical attention if concerning symptoms arise. Vomiting in children is a common symptom with causes ranging from benign (like viral gastroenteritis) to serious conditions requiring immediate attention (such as intestinal obstruction or increased intracranial pressure) 1. For parents concerned about a vomiting child, it's essential to monitor for warning signs and seek medical attention if necessary. Some key points to consider when evaluating vomiting in children include:

• The clinical differentiation between vomiting and regurgitation may be challenging, with regurgitation being a common and often non-pathologic manifestation of gastroesophageal reflux (GER) 1.
• Bilious emesis or repeated forceful vomiting should be evaluated for underlying obstruction, and a diagnostic workup should start with a thorough clinical evaluation, including history and physical examination 1.
• Mild cases of vomiting can often be managed at home with oral rehydration therapy using small, frequent sips of electrolyte solutions, and children should gradually return to a normal diet as tolerated, starting with bland foods 1.
• Medical attention should be sought if the child shows signs of dehydration, cannot keep fluids down, or exhibits any concerning symptoms, such as severe abdominal pain, altered mental status, or vomiting that persists beyond 24-48 hours 1. The most recent and highest quality study on this topic is from 2020, which provides guidance on the evaluation and management of vomiting in infants, including the role of imaging in evaluating complete or partial GI obstruction 1.

From the FDA Drug Label

Ondansetron tablets are indicated for the prevention of nausea and vomiting associated with: highly emetogenic cancer chemotherapy, including cisplatin greater than or equal to 50 mg/m 2. initial and repeat courses of moderately emetogenic cancer chemotherapy radiotherapy in patients receiving either total body irradiation, single high-dose fraction to the abdomen, or daily fractions to the abdomen. Ondansetron tablets are also indicated for the prevention of postoperative nausea and/or vomiting.

The question is about vomiting in children, but the provided drug label is for ondansetron, which is used to prevent nausea and vomiting in specific situations such as cancer chemotherapy, radiotherapy, and postoperative nausea and/or vomiting. There is no direct information in the provided drug label that specifically addresses vomiting in children. The FDA drug label does not answer the question.

From the Research

Causes of Vomiting in Children

• Vomiting in children can be caused by a variety of organic and nonorganic disorders, including gastrointestinal (GI) and non-GI disorders 2
• Acute gastritis and gastroenteritis (AGE) are the leading cause of acute vomiting in children 2
• Important life-threatening causes of vomiting in infancy include congenital intestinal obstruction, atresia, malrotation with volvulus, necrotizing enterocolitis, pyloric stenosis, intussusception, shaken baby syndrome, hydrocephalus, inborn errors of metabolism, congenital adrenal hypoplasia, obstructive uropathy, sepsis, meningitis, and encephalitis 2
• In older children, life-threatening causes of vomiting include appendicitis, intracranial mass lesion, diabetic ketoacidosis, Reye's syndrome, toxic ingestions, uremia, and meningitis 2

Evaluation and Management of Vomiting in Children

• Initial evaluation is directed at assessment of airway, breathing, and circulation, assessment of hydration status, and red flag signs (bilious or bloody vomiting, altered sensorium, toxic/septic/apprehensive look, inconsolable cry or excessive irritability, severe dehydration, concern for symptomatic hypoglycemia, severe wasting, Bent-over posture) 2
• The history and physical examination guide the approach in an individual patient 2
• Investigations (Serum electrolytes and blood gases, renal and liver functions, and radiological studies) are required in any child with dehydration or red flag signs to diagnose surgical causes 2
• Management priorities include treatment of dehydration, stoppage of oral fluids/feeds, and decompression of the stomach with a nasogastric tube in patients with bilious vomiting 2
• Antiemetic ondansetron is indicated in children unable to take orally due to persistent vomiting, post-operative vomiting, chemotherapy-induced vomiting, cyclic vomiting syndrome, and acute mountain sickness 2

Role of Ondansetron in Vomiting in Children with Acute Gastroenteritis

• Ondansetron can improve the efficacy of oral rehydration therapy in children with acute gastroenteritis 3
• Treatment with ondansetron compared with placebo increased the chance for vomiting cessation up to 1 hour after drug administration, reduced the risk of failure of oral rehydration therapy, increased the intake of oral rehydration solution, reduced the risk of hospitalization, and reduced the need for intravenous rehydration 3

Red Flags and Warning Signs

• Bilious emesis at any age is a sign of intestinal obstruction until proven otherwise and needs immediate attention 4
• Red flags include unstable vital signs, acidotic breathing, presence of bile or blood-stained vomitus, features of gastrointestinal (GI) obstruction, encephalopathy, and papilledema 5
• Signs of GI obstruction should prompt an abdominal X-ray and surgical consultation 5