Acute vomiting in infants and children

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Target exams

Red flags

• Bilious (green) vomiting at any age is malrotation with midgut volvulus until proven otherwise and demands urgent surgical review
• Abdominal distension, tenderness, guarding or an absence of bowel sounds signalling obstruction or peritonitis
• Blood in the vomit or a redcurrant-jelly stool pointing to intussusception or significant gastrointestinal bleeding
• A bulging fontanelle, early-morning vomiting, headache, abnormal eye movements or focal neurology suggesting raised intracranial pressure
• Altered conscious state, deep sighing (Kussmaul) breathing, or dehydration out of proportion to the history suggesting diabetic ketoacidosis or a metabolic crisis
• A shocked, mottled or lethargic infant in whom sepsis, a surgical abdomen or an inborn error of metabolism must be excluded
• Projectile non-bilious vomiting with visible peristalsis and weight loss in a 2 to 8 week old infant suggesting pyloric stenosis

Life stages

Care settings

Clinical exam formats

Board mappings

• Takes a structured vomiting history including the colour of the vomit and feeding pattern
• Recognises bilious vomiting as a surgical emergency at any age
• Assesses hydration and initiates oral or intravenous rehydration
• Builds an age-based differential and separates surgical from medical causes
• Justifies the selective use of ondansetron and the avoidance of routine antiemetics
• Recognises the dangerous non-gastrointestinal mimics of DKA, sepsis and raised intracranial pressure
• Emergency recognition and stabilisation of the bilious-vomiting infant
• Risk-stratified management of the dehydrated child with gastroenteritis
• Diagnosis of pyloric stenosis and its metabolic derangement
• Bedside assessment of hydration and the vomiting child
• Communication of the oral rehydration plan and safety-net to a family
• Explaining the need for urgent surgery to the parents of an infant with volvulus
• Level 1: Recognises bilious vomiting and dehydration as red flags
• Level 2: Diagnosis and initial management of the common causes of vomiting
• Level 3: Management of the shocked or surgical vomiting child and the dangerous mimics
• The vomiting reflex and its four afferent inputs
• The age-based differential diagnosis of vomiting
• The metabolic derangement of pyloric stenosis and the fluid management of DKA
• History and examination of the vomiting child
• Structured assessment of dehydration using a validated scale
• Communication of a rehydration and safety-net plan
• Diagnosis of the surgical causes of vomiting by age
• Oral rehydration therapy and the evidence for ondansetron
• Recognition of DKA and raised intracranial pressure in the vomiting child
• Emergency recognition of the surgical and metabolic vomiting child
• Risk-stratified outpatient versus inpatient management of gastroenteritis
• Fluid and electrolyte management of the dehydrated child
• Bilious vomiting and malrotation in the Canadian paediatric setting
• Clinical dehydration assessment and oral rehydration
• The dangerous non-gastrointestinal causes of paediatric vomiting