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Approachtotheinfantorchildwithnauseaandvomiting
Author: CarloDiLorenzo,MD
SectionEditor: BUKLi,MD
DeputyEditor: AlisonGHoppin,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Sep2016.|Thistopiclastupdated:Aug16,2016.
INTRODUCTIONNauseaandvomitingarecommonsequelaeofamultitudeofdisordersthatcan
rangefrommild,selflimitedillnessestosevere,lifethreateningconditions.Vomitingandnauseamayor
maynotoccurtogether,ormaybeperceivedatthesamelevelofintensity.Asanexample,vomitingcan
occurwithoutprecedingnauseainindividualswithmasslesionsinthebrainorincreasedintracranial
pressure(ICP).Furthermore,somemedicationsmayalleviatenauseabutnotvomiting,orviceversa.
Thesymptomsofnauseaandvomitingmaybecausedbymanypathologicstatesinvolvingseveral
systems(includinggastrointestinal,neurologic,renal,andpsychiatric).Youngerchildrenmaynotbeable
todescribenausea,whichmayfurthercomplicatediagnosis.Thebestcourseofactionshouldbedictated
bythemedicalhistory,takingintoconsiderationclinicalfeaturesofspecificdisordersandtheirrelative
frequencyamongchildrenindifferentagegroups.Themostimportantconsiderationduringtheinitial
encounterisrecognitionofseriousconditions,suchasintestinalobstructionandincreasedICP,forwhich
immediateinterventionisrequired.(See'Concerningsigns'below.)
Thistopicreviewwillprovideanoverviewoftheneurophysiologyanddifferentialdiagnosisofnauseaand
vomitinginchildren,whilesuggestingageneralapproachtospecifictesting.Individualdisordersare
discussedinfurtherdetailinlinkedtopicreviews.Severalgastrointestinaldisorderspresentwith
abdominalpaininadditiontonauseaandvomiting,andthesearediscussedbelow.However,evaluation
ofthechildinwhomabdominalpainistheprimarypresentingcomplaintisdiscussedseparately.(See
"Emergentevaluationofthechildwithacuteabdominalpain"and"Chronicabdominalpaininchildrenand
adolescents:Approachtotheevaluation".)
DEFINITIONS
Vomiting(emesis)referstotheforcefuloralexpulsionofgastriccontentsassociatedwithcontraction
oftheabdominalandchestwallmusculature.Vomitusoftenhasaslightyellowtinge,whichiscaused
byrefluxofsmallamountsofbileintothestomach.Vomitusisconsideredbiliousifithasagreenor
brightyellowcolor,indicatinglargeramountsofbileinthestomachbiliousvomitingisoften
associatedwithintestinalobstruction,asdescribedbelow.
Nauseagenerallyreferstoanunmistakablesensationofunpleasantnessthatmayprecedevomiting,
butmaybepresenteveninachildwhodoesnotvomit.Itisoftenassociatedwithautonomicchanges
suchassalivation,increasedheartandrespiratoryrates,andareductioningastrictoneandmucosal
bloodflow[1].Althoughthereisnoforcefulexpulsionofgastriccontentswithnausea,theremaybe
retrograderefluxoffluidsfromtheduodenumtothegastricantrum.
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Therelatedterms,regurgitation,anorexia,sitophobia,earlysatiety,retching,andruminationaredefined
inthetable(table1).
PHYSIOLOGYOFEMESIS
NeurophysiologyVomitingmayhaveaphysiologicbenefitsinceitprovidesameanstoexpel
potentialtoxins.Nauseaandvomitingmayalsoinduceaconditionedaversiontoingestedtoxins[2].In
diseasestates,however,vomitingpathwaysareactivatedinappropriately.Themajorpathwaysthrough
whichnauseaandvomitingareinducedarevagalafferents,theareapostrema,thevestibularsystem,
andtheamygdala[1].Fiveprincipalneurotransmitterreceptorsmediatevomiting:muscarinic(M1),
dopamine(D2),histamine(H1),serotonin(5hydroxytryptamine[5HT3]),andsubstanceP(neurokinin1).
(See"Characteristicsofantiemeticdrugs".)
VagalafferentpathwayAbdominalvagalafferentsareinvolvedintheemeticresponse.These
pathwayscanbeevokedbyeithermechanicalorchemosensorysensations.Examplesofsensations
thattriggerthispathwayincludeoverdistension,foodpoisoning,mucosalirritation,cytotoxicdrugs,
andradiation[2].Vagalafferentsareanimportantsiteofactionof5HT3receptorantagonistsused
asantiemeticdrugs[1].
AreapostremaTheareapostremahasbeenreferredtoasthe"chemoreceptortriggerzone."
Anatomically,thisregionislocatedatthecaudalextremityofthefloorofthefourthventricle.Because
theareapostremarepresentsarelativelypermeablebloodbrainbarrierregion,itistheplacewhere
many,butnotall,systemicchemicalsacttoinduceemesis[1].Theareapostremaisanimportant
siteforM1,D2,5HT3,andneurokinin1(NK1)receptors,eachofwhichisakeymediatorof
vomiting.
VestibularsystemThevestibularsystemisinvolvedintheemeticresponsetomotion.This
responseisoftenexacerbatedwhenvestibularinputisinconflictwithvisualsensations[2].Irritation
orlabyrinthineinflammationcanproducevomiting.Othershavesuggestedthatoverstimulationofthe
vestibularsystemisnotacompleteexplanationformotionsickness,andthatcirculatingneuroactive
compoundsmaybeinvolved.H1receptorsinthevestibularnucleushavearoleinthisresponse.
AmygdalaTheamygdalaisinvolvedinavarietyofstressandemotionalresponses.Amongother
structures,itreceivesinputfromtheolfactorybulbandolfactorycortexandsendsimpulsestothe
hypothalamus.Aberrantactivationoftheamygdalamayleadtoasensationofnausea.
SomatomotoreventsTheactofvomitingrepresentsahighlycoordinatedsequenceofevents.As
notedabove,vomitingdescribestheactofemptyingoutthestomach,characterizedbycyclesofretching
followedbytheforcefulexpulsionofgastriccontents.Thedetailedsequenceofeventsisasfollows[1]:
Thediaphragmdescendsandtheintercostalmusclescontractwhiletheglottisisclosed.
Theabdominalmusclescontractandthegastriccontentsareforcedintouppergastricvaultand
loweresophagus.
Theabdominalmusclerelaxesandtheesophagealrefluxateemptiesbackintothegastricvault.
Severalcyclesofretching,eachmorerhythmicalandforcefulinnature,occur,withshorterintervals
inbetween.
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Abdominalcontractionassociatedwithelevationofdiaphragmsresultsinforcefulexpulsionofgastric
contents.
APPROACHTOMANAGEMENTPatientswithacutevomiting,typicallyforhourstoafewdays,most
oftenpresenttoanemergencydepartment,whereaspatientswithchronicsymptomsaremoreoften
initiallyevaluatedinoutpatientofficesettings.Emergencydepartmentcliniciansshouldexpeditiously
excludelifethreateningdisorderssuchasbowelobstruction,diabeticketoacidosis,adrenalcrisis,toxic
ingestion,orincreasedintracranialpressure(ICP)(table2).
Inbothurgentcareandroutineoutpatientsettings,thefollowingthreestepsshouldgenerallybe
undertakeninpatientswithnauseaandvomiting:
Theetiologyshouldbesought,takingintoaccountthechild'sage,andwhetherthenauseaand
vomitingisacute,chronic,orepisodic.
Theconsequencesorcomplicationsofnauseaandvomiting(eg,fluiddepletion,hypokalemia,and
metabolicalkalosis)shouldbeidentifiedandcorrected.
Targetedtherapyshouldbeprovided,whenpossible(eg,surgeryforbowelobstructionordietary
changesforfoodsensitivity).Inothercases,thesymptomsshouldbetreated.
EVALUATIONAcarefulhistoryandphysicalexaminationshouldbeperformed.Inmanycases,the
causeofthenauseaandvomitingcanbedeterminedfromthehistory,andphysicalexaminationand
additionaltestingisnotrequired.Theurgencywithwhichvariousdiagnosticpossibilitiesshouldbe
pursueddependsuponanumberoffactors,includingthedurationofillness,overallclinicalstatusofthe
patient(especiallyhydration,circulatory,andneurologicstatus),andassociatedfindings.
ConcerningsignsWarningsignsthatmayindicateaseriouscauseofvomitinginclude(table3):
Nonspecificsymptoms
Prolongedvomiting
Profoundlethargy
Significantweightloss
Symptomsofgastrointestinalobstructionordisease
Biliousvomiting
Projectilevomitinginaninfantthreetosixweeksofage
Hematemesis
Hematochezia(rectalbleeding)
Markedabdominaldistensionandtenderness
Symptomsorsignssuggestingneurologicorsystemicdisease
Bulgingfontanelleinaneonateoryounginfant
Headache,positionaltriggersforvomitingorvomitingonawakening,and/orlackofnausea
Alteredconsciousness,seizures,orfocalneurologicabnormalities
Historyofheadtrauma
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Hypotensiondisproportionatetotheapparentillness,and/orhyponatremiaandhyperkalemia
Patientsshouldbereferredtoapediatricgastroenterologistorotherappropriatespecialist(eg,pediatric
surgeon,neurologist)whentherearesymptomsorphysicalfindingsthatareofparticularconcern.
Immediatepediatricsurgicalconsultationiswarrantedifappendicitis,bowelobstruction,orbowel
perforationaresuspected.
HistoryThehistoryshoulddetailtheonsetandpatternofthevomitingornausea(acute,chronic,or
episodic),andassociatedsymptoms,especiallyfever,abdominalpain,diarrhea,orheadache(table4).
Recentexposurestocontactswithsimilarsymptomsshouldbeexplored,aswellasahistoryofingestion,
oropportunityforingestion,ofmedicationsortoxicsubstances.Keyinformationfromthechild'spast
medicalhistoryincludesknownorsuspectedcongenitalanomaliesordiseases,developmentaldelay,and
neurologicsymptomsordisorders.
Thefollowingclinicalfeaturesareespeciallyimportant:
Natureofvomiting:
Bilious(greenorbrightyellow)vomitingsuggestsintestinalobstruction,especiallyinaneonate
(eg,duetointestinalatresiaorvolvulus)[3].(See'Intestinalobstruction'belowand
'Intussusception'below.)
Projectile(veryforceful)vomitinginaninfantthreetosixweeksofagesuggestspyloricstenosis.
(See'Pyloricstenosis'below.)
Bloodyvomiting(hematemesis)suggestsbleedingfromesophagealvaricesifsevere.
Hematemesisalsomaybecausedbyesophagealinjuryfromrecurrentvomiting(MalloryWeiss
tear),ormucosalinjuryfromerosiveesophagitis,gastritis,orpepticulcer.(See"MalloryWeiss
syndrome"and"Approachtouppergastrointestinalbleedinginchildren",sectionon'Etiology'.)
Periodicepisodesofvomitingsuggestinbornerrorsofmetabolism,especiallyinanewbornor
younginfant,orcyclicvomitingsyndrome.(See'Inbornerrorsofmetabolism'belowand'Cyclic
vomitingsyndrome'below.)
Earlymorningnauseaorvomitingsuggestspregnancy,increasedintracranialpressure(ICP),or
cyclicvomitingsyndrome.(See'Intracranialhypertension'below.)
Prolongedvomiting(eg,>12hoursinaneonate>24hoursinchildrenyoungerthantwoyears
>48hoursinolderchildren)suggestsacausethatmayrequireintervention,suchasobstruction,
metabolicdisorder,orcyclicvomitingsyndrome.Inaddition,patientswithprolongedvomitingare
atriskfordevelopingdehydrationandelectrolyteabnormalities.
Positionaltriggersforvomitingorvomitingonawakening,lackofassociatednausea,and/or
headachesuggestsincreasedICP.(See'Intracranialhypertension'below.)
Associatedsymptoms:
Diarrhea(withorwithoutfever)inapatientwithacuteonsetofvomitingisconsistentwithviral
gastroenteritis.Thispossibilityissupportedbyahistoryofclosecontactswithvomitingand/or
diarrheaandsuggestsgastroenteritis.However,moreseriouscausesofthesesymptomsshould
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beconsideredinpatientswithatypicalfeatures.Thesecausesincludeinfection(sepsis,
infectiousenteritis/colitis,appendicitis,orinflammatoryboweldisease[IBD]),andHirschsprung
diseaseassociatedenterocolitis(especiallyinneonatesorinfantswithriskfactors,suchas
trisomy21).(See'Gastroenteritis'below.)
Rectalbleeding(hematochezia)suggestsintussusception(especiallyininfantsandtoddlers),
infectiouscolitis,orIBD.(See'Intussusception'belowand'Inflammatoryboweldisease'below.)
Feverisassociatedwithmanycausesofnauseaandvomiting,includingviralgastroenteritis,
appendicitis,streptococcalpharyngitis,urinarytractinfection,andsometimesIBD.(See
'Gastroenteritis'belowand'Appendicitis'belowand'Otherinfections'belowand'Inflammatory
boweldisease'below.)
Ahistoryofchronicorrecurrentinfectionsraisesthepossibilityofanimmunodeficiency.
Recurrentpneumoniainaninfantalsomaybecausedbyatracheoesophagealfistula.(See
"Approachtothechildwithrecurrentinfections"and"Congenitalanomaliesoftheintrathoracic
airwaysandtracheoesophagealfistula",sectionon'Tracheoesophagealfistulaandesophageal
atresia'.)
Prominentheadacheassociatedwithnauseacanbeconsistentwitheithermigraineorincreased
ICP.(See'Migraine'belowand'Intracranialhypertension'below.)
PhysicalexaminationThephysicalexaminationshouldincludeadetailedevaluationoftheabdomen
forsignsofobstructionorfocaltenderness,aswellasaneurologicassessment(table4).
Abdominalexamination:
Signssuggestiveofintestinalobstructionincludemarkedabdominaldistensionvisiblebowel
loopsabsentbowelsoundsorincreasedhighpitchedbowelsounds("borborygmi")severe
abdominalpainorvomitusthatisbilious(greenoryellow)orfeculent(withtheodoroffeces).By
contrast,milderabdominaldistensionandactivebowelsoundswithnormalpitcharecommonin
simplegastroenteritis.(See'Intestinalobstruction'belowand'Intussusception'below.)
FocalabdominaltendernessintherightlowerquadrantsuggestsappendicitisorCrohndisease.
Focaltendernessintherightupperquadrantsuggestsgallbladderdisease(cholelithiasisor
cholecystitis)orpancreatitis.Tendernessinthecostovertebralanglesuggestspyelonephritis.
Abdominalpainortendernessintheepigastricareaisnonspecific,butisalsoconsistentwith
esophagitis,gastritis,pepticulcerdisease,orpancreatitis.(See'Appendicitis'belowand
'Inflammatoryboweldisease'below.)
Hepatomegaly,splenomegaly,orjaundicemaybecausedbyhepatitis,viralinfection,or
metabolicdisorders.(See'Inbornerrorsofmetabolism'below.)
Neurologicexamination:
Alteredconsciousness,seizures,orfocalneurologicabnormalitiesmaybecausedbytoxic
ingestion,diabeticketoacidosis,centralnervoussystemmass,orinbornerrorofmetabolism.
Bulgingfontanelleinaneonateoryounginfantsuggeststhepossibilityofhydrocephalusor
meningitis.
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Ataxia,dizziness,ornystagmus(eyetwitching)suggestvestibularneuronitisoracutecerebellar
ataxia.(See"Evaluationofdizzinessinchildrenandadolescents"and"Acutecerebellarataxiain
children".)
Otherfindings:
Ambiguousgenitaliaand/orhyperkalemiasuggestthepossibilityofadrenalcrisis(usuallydueto
congenitaladrenalhyperplasia).(See'Adrenalinsufficiency'below.)
Anunusualodoremanatingfromthepatientshouldpromptaninvestigationformetaboliccauses
ofvomiting.(See'Inbornerrorsofmetabolism'belowand"Inbornerrorsofmetabolism:
Epidemiology,pathogenesis,andclinicalfeatures",sectionon'Abnormalodors'.)
Enlargedparotidglandsinanadolescentshouldraisesuspicionforbulimia.(See'Bulimiaor
psychogenicvomiting'below.)
LaboratorytestingForpatientswithvomitingthatissevere,prolonged(eg,>12hoursinaneonate
>24hoursinchildrenyoungerthantwoyears>48hoursinolderchildren)orunexplained,screening
laboratorytestsshouldincludeacompletebloodcount,electrolytes,glucose,bloodureanitrogen(BUN),
amylase,lipase,liveraminotransferases,andurinalysis.Forpatientswithfever,urinarysymptoms,or
diarrhea,theevaluationmayincludeurinecultureandstoolstudiesforoccultblood,leukocytes,bacterial
pathogens,andparasites.
Additionallaboratorytestingandimagingshouldbetailoredtothedifferentialdiagnosisofthesymptoms,
baseduponthehistoryandphysicalexamination(table5).
DIFFERENTIALDIAGNOSISOFVOMITINGBYAGEGROUPThedifferentialdiagnosisofvomiting
varieswiththeageofthechild(table2).Thefollowingsectionswillsummarizetheclinicalfeaturesofthe
relativelycommondisordersandthelesscommonbutseriousdisordersinvariousagegroups.Manyof
thesedisordersoccurinseveralageranges,butarediscussedbelowwithintheagegroupinwhichthey
presentmostfrequently.
NeonatesandyounginfantsUncomplicatedgastroesophagealreflux,characterizedbyeffortless
regurgitation,iscommonandinconsequentialinotherwisehealthyinfants.Bycontrast,forcefuland
repeatedvomitingininfantsisnotnormalandshouldbetakenseriously,particularlyifthereareother
signsofillness(eg,fever,weightloss,orfeedingrefusal).Importantcausesofthesesymptomsinclude
pyloricstenosisandintestinalobstruction(table6).Otherconditionsthatmaypresentwithvomitingare
sepsis,excessivefeedingvolume,hydrocephalus,orinbornerrorsofmetabolism.
GastroesophagealrefluxdiseasePhysiologicgastroesophagealrefluxinnewbornsandinfantsis
common,andischaracterizedbyeffortlessregurgitationinanotherwisehealthyinfant(a"happyspitter").
Thissymptommaybedescribedasvomitingbyparents.Thesymptomgraduallyimprovesinmostinfants
duringthefirstyearoflife,andmaybeminimizedbyconservativeantirefluxmeasures[4].(See
"Gastroesophagealrefluxininfants".)
Aminorityofinfantswhoregurgitatehavepathologicalgastroesophagealreflux,termedgastroesophageal
refluxdisease(GERD).Nospecificclinicalfeaturesdefinitivelyidentifytheseinfants,buttheymayhave
recurrentfussinessorirritabilityandfeedingaversion.Thesesymptomsarethoughttoresultfrompain
causedbyesophagealacidexposure.Bradycardiaorcyanoticepisodesalsomayoccur,particularlyin
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pretermorneurologicallyimpairedinfants.Poorweightgaindespiteanadequateintakeofcaloriesshould
promptevaluationforcausesofvomitingandweightlossotherthanGERD.(See"Gastroesophageal
refluxininfants",sectionon'Managementbypresentingsymptoms'.)
GERDalsoisanimportantconsiderationinolderinfants,children,andadolescentspresentingwith
subacuteorchronicnauseaorvomiting.Theassessmentandmanagementofthisdisorderarediscussed
inseparatetopicreviews.(See"Clinicalmanifestationsanddiagnosisofgastroesophagealrefluxdisease
inchildrenandadolescents"and"Managementofgastroesophagealrefluxdiseaseinchildrenand
adolescents".)
FoodproteininducedenteropathyIntolerancetodietaryproteins(mostcommonlymilkprotein)
typicallymanifestsascolitis,presentingwithbloodystools.However,insomeinfantsthedietaryprotein
causesenteritis,withorwithoutassociatedcolitis,andaffectedinfantsmaypresentwithvomiting,
diarrhea,andfailuretothrive.Incontrasttofoodallergy/anaphylaxis,thesedisordersarenotmediatedby
immunoglobulinE(IgE),andtendtohavesubacuteordelayedonset.(See"Foodproteininduced
proctocolitisofinfancy".)
FoodproteininducedenterocolitissyndromeFoodproteininducedenterocolitissyndrome
(FPIES)isagastrointestinalfoodhypersensitivitythatmanifestsasprofuse,repetitivevomiting,oftenwith
diarrhea,leadingtodehydrationandlethargyintheacutesetting,orweightlossandfailuretothriveina
chronicform.Thediseaseusuallybeginsinearlyinfancy,withinonetofourweeksfollowingintroduction
ofcow'smilkorsoyprotein.Itismostcommonlycausedbycow'smilkorsoyprotein,althoughother
foodscanbetriggersitisuncommoninbreastfedinfants.FPIESisanonIgEmediatedreactiontofood,
similartofoodproteininducedenteropathy,butwithmoreseveremanifestations.(See"Foodprotein
inducedenterocolitissyndrome(FPIES)".)
PyloricstenosisInfantilehypertrophicpyloricstenosis(IHPS)isaconditionofhypertrophyofthe
pylorus,withelongationandthickening,eventuallyprogressingtonearcompleteobstructionofthegastric
outlet.Itoccursinapproximately3in1000livebirths,morecommonlyinmales(4:1to6:1).
Approximately30percentofcasesoccurinfirstbornchildren.(See"Infantilehypertrophicpyloric
stenosis".)
TheclassicpresentationofIHPSisthethreetosixweekoldbabywhodevelopsimmediatepostprandial,
nonbilious,oftenprojectilevomitinganddemandstoberefedsoonafterwards(a"hungryvomiter").Inthe
past,patientswereclassicallydescribedasbeingemaciatedanddehydratedwithapalpable"olivelike"
massatthelateraledgeoftherectusabdominusmuscleintherightupperquadrantoftheabdomen.
Laboratoryevaluationclassicallyshowedahypochloremic,metabolicalkalosisresultingfromthelossof
largeamountsofgastrichydrochloricacid,theseverityofwhichdependeduponthedurationofsymptoms
priortoinitialevaluation.
Thetypicalpresentationhaschangedovertime.Infantsarediagnosedearlier,tendtobebetter
nourished,andgenerallypresentwithoutsignificantelectrolyteimbalances.Thediagnosisismadeby
ultrasoundexaminationoftheabdomen(table7)[5].(See"Infantilehypertrophicpyloricstenosis".)
AdrenalinsufficiencyInfantspresentingwithsymptomssimilartothoseofpyloricstenosis,but
withhyponatremia,hyperkalemicacidosis,and/ordisproportionatehypotension,shouldraiseconcernfor
adrenalcrisis.Thisisalifethreateningconditionandshouldbeevaluatedandtreatedurgently.

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Themostcommoncauseofadrenalinsufficiencyininfantsiscongenitaladrenalhyperplasia(CAH)due
to21hydroxylasedeficiency.IntheUnitedStates,21hydroxylasedeficiencyispartofthenewborn
screeninmoststates,somostsuchinfantswillbediagnosedpriortodevelopingadrenalcrisis.Adrenal
crisisusuallypresentsbetweenthefirstandfourthweekoflife.Affectedfemaleswillhaveambiguous
genitaliamalesusuallyhavenoobviousgenitalabnormalities.(See"Causesandclinicalmanifestations
ofprimaryadrenalinsufficiencyinchildren",sectionon'Adrenalcrisis'.)
IntestinalobstructionTherearemultiplecausesofintestinalobstructioninneonatesandyoung
infants[6].Causesofintestinalobstructionthatpresentduringearlyinfancyinclude:
Intestinalatresia(see"Intestinalatresia")
Hirschsprungdisease(see"Congenitalaganglionicmegacolon(Hirschsprungdisease)")
Pyloricstenosis(see'Pyloricstenosis'above)
Malrotationwithorwithoutvolvulus(see"Intestinalmalrotationinchildren")
Intussusception(see'Intussusception'belowand"Intussusceptioninchildren")
Bilious(bilestained)vomitusinaneonateshouldbetreatedasalifethreateningemergencybecausethis
isoftenasymptomofobstructionduetointestinalatresiaormidgutvolvulus[3],althoughbiliousvomiting
canbeseenoccasionallyininfantswithoutbowelobstruction.Vomitingthatisnotbilestainedmaybe
causedbyproximalobstruction,suchaspyloricstenosis,upperduodenalstenosis,gastricvolvulus,or
annularpancreas[7].
Ifintestinalobstructionissuspected,thespecificdiagnosisoftencanbesuggestedbythepatient'shistory
andwithappropriateradiologicimaging.Plainradiographsoftheabdomengenerallyprovidearapid
assessmentofpossiblebowelobstructionwithrelativelylittleradiationexposure(table7).Abdominal
ultrasoundprovideshighsensitivityandspecificityfordetectingintussusception.Ifadiagnosisisnot
establishedbyultrasoundandproximalbowelobstructionissuspected,thenanuppergastrointestinal
contraststudyusuallyisappropriatefor.Iftheabdominalradiographorphysicalexaminationsuggests
distalbowelobstruction(asmightbeseeninHirschsprungdisease),thenacontrastenemausuallyis
appropriate.(See"Intussusceptioninchildren".)
MalrotationwithvolvulusMalrotationisananomalyoffetalintestinaldevelopmentthatoccurs
inabout1in6000newborns.Inthiscondition,thececumisabnormallypositionedintherightupper
quadrant,andisfixatedtotherightlateralabdominalwallbybandsofperitoneum.Theseabnormalities
predisposetointestinalvolvulus,inwhichtheintestinetwistsonitsmesentery.Thiscausesacutesmall
bowelobstructionandischemia,whichusuallypresentswithsuddenonsetofbiliousvomitingandan
acuteabdomen.Volvulusoccursearlyininfancyinapproximatelyonehalfofinfantswithmalrotation.
Otherinfantswithmalrotationmayremainasymptomaticorpresentlaterinchildhoodwithvolvulus.
Affectedinfantsalsomaypresentwithsignsofduodenalobstructionorwithassociatedcongenital
anomaliessuchasintestinalatresias.(See"Intestinalmalrotationinchildren".)
HirschsprungdiseaseMostpatientswithHirschsprungdiseasearediagnosedintheneonatal
period.Patientspresentwithsymptomsofdistalintestinalobstruction:biliousemesis,abdominal
distension,andfailuretopassstool.Thediagnosiscanbesuggestedbyadelayinpassageofthefirst
meconium(greaterthan48hoursofage).Affectedchildrenmayalsopresentinitiallywithenterocolitis,a
potentiallylifethreateningillnessinwhichpatientshaveasepsislikepicturewithfever,vomiting,
diarrhea,andabdominaldistension,whichcanprogresstotoxicmegacolon.(See"Congenitalaganglionic
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megacolon(Hirschsprungdisease)".)
InbornerrorsofmetabolismInbornerrorsofmetabolismarerarecausesofvomitinginneonates
andyounginfants.Nonetheless,recognitionofthesedisordersisimportantbecausetheinstitutionof
appropriatetherapycanbelifesaving.Theclinicalpresentationvarieswiththetypeofmetabolicdisorder.
Organicacidemiasandureacycledisordersarecharacterizedbyrecurrentepisodesofvomitingand
dehydration(see"Inbornerrorsofmetabolism:Epidemiology,pathogenesis,andclinicalfeatures"
and"Inbornerrorsofmetabolism:Metabolicemergencies"):
OrganicacidemiasThetypicalpresentationoforganicacidemiasinnewbornsisanacute,
severeillnesscharacterizedbylethargy,poorfeeding,vomiting,metabolicacidosis,andshock.
(See"Organicacidemias".)
UreacycledisordersUreacycledisorderstypicallypresentduringinfancyorearlychildhood,
withepisodesofalteredmentalstatuswithgastrointestinalsymptomsandhyperammonemia,
oftentriggeredbycatabolicstress(intercurrentillnessorfasting)orincreasedproteinload.(See
"Ureacycledisorders:Clinicalfeaturesanddiagnosis".)
Disordersofcarbohydrateintolerancearetriggeredbyspecificsugarsinthedietnonglucose
reducingsubstancesareusuallypresentintheurine:
GalactosemiaInfantswithclassicgalactosemiausuallypresentinthefirstfewdaysafterbirth
andinitiationofbreastmilkorcow'smilkbasedformulafeedings.Typicalsymptomsinclude
jaundice,vomiting,hepatomegaly,failuretothrive,poorfeeding,andsusceptibilitytogram
negativeinfectionssomedeveloplenticularcataracts.(See"Galactosemia:Clinicalfeaturesand
diagnosis".)
HereditaryfructoseintoleranceMostcasesofhereditaryfructoseintolerancepresentwith
recurrenthypoglycemiaandvomitingattheageofweaning,whenfructoseorsucrose(a
disaccharidethatishydrolyzedtoglucoseandfructose)typicallyisaddedtotheinfantdiet.
However,someinfantsmaypresentearlierbecausemanycommercialformulasandmedications
containsucrose.(See"Causesofhypoglycemiaininfantsandchildren",sectionon'Hereditary
fructoseintolerance'.)
OlderinfantsandchildrenGastroenteritisisbyfarthemostcommondisorderpresentingwith
vomitingininfants,children,andadolescents(table2).GERD,gastroparesis,mechanicalobstruction,
anaphylaxis,Munchausensyndromebyproxy(factitiousdisorderbyproxy),intracranialmasses,peptic
ulcerdisease,cyclicvomiting,anddiabeticketoacidosisalsomaybediagnosticconsiderations.Adrenal
crisisandanaphylaxisshouldbeconsideredinchildrenwithdisproportionatehypotensionand/or
predisposingfactors.
GastroenteritisGastroenteritisusuallyisviralinetiology,occurringinclusters,suddeninonset,
andquicktoresolve.Bacterialcausesmaybeassociatedwithmoreprolongedandsevereillness.(See
"Acuteviralgastroenteritisinchildreninresourcerichcountries:Clinicalfeaturesanddiagnosis"and
"Clinicalmanifestationsanddiagnosisofrotavirusinfection".)
OtherinfectionsPharyngitis(particularlystreptococcalpharyngitis)andurinarytractinfections
frequentlypresentwithnauseaand/orvomiting.(See"GroupAstreptococcaltonsillopharyngitisin
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childrenandadolescents:Clinicalfeaturesanddiagnosis",sectionon'Clinicalfeatures'and"Urinarytract
infectionsininfantsandchildrenolderthanonemonth:Clinicalfeaturesanddiagnosis",sectionon
'Clinicalpresentation'.)
GastroparesisGastroparesisistheconditionofimpairedemptyingofgastriccontentsintothe
duodenumintheabsenceofamechanicalobstructionthismaycausepostprandialfullnessandnausea,
andpostprandialvomiting.Ingastroparesis,thevomitingusuallyoccursmanyhoursafteringestionof
food,acharacteristicthatdifferentiatesthisentityfromgastroesophagealrefluxorruminationsyndrome,
inwhichtheemesisoccursduringorimmediatelyaftereating.(See"Gastroparesis:Etiology,clinical
manifestations,anddiagnosis".)
Thefollowingconditionsmaycausegastroparesis:
Viralillness(postviralgastroparesis)
Surgerywithvagusnervedamage(eg,fundoplication)
Useofdrugssuchasopioidsoranticholinergics
Metabolicdisturbancessuchashypokalemia,acidosis,orhypothyroidism
Eosinophilicgastroenteropathy
Neuromusculardisorderssuchascerebralpalsy,diabetesmellitus,pseudoobstruction,and
musculardystrophy
Postviralgastroparesisisoftenfoundinchildrenwhohaveexperiencedanacuteshortviralillness(often
rotavirusgastroenteritis)andisassociatedwithpostprandialantralhypomotility.Inmostcases,the
symptomsresolvespontaneouslywithin6to24months[8].
IntussusceptionIntussusceptionisthemostcommoncauseofintestinalobstructionininfants
between6and36monthsofage.Patientswithintussusceptiontypicallydevelopthesuddenonsetof
intermittent,severe,crampy,progressiveabdominalpain,accompaniedbyinconsolablecryingand
drawingupofthelegstowardtheabdomen.Theepisodesbecomemorefrequentandmoresevereover
time.Vomitingmayfollowepisodesofabdominalpain.Initially,emesisisnonbilious,butitmaybecome
biliousastheobstructionprogresses.Asausageshapedabdominalmassmaybefeltintherightsideof
theabdomen.Assymptomsprogress,increasinglethargydevelops,whichcanbemistakenfor
meningoencephalitis.Inupto70percentofcases,thestoolcontainsgrossoroccultblood.(See
"Intussusceptioninchildren".)
Intussusceptionalsocanoccurinneonatesandyounginfants.Ininfants,intussusceptionmaypresentas
lethargy,withorwithoutvomitingorrectalbleeding.Inyounginfants,intussusceptionismoreoften
causedbyapathologicalleadpoint,suchasMeckeldiverticulumoraduplicationcyst.
AnaphylaxisAnaphylaxis,triggeredbyingesteditems(typicallyfoodsormedications),tendsto
presentwithprominentgastrointestinalsymptoms,includingnausea,crampyorcolickyabdominalpain,
vomiting(sometimeslargequantitiesof"stringy"mucus),anddiarrhea.Theseimmediate(IgEmediated)
anaphylacticreactionsarerapidinonset,typicallybeginningwithinminutestotwohoursfromthetimeof
ingestion.
Duringanaphylaxis,gastrointestinalsymptomsusuallyareaccompaniedbyvarioussignsandsymptoms
involvingtheskinandmucosatissue,respiratorytract,and/orcardiovascularsystem.Theseinclude
pruritus,flushing,urticaria/angioedema,periorbitaledema,conjunctivalinjection,rhinorrhea,nasal
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congestion,cough,wheezing,dyspnea,changeofvoicequality,senseofchoking,tachycardia(or
bradycardialesscommonly),dizziness,hypotension,senseofimpendingdoom,andcardiovascular
collapse.Thegastrointestinalsymptomsarerarelythesolemanifestationsofafoodallergicreaction.In
mostcases,anallergicreactiontofoodcanbereadilydistinguishedfromothercausesofvomitingbythe
presenceofconcurrentanaphylacticsymptomsandbythehistory.Thediagnosisandtreatmentof
anaphylaxisisreviewedseparately.(See"Anaphylaxis:Emergencytreatment"and"Clinical
manifestationsoffoodallergy:Anoverview"and"Foodallergyinchildren:Prevalence,naturalhistory,
andmonitoringforresolution".)
AdrenalcrisisAlthoughitisuncommon,adrenalcrisisshouldbeconsideredinchildrenofanyage,
particularlyiftheyhaveriskfactors(suchasknownadrenalinsufficiencyorhistoryofglucocorticoiduse),
and/orpresentwithdisproportionatehypotension,hyponatremia,and/orhyperkalemicacidosis.(See
"Causesandclinicalmanifestationsofprimaryadrenalinsufficiencyinchildren",sectionon'Adrenal
crisis'.)
IntracranialhypertensionBraintumorsandotherintracranialmassescancausenausea,vomiting,
orboth,byincreasingtheintracranialpressure(ICP)attheareapostremaofthemedulla.(See"Elevated
intracranialpressure(ICP)inchildren".)
ClinicalcharacteristicssuggestingincreasedICPincludeemesisthatistriggeredbyanabruptchangein
bodyposition,especiallyuponawakening,withlittleornoaccompanyingnausea.Moreimportantly,
neurogenicvomitingusuallyisassociatedwithotherneurologicsymptomssuchasheadacheorfocal
neurologicdeficit,althoughthesesignsandsymptomsmaybesubtle.(See"Clinicalpresentationand
diagnosisofbraintumors".)
Idiopathicintracranialhypertension(pseudotumorcerebri)referstoincreasedICPwithnormal
cerebrospinalfluid(CSF)content,normalneuroimaging,theabsenceofneurologicsignsexceptcranial
nerveVIpalsy,andnoknowncause.Itisusuallyassociatedwithheadache,andoccasionallywith
nauseaandvomiting.Inthepediatricagerange,itismostlikelytoaffectadolescentgirlswhoareobese.
(See"Idiopathicintracranialhypertension(pseudotumorcerebri):Clinicalfeaturesanddiagnosis".)
CyclicvomitingsyndromeCyclicvomitingsyndromeisadisordercharacterizedbyrepeated
episodesofnauseaandvomitingthatlastforhourstodaysseparatedbysymptomfreeperiodsof
variablelength.Thisonoffpatternofemesisisquitedistinctfrommostothercausesofvomiting.Intense
vomitingandnauseaarethecardinalsymptomsandusuallyleadtosignificantdeficitsoffluidsand
electrolytes.Cyclicvomitinghasbeenmostoftendescribedinschoolagedchildren,butmayaffectother
agegroups.Theetiologyisunknown,althoughmanyhypotheseshavebeenproposed.Anassociation
betweencyclicvomitingsyndromeandmigraineheadacheshasbeenmostconsistentlydescribed,
suggestingthattheremaybeacommonpathophysiologicprocess.(See"Cyclicvomitingsyndrome".)
MigraineMigraineischaracterizedbyperiodicepisodesofparoxysmalheadacheoften
accompaniedbynausea,vomiting,abdominalpain,andreliefwithsleep.Thedisorderoccursatallages,
beginningbeforeage20yearsin50percentofcases.Thefamilyhistoryispositiveinmostpatients.
Migraineusuallycanbedistinguishedfromothercausesofvomitingbytheperiodicnatureand
associatedcharacteristicheadachewithphotophobiaandphonophobia.(See"Pathophysiology,clinical
features,anddiagnosisofmigraineinchildren".)
EosinophilicesophagitisorgastroenteritisEosinophilicdiseasecanaffectmultiplepartsofthe
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uppergastrointestinaltract,togetherorseparately.Ineosinophilicesophagitis,boyscomparedwithgirls
aredisproportionatelyaffected4:1.Toddlerstendtoexperienceepigastricpain,nauseaandvomiting,and
feedingaversion.Adolescentstendtohavesymptomsofdysphagiaandmaypresentacutelytothe
emergencydepartmentwithafoodimpaction[9].Inmanycases,thedisorderappearstobemediatedby
adelayed,cellmediatedhypersensitivitytofoods.Manybutnotallpatientshaveassociatedallergic
disorderssuchaseczemaandasthma.(See"Clinicalmanifestationsanddiagnosisofeosinophilic
esophagitis".)
Eosinophilicgastroenteritiscanpresentatanyagewithabdominalpain,nausea,diarrhea,malabsorption,
hypoalbuminemia,andweightloss.Ininfants,itmaypresentasoutletobstructionwithpostprandial
projectilevomiting.Inadolescentsandadults,itcanalsopresentwithnauseaandvomiting,ormaymimic
irritablebowelsyndrome.Symptomsvarydependingonthelayerandsiteofinvolvedgastrointestinal
tract.Approximatelyonehalfofpatientshaveallergicdisease,suchasdefinedfoodsensitivities,asthma,
eczema,orrhinitis.(See"Eosinophilicgastroenteritis".)
MunchausensyndromebyproxyMunchausensyndromebyproxy(alsoknownasfactitious
disorderbyproxy,Meadowsyndrome,andproxyfactitia)consistsoffabricatingorinducingillnessina
childinordertogetattention.Thepatientmayhaveahistoryoffrequentrecurrentillnesseswithouta
clearetiology.Asanexample,ipecacpoisoningcanpresentwithrecurrent,unexplainedvomitingand
repeatedhospitalizations,andcanbeconfirmedbyurinetoxicology[10,11].(See"Medicalchildabuse
(Munchausensyndromebyproxy)".)
Thediagnosisshouldbeconsideredifthefollowingfeaturesarepresent:
Thereportedhistoryvariesfromwhatisobservedordoesnotmakesense.
Theillnessisunexplained,unusual,orprolonged,anddoesnotrespondtotreatmentasexpected.
Thesymptomsseemtooriginateonlyinthepresenceofthesuspectedperpetrator.
Theproblemresolvesorimproveswhenthechildisseparatedfromthesuspectedperpetrator.
Theproblemrecurswhenthesuspectedperpetratoristoldthatthechildisimprovingorissoontobe
releasedfromthehospitalortreatmentprogram.
Familymembers(eg,siblings)haveunexplainedsymptoms,illness,ordeath.
Thesuspectedperpetratorbehavesinamannerthatappearstobeconsistentwithexaggeration,
fabrication,orinductionofphysical,psychological,orbehavioralproblemsinthechild.
Theallegedperpetratordoesnotseemtobeasworriedbythechild'sillnessasthehealth
professionalswhoarecaringforthechild.
AdolescentsInadditiontothedisordersaffectingchildrenlistedabove(see'Olderinfantsand
children'above),someofthemorecommoncausesofnauseaandvomitinginadolescentsinclude
gastroenteritis,appendicitis,inflammatoryboweldisease(IBD),pregnancy,andtoxicingestions(table2).
FunctionaldyspepsiaDyspepsiaisdefinedbyapersistentorrecurrentpainordiscomfort
localizedtotheupperabdomenitisoftenassociatedwithpostprandialnausea,vomiting,andearly
satiety.Inmostcases,dyspepsiaappearstobefunctionalinnatureduetoadisorderofupper
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gastrointestinalsensationandmotility[12].Patientswithfunctionaldyspepsiaoftenreportnausea,but
persistentvomitingisuncommon.Dyspepsiamayoccasionallyarisefromanorganicdiseasesuchas
pepticulcer(withorwithoutunderlyingHelicobacterpyloriinfection),foodallergy,orCrohndisease.The
approachtotheadolescentpatientwithdyspepticsymptoms,andamoredetaileddiscussionoffunctional
dyspepsiaaregivenseparately.(See"Chronicabdominalpaininchildrenandadolescents:Approachto
theevaluation",sectionon'Functionaldisorders'and"Approachtotheadultwithdyspepsia".)
FunctionalnauseaandfunctionalvomitingThesecategorieswereaddedtothedescriptionsof
functionalgastrointestinaldisordersinthe2016RomeIVclassification[13].Bydefinition,neitheris
causedbyunderlyinggastrointestinaldisease,andthevomitingisnotselfinduced.Somepatientshave
nauseaalone,othershavevomitingalone,andothershavebothsymptomstheremaybeassociated
autonomicsymptomssuchaspallor,sweating,ordizziness.Thesediagnosticcategoriesare
distinguishedfromfunctionaldyspepsiabytheabsenceofabdominalpain.Theyaremorecommonin
individualswithunderlyinganxietyordepression.Earlymorningnauseathatimprovesthroughouttheday
isacommontemporalpattern[14].
Theevaluationincludesafocusedhistoryandphysicalexaminationtoidentifyalarmsymptoms
suggestingacentralnervoussystemdisorder(eg,weightloss,neurologicalsymptoms,severemorning
vomitingorheadaches),exclusionofpregnancywhereappropriate,andassessmentforpsychological
distressandafamilyhistoryoffunctionalgastrointestinaldisorders.Thepossibilityofgastroparesis(eg,
postviral)shouldbeconsidered(see'Gastroparesis'above).Similartootherfunctionalgastrointestinal
disorders,themostvaluableinterventionisaninterdisciplinaryapproachaddressingthepsychosocial
contributors,whichmayincludereassurance,relaxationstrategies,and/orcognitivebehavioraltherapy.
Antiemeticmedicationsaregenerallyineffectiveforfunctionalnausea.Selectedpatientswithrefractory
functionalnauseaafterreferraltoaspecialistmaybenefitfromatrialofpharmacotherapywith
cyproheptadineorantidepressants[1416].(See"Functionalabdominalpaininchildrenandadolescents:
Managementinprimarycare".)
AppendicitisAppendicitispresentsmostfrequentlyintheseconddecadeoflifeandisthemost
commonindicationforemergentabdominalsurgeryinchildhood.Earlysignsandsymptomsof
appendicitisareoftensubtle,andmayvarydependinguponthelocationoftheappendix.Aninflamed
anteriororpelvicappendixproducesmarkedsymptomsintherightlowerquadrant,whilearetrocecal
appendixmaynotcausethesamedegreeoflocalsignsofperitonitisbecausetheinflammationismasked
bytheoverlyingbowel.
Inmanypatients,initialfeaturesarenonspecific,includingindigestion,flatulence,bowelirregularity,and
sometimesjustasenseoffeelingunwell.Thesesymptomsusuallyarefollowedbypainintheepigastrium
orperiumbilicalregion,whichisvisceralincharacter(ie,constant,notverysevereinintensity,andpoorly
localizable).Thesymptomseventuallylocalizetotherightlowerquadrantonceinflammationinvolvesthe
overlyingparietalperitoneum.Nauseaandvomiting,iftheyoccur,followtheonsetofpain.Thediagnosis
ofappendicitisislesslikelyinpatientsinwhomnauseaandemesisarethefirstsignsofillness.(See
"Acuteappendicitisinchildren:Clinicalmanifestationsanddiagnosis".)
InflammatoryboweldiseaseIBD(ulcerativecolitisandCrohndisease)maypresentwith
complaintsofnausea,butfrankvomitingisrarelyaprimarypresentingsymptom.Thediseaseshouldbe
considerediftherearesuggestivefeaturesinthehistoryandclinicalpresentation,especiallygrowth
failure,anemia,abdominalpain,perianaldisease,bloodydiarrhea,orarthritis.(See"Clinicalpresentation
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anddiagnosisofinflammatoryboweldiseaseininfants,children,andadolescents".)
PregnancyPediatriciansshouldhavealowthresholdforsuspectingpregnancyinadolescents.
Adolescentsmayormaynothaveconsideredthepossibilityofpregnancyormaypresentwithvague
complaintswithsuspectedpregnancyasher"hiddenagenda."(See"Pregnancyinadolescents",section
on'Diagnosisofpregnancy'.)
BulimiaorpsychogenicvomitingBulimianervosashouldbeconsideredinapatientwith
concernsaboutbodyweightandshape.Psychogenicvomitingismorelikelyinapatientwithananxiety
disorder,ormaycoincidewithparticularlystressfulsituations.(See"Eatingdisorders:Overviewof
epidemiology,clinicalfeatures,anddiagnosis"and"Somatization:Epidemiology,pathogenesis,clinical
features,medicalevaluation,anddiagnosis".)
RuminationsyndromeRuminationsyndrome,characterizedbyeffortlessregurgitationand/orre
swallowingoffood,haspreviouslybeenrecognizedasadisorderofemotionallydeprivedinfants.More
recently,itwasrecognizedasaproblemofolderchildrenandadolescents[17].Somepatientgroups,
suchasadolescentgirls,areathigherriskofruminationsyndrome[13].Ithasbeensuggestedthatthis
conditionmaybeconsideredanearlyorincompleteformofaneatingdisorder.Theseverityofadolescent
ruminationsyndromevaries,rangingfromabenigndisorder,amenabletobehavioraltherapies,tomuch
moresevereformsassociatedwithsubstantialweightlossandinabilitytoattendschool.(See"Eating
disorders:Overviewofepidemiology,clinicalfeatures,anddiagnosis",sectionon'Ruminationdisorder'.)
Thecharacteristicofthisconditionisthepresenceofregurgitationandrechewingorexpulsionoffood
beginningsoonafterameal,withoutnauseaorretching[13].Thesymptomsdisappearhoursaftereating
oncetheregurgitatedmaterialbecomesacidic,anddonotoccurduringsleep.Theclinicalcharacteristics
anddiagnosisofruminationsyndromearediscussedinmoredetailseparately.(See"Gastroparesis:
Etiology,clinicalmanifestations,anddiagnosis",sectionon'Differentialdiagnosis'.)
TREATMENTTreatmentshouldbedirectedtowardtheunderlyingetiology.Electrolyteabnormalities,
metabolicabnormalities,ornutritionaldeficienciesshouldbecorrected.Cognitivebehavioralinterventions
areusefulforvomitingassociatedwithfunctionaldyspepsia,adolescentruminationsyndrome,and
bulimia.
Antiemeticsareusefulforselectedcausesofpersistentvomiting,toavoidelectrolyteabnormalitiesor
nutritionalsequelae.Theytypicallyarenotrecommendedforvomitingofunknownetiology,andarenot
appropriatefortreatmentofvomitingcausedbyanatomicabnormalitiesorsurgicalabdomentheyare
alsocontraindicatedininfants.Selectionofantiemeticsvarieswiththecauseofthevomiting,as
summarizedinthetable(table8)moredetailsareavailableinthelinkedtopicreviews:
Gastroenteritis.(See"Oralrehydrationtherapy",sectionon'Antiemetictherapy'and"Acuteviral
gastroenteritisinchildreninresourcerichcountries:Managementandprevention",sectionon
'Antiemeticagents'.)
Cyclicvomitingsyndrome.(See"Cyclicvomitingsyndrome",sectionon'Treatment'.)
MotionsicknessThefirstlineapproachforpreventingmotionsicknessistoavoidenvironmental
triggers,suchasreadingorviewingascreenwhileridinginacar.Drugtherapyformotionsickness
dependsuponinhibitionofactivityinthevestibularnuclei,wherelabyrinthineandvisualsensorycues
arecombinedandsynthesized.Drugsthatreduceactivityinthevestibularnucleiinclude
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antihistaminesandanticholinergics[2].(See"Motionsickness",sectionon'Medication'.)
GastroparesisTheprokineticagentserythromycin,metoclopramide,anddomperidonehavearole
inthemanagementofchronicintestinalpseudoobstructionandgastroparesis(includingpostviral
gastroparesis)[8].TheUSFoodandDrugAdministration(FDA)hasissueda"boxedwarning"about
thepotentialfortardivedyskinesiaassociatedwithchronicorhighdoseuseofmetoclopramide.
Hence,thisdrugshouldbeusedonlyafteracarefuldiscussionwiththepatientandthecaretakers
aboutitspossiblerisksandbenefits.Drugselectionandthepotentialadverseeffectsofthesedrugs
arediscussedseparately.(See"Chronicintestinalpseudoobstruction",sectionon'Treatment'and
"Treatmentofgastroparesis",sectionon'Prokinetics'.)
PostoperativenauseaandvomitingDuringthelasttwodecades,therehavebeenconsiderable
advancesinthedevelopmentofantiemetics.Theseincludetheemergenceof5hydroxytryptamine3
receptor(5HT3)antagonists(ondansetron,granisetron),whichhaveoneprimarysiteofantagonism
andhavehelpedinthetreatmentofpostoperativenauseaandvomiting,andchemotherapy
associatedemesis[2,18].
ChemotherapyinducednauseaandvomitingTremendousstrideshavebeenmadeindevelopment
ofantiemeticsoverthepasttwodecades,especially5HT3antagonists(ondansetron)andneurokinin
1(NK1)antagonists(aprepitant).Factorsthatincreasetheincidenceofvomitingincludeyoungage
(toddler),femalesex,agentemetogenicity(especiallycisplatin),andhigherrateofadministration.5
HT3antagonistsaregenerallyeffectiveintheacutephasethefirst24hours,whereasNK1
antagonistsaremoreeffectiveinthedelayedphase>24hours.
Patientsandfamiliesareincreasinglyturningtocomplementaryandalternativemedicineforavarietyof
complaints,particularlyifthesymptomischronicordoesnothaveacleardiagnosticexplanation[19].
Applicationsofthesetechniquestothesymptomsofnauseaandvomitinghavenotbeenwellstudied,but
thereissomeevidenceforefficacyofsomenutraceuticals,suchasgingerandotherherbalcompounds
forfunctionaldyspepsiaandothermotilitydisorders[12,20,21].Hypnotherapyisoftenhelpfulfor
treatmentofanticipatorynauseaandvomiting(eg,priortochemotherapy)[22],whereasstudiesof
hypnotherapyforfunctionaldyspepsiaarelessconclusive[2325].Thedefinitionsandgeneral
approachesofothercomplementaryandalternativetechniquesarediscussedseparately.(See"Overview
ofcomplementaryandalternativemedicineinpediatrics".)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"The
Basics"and"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,at
the5thto6thgradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthave
aboutagivencondition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefer
short,easytoreadmaterials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,
andmoredetailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestfor
patientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremail
thesetopicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsby
searchingon"patientinfo"andthekeyword(s)ofinterest.)
Basicstopic(see"Patienteducation:Pyloricstenosisinbabies(TheBasics)")

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BeyondtheBasicstopic(see"Patienteducation:Nauseaandvomitingininfantsandchildren
(BeyondtheBasics)")
SUMMARYThesymptomsofnauseaandvomitingmaybecausedbyawiderangeofconditions
affectingseveraldifferentorgansystems,withvastlydifferenthealthimplications.Theimmediategoalof
theevaluationistorecognizeseriousconditionsforwhichimmediateinterventionisrequired,andthento
identifyaspecificcauseofthesymptoms.
Thecausesofvomitingvarybyage.Manyofthesedisorderspresentinseveralageranges,butcan
begroupedintoagerangesinwhichtheypresentmostfrequently(table2).(See'Differential
diagnosisofvomitingbyagegroup'above.)
Inmanycases,thecauseofthenauseaandvomitingcanbedeterminedfromthehistoryand
physicalexamination.Thedifferentialdiagnosisisinformedbythechild'sage,whetherthenausea
andvomitingisacute,chronic,orepisodic.Certainclinicalfeaturesmayofferdiagnosticcluesthat
canfurthernarrowthedifferentialdiagnosis(table4).Laboratorytestingshouldbeperformedto
screenforcausesofthesymptom,guidedbythehistoryandphysicalexamination(table5).(See
'Evaluation'above.)
ConcerningsignsThehistoryandphysicalexaminationprovidesimportantcluestodisorders
requiringurgentintervention(table3)(see'Concerningsigns'aboveand'History'aboveand'Physical
examination'above):
Prolongedvomiting(eg,>12hoursinaneonate>24hoursinchildrenyoungerthantwoyears
>48hoursinolderchildren)suggestsacausethatmayrequireurgentintervention.Inaddition,
patientswithprolongedvomitingareatriskfordevelopingdehydrationandelectrolyte
abnormalities.
Symptomsandsignssuggestiveofintestinalobstructionincludemarkedabdominaldistension,
visiblebowelloops,absentbowelsoundsorincreasedhighpitchedbowelsounds
("borborygmi"),severeabdominalpain,orvomitusthatisbilious(greenoryellow)orfeculent
(withtheodoroffeces).Biliousvomitingisaparticularlyimportantwarningsignofpossible
intestinalobstructioninaneonate(eg,duetointestinalatresiaorvolvulus).(See'Intestinal
obstruction'above.)
Thesuddenonsetofintermittent,severe,crampy,progressiveabdominalpaininaninfantor
toddlersuggeststhepossibilityofintussusception,whichisthemostcommoncauseofintestinal
obstructionininfantsbetween6and36monthsofage.(See'Intussusception'above.)
Headache,positionaltriggersforvomiting,lackofnausea,and/orvomitingonawakening
suggestthepossibilityofincreasedintracranialpressure.Anadolescentfemalewithearly
morningvomitingalsoshouldbeevaluatedforpregnancy.(See'Intracranialhypertension'
above.)
Alteredconsciousness,seizures,orfocalneurologicabnormalitiessuggestthepossibilityoftoxic
ingestionorcentralnervoussystemmass(allages),inbornerrorofmetabolism(primarilyinfants
andtoddlers),ordiabeticketoacidosis(DKA,primarilychildrenandadolescents).(See
'Intracranialhypertension'aboveand'Inbornerrorsofmetabolism'above.)
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Recurrentepisodesofvomitinganddehydrationinaninfantoryoungchildsuggestthe
possibilityofaninbornerrorofmetabolism,particularlyorganicacidemiasandureacycle
disorders.Similarpatternsareseenincyclicvomitingsyndrome,whichismostcommonin
schoolagedchildren.Migrainealsomaypresentwithperiodicvomiting,butcanusuallybe
distinguishedbythefamilyhistoryofmigraineandassociatedheadache.(See'Inbornerrorsof
metabolism'aboveand'Cyclicvomitingsyndrome'aboveand'Migraine'above.)
Hypotensiondisproportionatetotheapparentillnessand/orhyperkalemiasuggeststhe
possibilityofadrenalcrisis.(See'Adrenalcrisis'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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GRAPHICS
Definitionsofterminology
Vomiting

Forcefuloralexpulsionofgastriccontentsassociatedwithcontractionoftheabdominal,
diaphragmatic,andchestwallmusculature

Nausea

Theunpleasantsensationoftheimminentneedtovomit,usuallyreferredtothethroator
epigastriumasensationthatmayormaynotultimatelyleadtotheactofvomiting

Regurgitation

Theactbywhichfoodisbroughtbackintothemouthwithouttheabdominaland
diaphragmaticmuscularactivitythatcharacterizesvomiting

Anorexia

Lossofdesiretoeat,thatis,atruelossofappetite

Sitophobia

Fearofeatingbecauseofsubsequentorassociateddiscomfort

Earlysatiety

Thefeelingofbeingfullaftereatinganunusuallysmallquantityoffood

Retching

Spasmodicrespiratorymovementsagainstaclosedglottiswithcontractionsofthe
abdominalmusculaturewithoutexpulsionofanygastriccontents,referredtoas"dry
heaves"

Rumination

Chewingandswallowingofregurgitatedfoodthathascomebackintothemouththrougha
voluntaryincreaseinabdominalpressurewithinminutesofeatingorduringeating

Reproducedwithpermissionfrom:theAmericanGastroenterologicalAssociation.Gastroenterology2001120:263.
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Commonorcriticalcausesofvomitinginthepediatricagerange
Neonate

Infancy

Childhood

Adolescence

Physiologicrefluxor
GERD*

Physiologicrefluxor
GERD*

Gastroenteritis*

Gastroenteritis*

Dietaryprotein
intolerance*or
allergy(eg,milkprotein
inducedenteritis)

Gastroenteritis*

Streptococcal
pharyngitis*

Posttussive*(asthma,
infection,foreignbody)

Posttussive*
(asthma,infection,
foreignbody)

Functionaldyspepsia*

Pyloricstenosis
Necrotizingenterocolitis
Malrotationwithmidgut
volvulus
Congenitalatresias,
stenoses,webs
Gastroenteritis
Hirschsprungdisease
Inbornerrorsof
metabolism(eg,organic
acidemias,ureacycle
disorders,galactosemia,
hereditaryfructose
intolerance)
Feedingintolerance(may
beassociatedwith
cardiac,pulmonary,renal,
orneuromotordisorders)
Adrenalcrisis
Hepatobiliarydisease

Dietaryprotein
intolerance*orallergy(eg,
milkproteininduced
enteritis)
Obstruction(eg,
intussusception,
malrotation,Hirschsprung
disease,pyloricstenosis)

Functional
dyspepsia*

GERD*
Streptococcalpharyngitis
Pregnancy

GERD*

Bulimia

Pepticulcer

Drugsofabuse

Cyclicvomiting

Suicideattempt

Psychogenic

Pepticulcer
Appendicitis

Munchausensyndromeby
proxy

Increased
intracranialpressure
(tumor,
hydrocephalus,
subduralhematoma
fromchildabuse)

Infantrumination

Otitismedia

Otitismedia
Urinarytractinfection

Urinarytract
infection

Toxicingestion

Toxicingestion

Increasedintracranial
pressure(subdural
hematomafromchild
abuse,hydrocephalus)

Diabeticketoacidosis

Inbornerrorsof
metabolism(eg,
hereditaryfructose
intolerance,galactosemia,
organicacidemias,urea
cycledisorders)

Hepatobiliarydisease
Renaldisease(obstructive
uropathy,renal
insufficiency)
Pancreatitis
Adrenalcrisis

Eosinophilic
esophagitis
Obstruction(eg,
malrotation,
intussusception,
incarceratedhernia)
Hepatobiliarydisease
Renaldisease(renal
insufficiency)
Pancreatitis

Psychogenic
Gastroparesis
Intracranialmass
Cyclicvomiting
Eosinophilic
gastroenteritis/esophagitis
Diabeticketoacidosis
Obstruction(eg,
malrotation,
intussusception,
incarceratedhernia)
Hepatobiliarydisease
Renaldisease(renal
insufficiency)
Pancreatitis
Adolescentrumination
syndrome
Adrenalcrisis

Gastroparesis
Adrenalcrisis
GERD:gastroesophagealrefluxdisease
*Commoncauseinthisagegroup
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Concerningsignsinaninfantorchildwithnauseaorvomiting
Increasedpossibilityofanunderlying
systemicormetabolicdisorder:
Concerningsigns

Commentsordiagnosticconsiderations

Nonspecificsymptoms
Prolongedvomiting
>12hoursinaneonate
>24hoursinchildren<2years

Concernsforfluidandelectrolyteabnormalities
Increasedpossibilityofunderlyingsystemicor
metabolicdisorder

>48hoursinolderchildren
Profoundlethargy

Increasedpossibilityofanunderlyingsystemicor
metabolicdisorder

Significantweightloss

Increasedpossibilityofanunderlyingsystemicor
metabolicdisorder

SymptomsofGIobstructionordisease
Biliousvomiting
Projectilevomiting

Intestinalobstruction,especiallyinaneonate
Pyloricstenosisinayounginfant(3to6weeksof
age)
Intestinalobstruction,cyclicvomitingsyndrome

Hematemesis

Severehematemesissuggestsesophagealvarices.
Milderhematemesismaybeduetoinjurytothe
esophagus(MalloryWeisstear)orstomach
(prolapsegastropathy),duetorecurrentvomiting.

Hematochezia

Intussusception(especiallyininfantsandtoddlers),
infectiouscolitis,orIBD

Markedabdominaldistension,peritonealsigns

Intestinalobstructionorintraabdominalprocess(eg,
appendicitis,obstruction)

Symptomsorsignssuggestingneurologicorsystemicdisease
Bulgingfontanelle(infant)

Hydrocephalusormeningitis

Headache,positionaltriggersforvomitingor
vomitingonawakening,lackofnausea

Increasedintracranialpressure(eg,CNSmass,
hydrocephalus,orpseudotumorcerebri)

Alteredconsciousness,seizures,orfocal
neurologicabnormalities

Toxicingestion,diabeticketoacidosis,CNSmass,or
inbornerrorofmetabolism

Historyorphysicalsignsoftrauma

Intracranialorintraabdominalinjury(eg,duodenal
hematoma)

Hypotensiondisproportionatetoapparentillness,
and/orhyponatremiawithhyperkalemia

Adrenalcrisis

GI:gastrointestinalIBD:inflammatoryboweldiseaseCNS:centralnervoussystem.
CourtesyofDr.CarloDiLorenzo.
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Keyelementsofthehistoryandphysicalexaminationinapediatricpatient
withnauseaorvomiting
Symptoms

Diagnosticconsiderations

History
Contactswithvomitingor
diarrhea

Gastroenteritis

Acuteonsetofdiarrheaand
fever

Viralgastroenteritis(iftypicalfeatures)
Infection(sepsis,infectiousenteritis/colitis,appendicitis,IBD)
Hirschsprungassociatedenterocolitis

Earlymorningvomiting

Pregnancy(adolescentfemales),increasedICP,orcyclicvomiting
syndrome

Vomitingwithoutnausea

IncreasedICP

Effortlessvomiting

Gastroesophagealreflux
Ruminationsyndrome

Chronicorrecurrent
infections

Immunodeficiency

Periodicepisodesofvomiting

Cyclicvomitingsyndrome

Tracheoesophagealfistula(infantwithrecurrentpneumonia)

Inbornerrorofmetabolism
Migraine(usuallywithheadacheandfamilyhistory)
Porphyria,carcinoid,pheochromocytoma,familialdysautonomia
Vomitingtriggeredbyspecificfoods
Vomitingbeginswithin
minutestotwohoursof
ingestingthefood,usually
withcutaneousorrespiratory
symptoms

Foodallergy(eg,anaphylaxis)

Subacuteorchronic,with
diarrhea

FoodproteininducedenteropathyorFPIES

Triggeredbyintroductionof
lactose

Galactosemia

Triggeredbyintroductionof
fructoseorsucrose

Hereditaryfructoseintolerance

Undigestedfoodinvomitus

Achalasia

Heartburn

Esophagitis(pepticoreosinophilic)

Physicalexamination
Markedabdominal
distensionvisiblebowel
loopsbiliousvomitus(green
oryellow)absentbowel
soundsorincreasedhigh
pitchedbowelsounds
("borborygmi")orfeculent
(withtheodoroffeces)

Intestinalobstruction

Focaltenderness

RLQ:AppendicitisorCrohndisease

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RUQ:Gallbladderdisease,pancreatitis
Costovertebralangle:Pyelonephritis
Epigastric:Pancreatitis,pepticulcerdisease/gastritis
Hepatomegaly,
splenomegaly,jaundice

Hepatitis,viralinfection(eg,EBV),metabolicdisorders

Ataxia,dizziness,nystagmus

Vestibularneuronitisoracutecerebellarataxia

Papilledema

IncreasedICP

Ambiguousgenitalia

Congenitaladrenalhyperplasiawithvomitingduetoadrenalcrisis

Unusualodor

Inbornerrorofmetabolism

Enlargedparotidglands

Bulimia

IBD:inflammatoryboweldiseaseICP:intracranialpressureFPIES:foodproteininducedenterocolitissyndrome
RLQ:rightlowerquadrantRUQ:rightupperquadrantEBV:EpsteinBarrvirus.
CourtesyofDr.CarloDiLorenzo.
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Clinicalutilityofvariousdiagnosticstudiesinthediagnosisofvomitingina
child
Nameof
study
Completeblood
count

Utility
Anemiaandirondeficiencymaybeassociatedwithobstruction,IBD,gastritis,andulcer
disease.
Elevatedwhitebloodcellcountisassociatedwithbacterialinfectionsandsepsis.

Electrolytes,
BUN/Creatinine

Electrolyteabnormalitiesareassociatedwithpyloricstenosis,adrenalinsufficiency,and
metabolicdiseases.
ElevatedBUN/Creatinineareseeninrenaldisease.

Liverfunction
tests

ElevatedAST,ALT,totalbilirubin,andGGTareseeninliverandgallbladderdisease.

Amylase,lipase

Elevatedinpancreatitis.

Plasma
ammonia,urine
reducing
substances

Ifaninbornerrorofmetabolismissuspected.Ammoniaiselevatedinureacycledisorders
andorganicacidemias.Nonglucosereducingsubstancesareusuallypresentintheurinein
galactosemiaorhereditaryfructoseintolerance.

Plainradiograph
oftheabdomen

Ifintestinalobstructionissuspected.

Upper
gastrointestinal
series

IfananatomicabnormalityofupperGItractissuspected(eg,neonatewithbilious
vomiting).

CTofthehead

Ifincreasedintracranialpressureissuspected(ruleoutmass).

Abdominal
ultrasound

Ifpyloricstenosisorintussusceptionaresuspectedalsousefulforevaluationofliver,
gallbladder,kidneys,andpancreas.

Radionucleotide
gastricemptying
study

Ifgastroparesisissuspected.

Endoscopy

Ifpepticdisease,eosinophilicesophagitis,IBD,orothercausesofintestinalinflammationare
suspected.

IBD:inflammatoryboweldiseaseBUN:bloodureanitrogenAST:aspartateaminotransferaseALT:alanine
aminotransferaseGGT:gammaglutamyltranspeptidaseGI:gastrointestinalCT:computerizedtomography.
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Differentialdiagnosisofvomitingininfants
Gastrointestinalobstruction

Infectious

Pyloricstenosis

Sepsis

Malrotationwithvolvulus

Meningitis

Intussusception(maybeintermittent)

Urinarytractinfection

Intestinalduplication,stenosis,oratresia

Pneumonia

Hirschsprungdisease

Otitismedia

Antral/duodenalweb

Hepatitis

Foreignbody

Metabolic/endocrine

Incarceratedhernia

Galactosemia

Othergastrointestinalcauses

Hereditaryfructoseintolerance

PhysiologicalgastroesophagealrefluxorGERD

Ureacycledefects

Foodproteininduced(eg,anaphylaxis,foodproteininduced
enteropathy,orFPIES)

Aminoandorganicacidemias

Gastroenteritis
Pepticulcerdisease

Fattyacidoxidationdisorders
Metabolicacidosis

Eosinophilicesophagitis/gastroenteritis

Congenitaladrenal
hyperplasia/adrenalcrisis

Gastroparesis

Renal

Pancreatitis

Obstructiveuropathy

Neurologic

Renalinsufficiency

Hydrocephalus

Toxic

Subduralhematoma

Lead

Intracranialhemorrhage

Iron

Masslesion

VitaminAorD
Medications(ipecac,digoxin,
theophylline,etc)
Othertoxins

Cardiac
Heartfailure
GERD:gastroesophagealrefluxdiseaseFPIES:foodproteininducedenterocolitissyndrome.
Modifiedwithpermissionfrom:RudolphCD,MazurLJ,LiptakGS,etal.Guidelinesforevaluationandtreatmentof
gastroesophagealrefluxininfantsandchildren:recommendationsoftheNorthAmericanSocietyforPediatric
GastroenterologyandNutrition.JPediatrGastroenterolNutr200132:S1.Copyright2001LippincottWilliams&
Wilkins.
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Appropriatenessofvariousimagingoptionsininfants0to3monthswith
vomiting
Radiologicprocedure

Rating

Comments

RRL

Variant1:Biliousvomitinginneonateupto1weekold
Xrayabdomen

Aninitialradiographwillhelpdetermine
furtherworkupstrategy.

XrayupperGIseries

Xraycontrastenema

Considerthisprocedurewhenabdominal
radiographsuggestsdistalbowel
obstruction.

USabdomen(UGItract)

++
+++
++++

Variant2:Biliousvomitingininfant1weekto3monthsold
XrayupperGIseries

+++

Xrayabdomen

++

USabdomen(UGItract)

Tc99msulfurcolloidrefluxscintigraphy

+++

Variant3:Intermittentnonbiliousvomitingsincebirth
XrayupperGIseries

+++

USabdomen(UGItract)

Tc99msulfurcolloidrefluxscintigraphy

Thisproceduremayseldomprovideuseful
informationaboutgastricemptyingand
GER.

Xrayabdomen

USabdomen(UGItract)

Inthisprocedure,particularattention
shouldbepaidtogastricpylorus.

XrayupperGIseries

Thisprocedureisthefirstchoiceif
technicianhaslimitedexperiencewithUS
ofthepylorusandifclinicalpresentationis
atypicalforhypertrophicpyloricstenosis.

Xrayabdomen

++

Tc99msulfurcolloidrefluxscintigraphy

+++

+++

++

Variant4:Newonsetnonbiliousvomiting
0
+++

Ratingscale:1,2,3usuallynotappropriate4,5,6maybeappropriate7,8,9
usuallyappropriate
RRL:relativeradiationlevelGI:gastrointestinalUGI:uppergastrointestinalGER:gastroesophagealreflux.
*Relativeradiationlevel.
+++denotesapediatriceffectivedoseestimaterangefrom0.3to3mSv.
++++denotesarangefrom3to10mSv.
Reproducedwithpermissionfrom:Vomitingininfantsupto3monthsofage.AmericanCollegeofRadiology.ACR
AppropriatenessCriteria.Copyright2015AmericanCollegeofRadiology.ThecompleteversionoftheACR
AppropriatenessCriteriacanbeaccessedontheACRwebsiteatwww.acr.org/ac.
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Antinausea,antiemetic,andrelatedmedicationsusedforchildren
Drugclassand
drug
Antihistamines

Mechanismof
action

Indications

Minimalantiemetic
activity

Vestibularsuppression,
antiACheffect,andH 1
antagonist

Motionsickness

Mildmoderate
antiemeticactivity

Promethazine

D 2 antagonistatCTZand
H 1 antagonist

Chemotherapyinduced
vomiting

Prochlorperazine

D 2 antagonistatCTZ

Diphenhydramine
Hydroxyzine

Sideeffects

Sedation,antiACh
effects*

Dimenhydrinate
Meclizine
Phenothiazines

AntiACheffects,*
extrapyramidalreactions

Chlorpromazine
Substituted
benzamides

Moderateantiemetic
activity

Metoclopramide

D 2 antagonistatCTZand
5HT 4 agonistingut

Irritabilityand
extrapyramidalreactions

Trimethobenzamide

D 2 antagonistatCTZ

GERD,gastroparesis,
chemotherapyinduced
vomiting

Cisapride

5HT 4 agonist,ACh
releaseingut

GERD,gastroparesis

Diarrhea,abdominalpain,
headache,QT
prolongation

Moderateantiemetic
activity

D 2 antagonistingut

Gastroparesis,
chemotherapyinduced
vomiting

Highantiemetic
activity

5HT 3 antagonistatCTZ
andvagalafferents
fromgut

Chemotherapyand
postoperativeinduced
vomiting,cyclicvomiting.

Benzimidazole
derivatives
Domperidone

5HT 3 receptor
antagonists
Ondansetron
Granisetron

Aprepitant

Anticholinergics
Scopolamine

Headache

Ondansetronasalsobeen
usedinthetreatmentof
acutegastroenteritis.

Tropisetron
Tachykininreceptor
antagonists

Headaches.Thisdrugis
notavailableinUnited
States.

Highantiemetic
activity

NK 1 antagonistonemesis
program

Chemotherapyinduced
vomiting,effectingon
delayedphase

Minimalmild
antiemeticactivity

Vestibularsuppression,

Motionsickness

Fatigue,dizziness,
diarrhea

Sedation,antiACh

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antiACh
Butyrophenones
Droperidol

Benzodiazepines
Lorazepam

Diazepam

Antimigraineabortive
triptans
Sumatriptan

effects*

Moderateantiemetic
activity

D 2 antagonistatCTZ
anxiolyticactionand
sedation

Chemotherapyand
postoperativeinduced
vomiting

Minimalantiemetic
activity

EnhancedcentralGABA
ergicinductionof
anxiolysis,sedation,and
amnesia

Adjunctivetherapy
(sedation)for
chemotherapyinduced
vomitingandcyclic
vomiting

Sedation,respiratory
depression

Abortiveapproachfor
migraine,abdominal
migraine,cyclicvomiting
subcutaneous,PO,and
nasalforms

Transientburning
sensationinchestand
neck

5HT 1B1D agonist

inducescerebral
vasoconstriction,relaxes
gastricfundus

Zolmitriptan

PO,nasalforms

Frovatriptan

PO,longerhalflife

OtherNSAIDS
Ketorolac
Antimigraine
prophylactic
medication

Hypotension,sedation,
extrapyramidaleffects

Cyclooxygenaseinhibitor
ofprostaglandinsynthesis

Abortiveapproachfor
migraine,cyclicvomiting

Gastrointestinalbleeding

Preventionofmigraine,
abdominalmigraine,
cyclicvomiting

Sedation,antiACh
effects,*weightgaindue
toappetitestimulation

Cyproheptadine

H 1 antagonistand5HT 2
antagonist

Pizotyline

5HT 2 antagonist

Propranolol

1 , 2 adrenergic
antagonist

Preventionofabdominal
migraine,cyclicvomiting

Hypotension,bradycardia,
fatigabilitymonitorpulse

Amitriptyline

5HT 2 antagonist,
synapticnorepinephrine

Preventionofmigraine,
abdominalmigraine,
cyclicvomiting

Sedation,antiACh
effects,*QTprolongation

Phenobarbital

GABA A inhibitionresults
inchlorideioncurrent

Preventionofcyclic
vomiting

Sedation,cognitive
learningdifficulties

Adjunctivetherapyfor
chemotherapyand
postoperativeinduced
vomiting

Adrenalsuppression

Chemotherapyinduced

Disorientation,vertigo,

Corticosteroids
Dexamethasone

Cannabinoids
Dronabinol

NotavailableinUnited
States

Unknown

ActsonCB1Rreceptors

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Nabilone

onvagus

vomiting

hallucinations

ACh:acetylcholineCB1R:cannabinoidreceptor1CTZ:chemoreceptortriggerzoneD:dopamineGERD:
gastroesophagealrefluxdiseaseH:histamine5HT:5hydroxytryptamine(serotonin)GABA:gammaaminobutyric
acidNK:neurokininQT:QTintervalNSAID:nonsteroidalantiinflammatorydrug.
*Anticholinergiceffectsincludeblurredvision,drymouth,hypotension,palpitations,urinaryretention.
FromBUK.Li,"Vomitingandpyloricstenosis."InWalker'sPediatricGastrointestinalDisease,5thEdition.Kleinman
RE,SandersonIR,GouletO,ShermanPM,MieliVerganiG,andShneiderBL,Eds.B.C.DeckerInc.Hamilton,Ontario,
2008.UsedwithpermissionfromPeople'sMedicalPublishingHouseUSA(PMPHUSA),Shelton,CT.
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