Acute vomiting illnesses are common in childhood, although will not be covered in this guideline. If there is significant concern regarding a child's ability to maintain hydration, or the underlying cause of the vomiting is unclear (remember that vomiting without diarrhoea does not equate to a diagnosis of gastroenteritis), please refer to a local Emergency Department.
Chronic vomiting is less common in childhood outside the infant age group and will be covered here. Please refer to the gastroesophageal reflux disease pre-referral guideline for further information on vomiting infants.
Chronic vomiting can have multiple different causes, with the age of the child and and careful history and examination being critical in determining the cause.
Differentials (not exhaustive)
Gastrointestinal disease - celiac disease (see celiac disease), chronic gastritis and oesophagitis can present with vomiting in varying ages throughout childhood, as can (less commonly) inflammatory bowel disease, Helicobacter pylori and achalasia. Tumours of the gastrointestinal tract in children are extremely rare.
Cyclical vomiting and/or abdominal migraine are not uncommon and can be seen at any age, although have a peak onset from 5-9 years age. These are characterised by episodic, often severe episodes of vomiting and/or abdominal pain with no symptoms between episodes, often related to distinguishable triggers with a family history of abdominal or classical migraine. They remain a diagnosis of exclusion.
Neurological diseases causing chronic vomiting are usually accompanied by other signs and symptoms. Space occupying lesions typically present with morning (characteristically waking the child) vomiting and headache.
Endocrine causes of vomiting in childhood are rare, other than type 1 diabetes, which can present with vomiting and abdominal pain.
Self induced vomiting - anorexia and bulimia nervosa are more common in adolescence (see eating disorders), often presenting with other food related eating disordered behaviours, distorted body image, weight loss and/or other mental health difficulties. Medication use/abuse can also lead to vomiting.
Toddler vomiting - vomiting is commonly a behavioural reaction in toddler aged children, often seen in children with feeding difficulties. History will often distinguish this presentation.
Infant vomiting - vomiting from a very young age is commonly seen in GORD (see gastro-esophageal reflux disease). Less chronic vomiting, although still commonly seen over several weeks, can be seen with pyloric stenosis, characterised by progressive non-bilious projectile vomiting, post-vomiting hunger, loss of weight and hypochloraemic hypokalaemic alkalosis, usually in those less than 5 months. Recurrent UTI (see urinary tract infection) should also be considered.
- Chronic vomiting can have multiple different causes, with the age of the child and and careful history and examination being critical in determining the cause.
- Investigations and management of chronic vomiting should be directed by clinical presentation, rather than simply 'screening for everything'.
- Be aware of 'red flags' that warrant more careful evaluation and timely referral.
Investigations and management of chronic vomiting should be directed by clinical presentation, rather than simply 'screening for everything'.
Reg flags that warrant more careful evaluation and timely referral of chronic vomiting include:
- persistent morning vomiting and headache or the presence of neurological signs
- significant associated loss of weight or dehydration
- a progressive picture of vomiting
- significant co-morbid mental health disturbance.
- Referral to outpatient services is not appropriate for acute vomiting illnesses.
- Emergency department referral or early discussion with paediatric services should be undertaken in children with red flags (see above) or when acutely unwell.
- Referral to paediatric outpatient services can be considered in the management of chronic vomiting when the cause in uncertain or further management requires specialist input.
- Feeding clinic
- Referral to the BHS Feeding clinic is appropriate for younger children with behavioural food-related difficulties, including those with poor growth.
- Referral for sub specialist opinion can be considered after consultation with paediatric services.