Evaluation of nausea and vomiting in children

characterized by foul-smelling watery diarrhea, fever, multiple episodes of vomiting, and abdominal pain; usually self-limited but significant volume depletion and malnutrition can occur

signs of volume depletion (i.e., depressed anterior fontanel in infants, sunken eyes, dry mucosal membranes, sticky saliva, loss of skin turgor, slow capillary refill) may be present; mild abdominal tenderness, hyperactive bowel sounds

history of contaminated water/food, diarrhea (may be bloody or mixed with mucus), abdominal pain, fever, and multiple episodes of vomiting

abdominal distension and tenderness, signs of volume depletion (i.e., depressed anterior fontanel in infants, sunken eyes, dry mucosal membranes, sticky saliva, loss of skin turgor, slow capillary refill) may be present

history of travel, contaminated water/food, IgA deficiency, foul-smelling watery/fatty stools, abdominal pain, bloating, or weight loss

usually unremarkable in acute disease but abdominal distension, pallor, edema, or growth retardation can occur in chronic disease

headache (paroxysmal episodes that can be unilateral or bilateral), photophobia; these symptoms may be preceded by an aura

usually normal

history of passive movement (can be visual), dizziness, eructation, increased salivation, and malaise

often normal but pallor, diaphoresis, unsteadiness, and lack of coordination can be seen

history of vertigo, dizziness, hearing loss, tinnitus, otalgia, and flu-like symptoms; irritation of the vestibular system can be secondary to trauma, central nervous system, ear infection, or vestibular neuritis

nystagmus or signs of infection in the ear

history of head trauma or participation in contact sport; symptoms include headache, altered mental status, confusion, amnesia, and behavioral changes; loss of consciousness does not always occur

altered mental and cognitive status, confusion, altered coordination, normal neurologic exam

headache, nuchal rigidity, photophobia, fever, altered mental status, confusion, history of previous infection; with infants, irritability, lethargy, and poor feeding

bulging fontanel indicates increased intracranial pressure (infants); seizures, petechial or purpuric rash, nuchal rigidity (uncommon in children <2 years of age; absence does not exclude meningitis), and Kernig or Brudzinski signs can occur; some children may not exhibit meningeal signs

irritability and lethargy in infants; headache or nausea/vomiting on waking, abnormal gait, seizures, and behavioral changes in older children

bulging fontanel and macrocephaly in infants; papilledema, focal neurologic signs, and cranial nerve paralysis in older children

irritability and lethargy in infants; headache or nausea/vomiting on waking and behavioral changes in older children; associated with prematurity, meningocele, and genetic syndromes

bulging fontanel, macrocephaly, dilated scalp veins, frontal bossing, and spasticity in infants; papilledema and cranial nerve paralysis in older children; may result in brain injury if not treated

family history, more common in males, symptoms usually presents between 2 and 12 weeks of age, postprandial nonbilious projectile vomiting (usually contains ingested formula content), lack of weight gain or weight loss

undernourished infant, presence of mobile epigastric mass (rarely detected), visible peristalsis; signs of volume depletion may be present; jaundice may occur

usual age 3-6 months (up to 5 years), abdominal pain alternating with periods of exhaustion, hematochezia (may be described as currant jelly stool)

abdominal distension and abdominal mass may be present; may cause intestinal necrosis, acute abdomen, or obstruction

onset <1 month age with bilious vomiting; more concerning symptoms include hematochezia, abdominal distension, and shock; for older children, presents as chronic vomiting and poor weight gain

exam initially normal but may demonstrate rapid progression to acute abdomen secondary to bowel necrosis; there is a high risk of midgut volvulus and intestinal necrosis

history of polyhydramnios or Down syndrome with symptoms of feeding intolerance and vomiting appearing soon after birth

abdominal distension (absent in proximal atresia, severe with visible loops in distal compromise, tenderness indicates peritonitis, mass indicates meconium peritonitis), possible failure to pass meconium, signs of volume depletion may be present

poorly controlled diabetes type 1 is typical; may be first manifestation of diabetes with polyuria, polydipsia, polyphagia, weight loss, drowsiness, lethargy, anorexia, and abdominal pain

altered mental status, acetone breath, tachycardia, hypotension, hyperventilation, and signs of volume depletion can be present; can cause severe complications or even death if untreated

regurgitation is present in 50% of infants with no other symptoms; symptoms include feeding refusal, irritability, hematemesis, failure to thrive (infants), laryngitis (children), and heartburn/acid regurgitation (adolescents)

usually normal, pallor (due to anemia in severe cases)

family history of migraine, stereotypical episodes of vomiting for hours or days, episodes alternate with normal periods of health; lethargy, headache, and diarrhea may be present

usually normal, absence of red flags (e.g., weight loss, neurologic findings, papilledema, anemia, abdominal mass tenderness, positive fecal occult blood)

may occur after a viral disease or be associated with systemic conditions; symptoms include postprandial vomiting of food contents 1-4 hours after meals, poor appetite, early satiety, and abdominal pain

usually normal but abdominal distension may be present

usual age less than 1 year or 2-4 years with fewer than 3 bowel movements per week, withholding maneuvers, toilet avoidance, straining, large stools, and fecal incontinence

abdominal distension, fecal mass palpated in the abdomen

children and adolescents with epigastric abdominal pain, indigestion, early satiety, and absence of red flags (e.g., weight loss, blood in stool or urine, fever, vomiting, abnormal growth)

usually normal

males with acute onset of testicular/scrotal pain and abdominal pain; nausea and vomiting occur in many patients

scrotal edema or erythema with scrotal tenderness to palpation

fever, irritability, lethargy, poor feeding, and failure to thrive in infants and toddlers; dysuria, urinary frequency, and flank pain in children and adolescents

usually normal; suprapubic tenderness in infants; costovertebral tenderness seen with pyelonephritis in children and adolescents

positive family history, acute severe flank/abdominal pain, hematuria, dysuria, urgent nausea and vomiting

costovertebral angle tenderness

risk factors include Helicobacter pylori infection, chronic nonsteroidal anti-inflammatory drug use, and stress; symptoms include irritability and feeding intolerance in infants and toddlers; dyspepsia, epigastric pain, hematemesis, and melena in children and adolescents​

epigastric tenderness, pointing sign, and pallor in presence of anemia; can lead to bleeding, anemia, or stricture if diagnosis is missed

abdominal pain, anorexia, and fever

right lower quadrant tenderness, Rovsing sign, psoas sign, obturator sign, and diminished bowel sounds

midepigastric abdominal pain (may radiate to back), anorexia, and malaise

epigastric and periumbilical abdominal pain on palpation and signs of volume depletion may be present

often asymptomatic but fever, malaise, jaundice, and abdominal pain may be present

usually normal; jaundice, hepatomegaly, and right upper quadrant abdominal tenderness can be present but are more common in adolescents

frequent in Asian and African-American people; can be secondary to prematurity, gastroenteritis, or medications; family history, abdominal pain, flatulence, diarrhea, and symptoms after ingestion of dairy products

usually normal; may note abdominal distension after lactose ingestion and a perianal erythematous rash due to carbohydrate malabsorption

onset generally <1 year of age with cough, rash, diarrhea or constipation, hematochezia, and failure to thrive; symptoms often associated with wheat, milk, soy, egg, peanut, or shellfish ingestion

eczema, rhinitis, wheezing, pallor, and abdominal distension

dysphagia, choking with eating, food impaction, and atopy with eosinophilic esophagitis; diarrhea, hematochezia, and failure to thrive with eosinophilic gastroenteritis

usually normal but may note pallor, eczema, and abdominal distension

recurrent episodes of binge eating with self-induced vomiting, uncontrolled food intake, concern about weight gain/ body image, depression, anxiety, low self-esteem, and hematemesis

dental enamel erosion, pallor, signs of volume depletion may be present, and arrhythmia

witnessed or deliberate ingestion or medication error; symptoms vary from mild and nonspecific to severe and depend on toxin ingested; examples of ingestions in children ages ≤5 years are cosmetics, cleaning substances, analgesics, pesticides, cough and cold preparations, cardiovascular drugs, stimulants and street drugs, and essential oils

symptoms range from normal to altered mental status, hypoxemia, seizures, hypotension, arrhythmias, respiratory depression, and possible death

history of taking drug known to cause nausea and vomiting (e.g., chemotherapy, opioid analgesics, anticholinergic drugs such as antidepressants or antispasmodics, nonsteroidal anti-inflammatory drugs, antibiotics)

nonspecific

common cause of vertigo in children with intermittent episodes of vertigo alternating with normal periods, disequilibrium, diaphoresis, and specific provoking positions

nystagmus during Dix-Hallpike maneuver with normal exam between episodes

family history, visual field loss, diplopia, headache, tinnitus, obesity, and specific medication history (e.g., nalidixic acid, nitrofurantoin, indomethacin, isotretinoin, lithium, anabolic steroids)

papilledema, cranial nerve paralysis, and decreased visual function

recent weight loss, prolonged bed rest, or spinal surgery with intermittent nausea/vomiting and abdominal pain following eating; symptoms improve in left lateral or prone position

thin body habitus and low weight; upper abdominal distension not always present

secondary to autoimmune disorders, infectious diseases, or chronic use of corticosteroids; symptoms include lethargy, anorexia, weight loss, failure to thrive, and salt craving

hypotension and oral hyperpigmentation; may result in shock if left untreated

failure to thrive, weight loss, poor feeding, irregular menses, and precocious puberty

hypotension, hyperpigmentation, hirsutism, and ambiguous genitalia in neonates

includes organic acidemias and urea cycle disorders; newborn or infant with possible family history, poor feeding, failure to thrive, and lethargy; metabolic crisis may be precipitated by illness or surgery

seizures, floppiness, and low muscular tone

includes galactosemia and fructosemia; newborn or infant with poor feeding, vomiting after feeds, lethargy, and bleeding; may lead to liver dysfunction, sepsis, or brain damage

septic appearance, jaundice, and hepatomegaly

occurs more frequently in adolescents and girls with symptoms usually occurring in the morning or with postural changes; nausea is commonly associated with orthostatic dizziness, anxiety, fainting/near-fainting episodes, abdominal pain, early satiety, bloating, and constipation

orthostatic hypotension, tachycardia, and skin color changes

passage of meconium greater than 48 hours after birth with explosive diarrhea, bilious vomiting, and failure to thrive

abdominal distension and absence of stool in rectal vault with possible production of large volume watery stool on rectal exam

adolescent females with severe sharp lower abdominal pain and fever; vaginal bleeding uncommon

abdominal distension, abdominal/pelvic tenderness, palpable adnexal mass, and tachycardia

children generally <5 years of age with abdominal pain and bloody diarrhea; fever can be absent; seizures can be present

hypertension, pallor, petechiae, and peripheral edema

frequently diagnosed prenatally; symptoms depend on age but can include hematuria and failure to thrive in infants, and recurrent abdominal or back pain with cyclic vomiting in older children

abdominal mass in infants

higher incidence in celiac disease and certain gastrointestinal infections (e.g., Campylobacter); abdominal pain, diarrhea, weight loss, fever, and bilious vomiting if obstruction present

pallor, abdominal distension, abdominal tenderness, presence of mass on palpation, organomegaly, ascites, clubbing, signs of obstruction or perforation

usually in developmentally delayed children but may also occur with normal development; presence of postprandial effortless oral regurgitations (contents may be re-swallowed) with absence of heartburn or nausea, and weight loss​

usually normal but dental erosions can be present

perpetrator is frequently one parent, who may be involved in healthcare industry; presence of multiple unexplained symptoms, including nausea and vomiting, where symptoms do not improve despite medical management; may lead to severe iatrogenic surgery and even death if diagnosis missed

usually normal

frequent to daily cannabis use, intermittent nausea and vomiting, compulsory bathing behaviors that improve symptoms, insomnia, polydipsia, and abdominal pain; does not respond to treatment with medications

usually normal

fever, sleep disturbance, headache, diarrhea, irritability in infants, otalgia in older children, poor appetite

bulging, erythematous, or opaque tympanic membrane; myringitis

symptoms depend on age but can include fever, lethargy, cough, dyspnea, chest pain, poor oral intake, and abdominal pain

respiratory distress (tachypnea, cyanosis, retractions, decreased breath sounds and crackles, low oxygen saturation); sepsis and respiratory failure can occur if diagnosis missed