#paeds See [RCH guideline vomiting](https://www.rch.org.au/clinicalguide/guideline_index/Vomiting/) see also: [[Gastroenteritis]], [[neonatal bowel obstruction]], [[Abdominal pain (paeds)]] > [!key points] > 1. **Bilious** (dark green) vomiting is due to a gastrointestinal obstruction until proven otherwise, and requires urgent surgical referral > 2. In a vomiting child without diarrhoea, consider causes other than gastroenteritis  > 3. Intracranial causes eg non-accidental injury (NAI), should always be considered  > 4. Ondansetron can be used for symptomatic relief, however cessation of vomiting does not exclude a serious cause # ddx by age ![[Pasted image 20240223182445.png]] ## neonate vomiting **Obstructive**: - [[neonatal bowel obstruction#small bowel atresia|duodenal atresia]] - midgut [[Volvulus]] / malrotation - [[pyloric stenosis]] - hirschsprung disease [[neonatal bowel obstruction#Hirschsprung disease|Hirschsprung disease]] - hernia (incarcerated/strangulated hernia) - necrotising enterocolitis ([[Necrotising enterocolitis|NEC]]) - [[neonatal jaundice|biliary atresia]] - [[Intussusception]] **Non-obstructive**: - acute [[Gastroenteritis]] - sepsis (eg UTI) - inborn errors of metabolism - [[Non-accidental injury|NAI]] ## infant vomiting - intussceception - volvulus/ malrotation (bilious vomiting surgical emergency) - incarcerated/strangulated hernia - age 2-12 months - infections (UTI, sepsis, gastroenteritis) - hepatobiliary disease - inborn errors of metabolism (look for low glucose and met acidosis) - pyloric stenosis - projectile vomiting end of feeding presents at 2-6 months ; rare older than this - tox ingestion eg iron ingestion # Overview of causes ## small bowel atresia - **most common cause of neonatal intestinal obstruction** - duodenal atresia "double bubble" X ray - 1/3 of cases a/w Down syndrome - higher the atresia , earlier vomiting ## Malrotation/midgut volvulus - usually neonatal sudden onset pain, irritability, and bilious vomiting - - abdo **distension**, rectal bleeding, hypovolaemic shock - neonates with unexplained bilious vomiting need upper GI contrast study ## meconium ileus - small bowel obstruction from viscous meconium - usually due to **cystic fibrosis** - surgery for complex case, otherwise isotonic contrast enema ## Hirschsprung disease - failed migration of colonic ganglion cells --> tonic intestinal contraction → **functional obstruction** - males > females - enterocolitis is a potentially fatal complication - need rectal lavage ## hypertrophic pyloric stenosis - male > F - formula fed - **non-bilious vomiting** after feeds from 2-6 weeks of age , progressively more frequent - failure to thrive - **hypochloraemic, hypokalemia, met alkalosis** # treatment - Treat [shock](https://www.rch.org.au/clinicalguide/guideline_index/Intravenous_fluids/) with a bolus of 20 mL/kg sodium chloride 0.9% - If BGL less than 2.6 mmol/L  (<1.5 mmol/L in newborns), treat with 2 mL/kg of glucose 10%. If the child is unable to tolerate oral intake or is unwell, start IV fluids with glucose at maintenance rate as per [[Hypoglycaemia (paeds)]] guideline