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BACKGROUND
Vomiting is a common, nonspecific sign of a range of childhood illnesses. It may be acute or chronic and the general practitioner has a key role in identifying whether a child needs further investigation and management.
OBJECTIVE
This article outlines the main differential diagnoses, investigation and management of children presenting with acute and chronic vomiting.
DISCUSSION
Viral gastroenteritis is the most common cause of acute vomiting but should only be made after careful consideration of other causes. Management of hydration status in a child with a self limiting case of vomiting is vital. Regular review in the early phases of an undifferentiated vomiting illness will ensure that more fulminant illnesses are not overlooked and that secondary complications of dehydration do not arise. Chronic regurgitation and gastro-oesophageal reflux in infancy are common presentations that require considered management and may be a presenting symptom of food allergy. Other chronic presentations of nausea and vomiting in the older child may require referral for specialist assessment.
As for most paediatric conditions, the age of presentation and chronicity of symptoms are both important clinical features to assess in the diagnosis and management of nausea in childhood. If the presentation of vomiting is acute the general practitioner needs to ask: 'Does the child have a cause other than infective gastroenteritis?' And regarding hydration: 'Is there any reason why oral rehydration is not appropriate?' 'Does the child need admission to hospital for nasogastric or intravenous rehydration?' If symptoms have been present for weeks or months the GP needs to consider: 'Is the child failing to thrive?' and 'Does the child require referral for specialist investigation?'
What diagnoses should be considered in a child presenting with acute onset vomiting?
Although viral gastroenteritis commonly presents with acute vomiting and diarrhoea, other conditions should always be considered as a cause of these presenting clinical features. An acute presentation of vomiting may be the presentation of another infection (eg. undiagnosed urinary tract infection, meningitis, septicaemia or appendicitis), an acutely evolving surgical abdomen (eg. intussusception, malrotation with volvulus of the midgut) or a metabolic illness (eg. diabetic ketoacidosis) (Table 1).
What are the red flags (or reasons to think again) of an acutely presenting child with vomiting?
Any child who is vomiting blood or bile...