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Vomiting in infants and children
I
Alimentary tract
Mini-symposium
Vomiting in infants and children
P. B. Sullivan, M. J. Brueton
to reduce vomiting. Amongst the benign causes of vomiting in infancy must be included rumination, a rare disorder in which an infant regurgitates food into the mouth and retastes it for pleasure.’ If this becomes a compulsive habit the infant may fail to thrive. Satisfactory weight gain as indicated by progress along standard growth charts is a useful indicator that vomiting is likely to be benign in an otherwise well child. Persistent vomiting, bile stained vomit or projectile vomiting alert the physician to a search for organic causes. Similarly, associated poor feeding, drowsiness, and fever suggest the possibility of some underlying disease, as do signs of abdominal distension, visible peristalsis or a mass palpable per abdomen. A bulging fontanelle may be a sign of raised intracranial pressure and requires exclusion of intracerebral infection, haemorrhage or tumour. An organic cause is more likely if a child suddenly begins to vomit after being previously well, in which case the most common cause is infection. In the older child vomiting secondary to emotional factors is not uncommon and anxiety, excitement or fear may result in an episode of vomiting. Occasionally children induce vomiting as an attention-seeking stratagem particularly if it is seen to create alarm in the parents. Cyclical vomiting is one manifestation of the periodic syndrome and is characterised by recurrent attacks of vomiting often in association with colicky abdominal pain in a child who becomes pale, irritable, anorexic and often ketotic. These attacks often occur with a definite periodicity of weeks or months, in between the attacks the child is quite well. The aetiology is unknown but recognised causes are partial epilepsy with autonomic manifestations, migraine and increased intrancranial pressure. The condition generally ceases around the time of puberty but in some it may be succeeded by attacks of classical migraine.*
The infant ‘mewling and puking in the nurse’s arms’ is so familiar as to be regarded as a normal stage of human development and, indeed, in the majority of instances vomiting in infants is of no great significance. It may fall to the doctor, however, to differentiate this benign vomiting from that associated with underlying pathology. Common causes of vomiting in children include: benign infection gastro-oesophageal reflux intestinal obstruction food allergy raised intra-cranial pressure drugs and poisoning
Benign Poor feeding technique, inappropriate handling and overfeeding are common causes of excessive possetting. Regurgitation after feeds occurs in the majority of babies whether they are breast or bottle fed. The commonest cause is excess wind arising from inadequate ‘winding’ and careless handling after feeds. In the bottle fed infant it is important to ensure a free flow of milk through an adequate hole in the teat and not to allow the infant to suck on an empty bottle. In the breast fed baby retracted nipples or a poor milk supply encourage aerophagy, as does leaving the infant too long on the breast. It is possible, particularly in the preterm infant and in the bottle fed, to offer more milk than is required - the surplus may simply be vomited back. There is no evidence that changes in the brand of the milk formula are ever necessary P. B. Sullivan, M. J. Jkuetoo, Department of Child Health, Westminster Children’s Hospital, London SWlP 2NS, UK. Correspondence and requests for offprints to PBS. Currenr Paediamcs (1991) 1, 13-16 0 1991 Loogman Group UK Ltd
13
14
CURRENT
PAEDIATRICS
Infection In the pre-school child especially almost any systemic infection may present with vomiting. Urinary tract infection, tonsillitis, otitis media, septicaemia or meningitis should all be considered. Respiratory infections, particularly pertussis, may involve vomiting as a prominent symptom. The commonest infection associated with vomiting is gastroenteritis which may be due to viruses (e.g. Rotavirus, Adenovirus), bacteria (e.g. Shigella sp, Salmonella sp, Yersinia enterocolitica, or toxin-producing organisms such as enterotoxigenic Escherichia coli) or parasites (e.g. Giardia lamblia, Strongyloides stercoralis). Enteric infection will be suggested by the history, particularly if there is a known contact, and may be confirmed by microbiological examination of fresh stool specimens. Vomiting together with periumbilical pain and fever constitute the classical triad of symptoms in acute appendicitis, which may in some cases have an infective component, occurs in 80% of affected children. Recurrent vomiting especially in association with recurring abdominal pain should lead to a search for Helicobacter pylori (formerly Campylobacter pylori)associated gastritis particularly if there is a positive family history of dyspeptic disease.3 In adults, up to 90% of cases of duodenal ulcer are associated with H. pylori gastritis and duodenal ulcers although less common in children do occur.4 Vomiting was the presenting complaint in 17/49 cases of childhood duodenal ulcer in children age less than 13 years in the series of Robb et al, (1972) and the commonest presenting complaint in those less than 4 years of age.4 In 16 children with H.pylori gastritis studied by Drumm et al, (1988) in Toronto, duodenal ulcer was found in 1O.5 Thus upper gastrointestinal endoscopy may play an important role in the investigation of children with recurrent vomiting.
Gastro-oesophagealreflux Vomiting is the clinical hallmark of gastro-oesophageal reflux (GOR) in infants but its absence does not exclude this diagnosis.5*6 The vomiting is recurrent and may be regurgitant or projectile. Rarely it is associated with haematemesis. The older child with GOR may also complain of symptoms suggestive of dyspepsia or heartburn and iron-deficiency anaemia is not uncommon. The mechanisms that normally control GOR include the lower oesophageal sphincter, the intraabdominal segment of the oesophagus, the gastro-oesophageal angle of His, the mucosal rosette in the lower oesophagus and the pinchcock effect of the diaphragmatic crura. These anatomical features together with the coordinated effective peristaltic clearance of the distal oesophagus and prompt gastric emptying act to prevent significant reflux of acidic gastric contents. A defect in any of the components listed above can lead to GOR. A common cause of persistent GOR is an hiatus hernia which
may be secondary to a developmental anomaly of the sphincteric smooth muscle. The diagnosis is most confidently made by 24 h pH monitoring in the lower oesophagus and a barium oesophagogram which can confirm the diagnosis and indicate underlying anatomical abnormalities. Fibreoptic endoscopy will detect any associated oesophagitis. Uncomplicated cases may respond to simple measures such as thickening the feeds with cereal; if oesophagitis is present an Hz-receptor antagonist such as ranitidine (4 mg/kg in two divided doses) is useful. Positional management is one of the simplest means of controlling reflux and it has been shown that nursing infants in the prone, head-elevated position (30”) is an effective therapy in infants with GOR.* The prokinetic agent cisapride has been shown to be valuable in the management of children with GOR.9 Ninety percent of patients can be managed medically but fundoplication may be required if GOR is associated with an anatomical abnormality such as a large hiatus hernia, oesophageal stricture or ulcerative oesophagitis refractory to medical management. Aspiration related to GOR has been reported in children with near-miss infant death (See et al, 1989) and this would be a further indication for surgical as opposed to medical management. lo Medical management of GOR includes: l l l l l
thickened feeds postural adjustment antacids (‘Gaviscon’) Metoclopramide; cisapride H, receptor antagonists
Intestinal obstruction Bile stained vomit should always be regarded as an indication of pathology and intestinal obstruction in particular must be excluded. Typical causes of intestinal obstruction in early infancy include malrotation with congenital duodenal bands, intestinal atresias/ stenoses, enteric duplication and Hirschprung’s disease. The latter is the commonest cause of intestinal obstruction in the newborn. Diagnostic radiological studies form the basis for the clinical evaluation of problems of intestinal rotation and suspected intestinal obstruction. Intussusception characteristically presents in a male child in the second half of infancy who has vomiting associated with intermittent bouts of screaming as a result of severe abdominal pain, in between these attacks he appears to be well. Later he will become pale, sweaty and apathetic; he will vomit repeatedly and pass bloody mucus per rectum. This condition has a very typical presentation and if missed and not treated is likely to be fatal within 5 days. Projectile vomiting is typically associated with hypertrophic pyloric stenosis although the association is by no means exclusive. l1 Affected infants, usually males, typically present at 3 weeks of age with vomit-
VOMITING
ing which occurs once or twice a day, but as the obstruction increases, the vomiting becomes more forceful and more constant. Dehydration may ensue accompanied by metabolic alkalosis and profound weight loss. The diagnosis is confirmed most reliably by barium swallow and ultrasonography is used increasingly as a non-invasive diagnostic aidI although it has a relatively high (12%) false negative rate.r3
Food allergy or intolerance Food allergy is increasingly being blamed for a wide variety of paediatric ailments, frequently with little or no evidence. It is, however, clearly established that vomiting alone or in association with diarrhoea may be a manifestation of food intolerance14 and in the acute phase this may be indistinguishable from gastroenteritis. The commonest example of this is cow milk protein intolerance (CMPI) which usually presents in the first 2 years of life. This has a prevalence of between 1% and 3% and occurs more commonly in infants from atopic families; affected babies often have other signs of allergic disease such as wheezing, eczema or urticaria. Diagnosis is based on remission of symptoms upon withdrawal of cow milk followed by a relapse after cow milk challenge. Most patients have recovered by 18 months to 2 years of age. Soya formula is frequently given as a substitute for cow milk but it is important to know that about a quarter of children with CMPI will develop intolerance to soya. Several other foods have been demonstrated to produce similar symptoms of intolerance to cow and soya milk including egg, rice, fish and chicken.r5 Coeliac disease may present as vomiting when glutencontaining foods are introduced for the first time.
Raised in&a-cranial pressureand post-traumatic emesis In the older child persistent vomiting should always be regarded as due to raised intra-cranial pressure until proved otherwise. Thus vomiting may be an important symptom of cerebral oedema, intra-cranial haemorrhage (e.g. a sub-dural haematoma), intracranial tumour or hyper tension. Vomiting not caused by central nervous system pathology is usually part of a symptom complex that includes fever and severe abdominal pain, or a notable alteration in bowel pattern. The recurrence of a pattern of effortless vomiting with minimal systemic complaints may distinguish vomiting due to an intra-cranial mass from most other causes.“j Many children vomit following a head injury and Hugenholz et al (1987) have shown that post-traumatic emesis occurs more frequently in children over 2 years and in children within an hour of intake of food or drink and that there is no significant difference in the incidence of vomiting between children with minor head injuries with a skull fracture and those without.”
IN INFANTS
AND CHILDREN
15
Drugs and poisoning Nausea and vomiting are very common adverse reactions to drugs and it is likely that virtually all groups of drugs are capable of causing them under appropriate conditions. Cytotoxic drugs, opiates, digoxin, theophylline, potassium salts, iron salts and antibiotics can all cause vomiting. It is important to remember that vomiting may be a sign of poisoning (e.g. lead poisoning) in children and this should always be considered when a previously well child begins to vomit without an identifiable cause. Such poisoning may be accidental or deliberate in a case of child abuse. The causes of vomiting in children are of course legion and it is impossible to provide a comprehensive list. Nevertheless, the above outlines the major framework within which the majority of cases will fall. Rarer causes include extraintestinal abdominal disorders (e.g. hepatitis, cholecystitis and pancreatitis) and metabolic disorders (e.g. congenital adrenal hyperplasia, galactosaemia, phenylketonuria, hypercalcaemia, diabetic ketoacidosis). The encephalopathy of Reye’s syndrome is often preceeded by recurrent vomiting. Vomiting has recently been reported as an ictal manifestation of epileptic syndromes in childhood.’ 8 Treatment of vomiting is initially directed towards correction of any underlying disorder and then alleviation of the symptoms. l9 Intravenous fluids may be required until the vomiting settles. Anti-emetics are ineffective in the treatment of vomiting caused by gastroenteritis and should not be prescribed. Phenothiazines act on the chemoreceptor trigger zone to depress vomiting but they have a number of side effects including extra-pyramidal reactions and seizures. Anti-histamines are effective antiemetics for motion sickness, but they commonly cause drowsiness. As a result of their sedative effects, the anti-emetics may mask serious causes of vomiting such as diseases of the central nervous system. One instance in which anti-emetic drug therapy plays an important part in patient management is in the treatment of vomiting induced by cytotoxic drugs.20 Commonly used anti-emetics as an adjunct to chemotherapy include phenothiazines, metoclopramide and domperidone all of which block dopamine stimulation of the chemoreceptor trigger zone. In the treatment of cyclical vomiting chlorpromazine, phenobarbitone, propanolol and clonidine have been used effectively in some patients.
References 1. Winton ASW, Singh NN. Rumination in pediatric populations: A behavioral analvsis. J Am Acad Child Psvch i983;
22: 269-275.
2. Reinhart JB, Evans SL, McFadden DL. Cyclic vomiting in children: Seen through the psychiatrist’s eye. Pediatr 1977; 59: 371-77. 3. Oderda G, Forni M, Poli E et al. Helicobacter pylori gastritis in children: Wide spectrum of symptoms. Presented at
I6
4. 5.
6. 7. 8.
9.
10. 1 I.
CURRENT
PAEDIATRICS
XXIIIrd annual conference of European Society of Paediatric Gastroenterology and Nutrition, Amsterdam, April, 1990. Rbbb JDA, Thomas PS, Orszulok J et al. Duodenal ulcer in Children. Arch Dis Child 1972: 47: 688-696. Drumm B, Sharman P, Chiasson D et al. Treatment of Campylobacter pylori associated autral gastritis in children with bismuth subsalicylate and ampicillin. J Pediatr 1988; 113: 908-912. Balistreri WF, Farrell MK. Gastroesophageal reflux in infants. New Eng J Med 1983; 390(13): 790-792. Paton JY, Nanayakkhara CS, Simpson H. Vomiting and gastro-oesophageal reflux. Arch Dis Child 1988; 63: 837-856. Vandenplas Y, Sacre-Smits L. Seventeen-hour continuous esophageal pH monitoring in the newborn: Evaluation of the influence of position in asymptomatic and symptomatic babies. J Pediatr Gastroenterol Nutr 1985; 4: 356-361. Cucchiara S, Staiano A, Boccieri A et al. Effects of cisapride on parameters of oesophageal motility and on the prolonged intraoesophageal pH test in infants with gastro-oesophageal reflux disease. Gut 1990; 31: 21-25. See CC, Newman LJ, Berezin S et al. Gastroesophageal reflux-induced hypoxemia in infants with apparent lifethreatening events. Am J Dis Child 1989; 143: 951-4. Benson CD. Infantile hypertrophic pyloric stenosis. In: Pediatric Surgery eds. Welch KJ. Randolph JG.
12. 13. 14. 15. 16. 17. 18. 19. 20.
Ravitch MM. G’Neill JA and Rowe MI. 1986. Year Book Medical Publishers Inc. Chapter 8 1; 8 1 l-8 15. A’Delbert Bowen. The vomiting infant: Recent advances and unsettled issues in imaging. Radio1 Clin North Am 1988; 26; 377-392. Foley LC, Slovis TL, Campbell JB et al. Evaluation of the vomiting infant. Am J Dis Child 1989; 143: 660-661. Hill DJ, Firer MA, Shelton MJ, Hosking CS. Manifestations of milk allergy in infancy: clinical and immunologic findings J Pediatr 1986; 109: 270-276. Vitoria JC, Camarero C, Sojo et al. Enteropathy related to fish, rice and chicken. Arch Dis Child 1982; 57: 44-8. Squires RH. Intracranial Tumors: Vomiting as a presenting sign. A gastroenterologist’s perspective. Clin Pediatr 1989; 28: 251-4. Hugenholtz H, Izukawa D, Shear P et al. Vomiting in children following head injury. Child’s Nerv Syst 1987; 3; 266-270. Panayiotopoulos CP. Vomiting as an ictal manifestation of epileptic seizures and syndromes. J Neurol Neurosurg Psych 1988; 51: 1448-1451. Jaudes PK. Christoffel KK. Differences among physicians in the treatment of children with vomiting. Fam Pratt Res J 1986; 6: 47-53. Cunningham D. Treatment of emesis induced by cytotoxic drugs. Hosp Update 1990; 16: 99-108.
Alimentary tract
Mini-symposium
Vomiting in infants and children
P. B. Sullivan, M. J. Brueton
to reduce vomiting. Amongst the benign causes of vomiting in infancy must be included rumination, a rare disorder in which an infant regurgitates food into the mouth and retastes it for pleasure.’ If this becomes a compulsive habit the infant may fail to thrive. Satisfactory weight gain as indicated by progress along standard growth charts is a useful indicator that vomiting is likely to be benign in an otherwise well child. Persistent vomiting, bile stained vomit or projectile vomiting alert the physician to a search for organic causes. Similarly, associated poor feeding, drowsiness, and fever suggest the possibility of some underlying disease, as do signs of abdominal distension, visible peristalsis or a mass palpable per abdomen. A bulging fontanelle may be a sign of raised intracranial pressure and requires exclusion of intracerebral infection, haemorrhage or tumour. An organic cause is more likely if a child suddenly begins to vomit after being previously well, in which case the most common cause is infection. In the older child vomiting secondary to emotional factors is not uncommon and anxiety, excitement or fear may result in an episode of vomiting. Occasionally children induce vomiting as an attention-seeking stratagem particularly if it is seen to create alarm in the parents. Cyclical vomiting is one manifestation of the periodic syndrome and is characterised by recurrent attacks of vomiting often in association with colicky abdominal pain in a child who becomes pale, irritable, anorexic and often ketotic. These attacks often occur with a definite periodicity of weeks or months, in between the attacks the child is quite well. The aetiology is unknown but recognised causes are partial epilepsy with autonomic manifestations, migraine and increased intrancranial pressure. The condition generally ceases around the time of puberty but in some it may be succeeded by attacks of classical migraine.*
The infant ‘mewling and puking in the nurse’s arms’ is so familiar as to be regarded as a normal stage of human development and, indeed, in the majority of instances vomiting in infants is of no great significance. It may fall to the doctor, however, to differentiate this benign vomiting from that associated with underlying pathology. Common causes of vomiting in children include: benign infection gastro-oesophageal reflux intestinal obstruction food allergy raised intra-cranial pressure drugs and poisoning
Benign Poor feeding technique, inappropriate handling and overfeeding are common causes of excessive possetting. Regurgitation after feeds occurs in the majority of babies whether they are breast or bottle fed. The commonest cause is excess wind arising from inadequate ‘winding’ and careless handling after feeds. In the bottle fed infant it is important to ensure a free flow of milk through an adequate hole in the teat and not to allow the infant to suck on an empty bottle. In the breast fed baby retracted nipples or a poor milk supply encourage aerophagy, as does leaving the infant too long on the breast. It is possible, particularly in the preterm infant and in the bottle fed, to offer more milk than is required - the surplus may simply be vomited back. There is no evidence that changes in the brand of the milk formula are ever necessary P. B. Sullivan, M. J. Jkuetoo, Department of Child Health, Westminster Children’s Hospital, London SWlP 2NS, UK. Correspondence and requests for offprints to PBS. Currenr Paediamcs (1991) 1, 13-16 0 1991 Loogman Group UK Ltd
13
14
CURRENT
PAEDIATRICS
Infection In the pre-school child especially almost any systemic infection may present with vomiting. Urinary tract infection, tonsillitis, otitis media, septicaemia or meningitis should all be considered. Respiratory infections, particularly pertussis, may involve vomiting as a prominent symptom. The commonest infection associated with vomiting is gastroenteritis which may be due to viruses (e.g. Rotavirus, Adenovirus), bacteria (e.g. Shigella sp, Salmonella sp, Yersinia enterocolitica, or toxin-producing organisms such as enterotoxigenic Escherichia coli) or parasites (e.g. Giardia lamblia, Strongyloides stercoralis). Enteric infection will be suggested by the history, particularly if there is a known contact, and may be confirmed by microbiological examination of fresh stool specimens. Vomiting together with periumbilical pain and fever constitute the classical triad of symptoms in acute appendicitis, which may in some cases have an infective component, occurs in 80% of affected children. Recurrent vomiting especially in association with recurring abdominal pain should lead to a search for Helicobacter pylori (formerly Campylobacter pylori)associated gastritis particularly if there is a positive family history of dyspeptic disease.3 In adults, up to 90% of cases of duodenal ulcer are associated with H. pylori gastritis and duodenal ulcers although less common in children do occur.4 Vomiting was the presenting complaint in 17/49 cases of childhood duodenal ulcer in children age less than 13 years in the series of Robb et al, (1972) and the commonest presenting complaint in those less than 4 years of age.4 In 16 children with H.pylori gastritis studied by Drumm et al, (1988) in Toronto, duodenal ulcer was found in 1O.5 Thus upper gastrointestinal endoscopy may play an important role in the investigation of children with recurrent vomiting.
Gastro-oesophagealreflux Vomiting is the clinical hallmark of gastro-oesophageal reflux (GOR) in infants but its absence does not exclude this diagnosis.5*6 The vomiting is recurrent and may be regurgitant or projectile. Rarely it is associated with haematemesis. The older child with GOR may also complain of symptoms suggestive of dyspepsia or heartburn and iron-deficiency anaemia is not uncommon. The mechanisms that normally control GOR include the lower oesophageal sphincter, the intraabdominal segment of the oesophagus, the gastro-oesophageal angle of His, the mucosal rosette in the lower oesophagus and the pinchcock effect of the diaphragmatic crura. These anatomical features together with the coordinated effective peristaltic clearance of the distal oesophagus and prompt gastric emptying act to prevent significant reflux of acidic gastric contents. A defect in any of the components listed above can lead to GOR. A common cause of persistent GOR is an hiatus hernia which
may be secondary to a developmental anomaly of the sphincteric smooth muscle. The diagnosis is most confidently made by 24 h pH monitoring in the lower oesophagus and a barium oesophagogram which can confirm the diagnosis and indicate underlying anatomical abnormalities. Fibreoptic endoscopy will detect any associated oesophagitis. Uncomplicated cases may respond to simple measures such as thickening the feeds with cereal; if oesophagitis is present an Hz-receptor antagonist such as ranitidine (4 mg/kg in two divided doses) is useful. Positional management is one of the simplest means of controlling reflux and it has been shown that nursing infants in the prone, head-elevated position (30”) is an effective therapy in infants with GOR.* The prokinetic agent cisapride has been shown to be valuable in the management of children with GOR.9 Ninety percent of patients can be managed medically but fundoplication may be required if GOR is associated with an anatomical abnormality such as a large hiatus hernia, oesophageal stricture or ulcerative oesophagitis refractory to medical management. Aspiration related to GOR has been reported in children with near-miss infant death (See et al, 1989) and this would be a further indication for surgical as opposed to medical management. lo Medical management of GOR includes: l l l l l
thickened feeds postural adjustment antacids (‘Gaviscon’) Metoclopramide; cisapride H, receptor antagonists
Intestinal obstruction Bile stained vomit should always be regarded as an indication of pathology and intestinal obstruction in particular must be excluded. Typical causes of intestinal obstruction in early infancy include malrotation with congenital duodenal bands, intestinal atresias/ stenoses, enteric duplication and Hirschprung’s disease. The latter is the commonest cause of intestinal obstruction in the newborn. Diagnostic radiological studies form the basis for the clinical evaluation of problems of intestinal rotation and suspected intestinal obstruction. Intussusception characteristically presents in a male child in the second half of infancy who has vomiting associated with intermittent bouts of screaming as a result of severe abdominal pain, in between these attacks he appears to be well. Later he will become pale, sweaty and apathetic; he will vomit repeatedly and pass bloody mucus per rectum. This condition has a very typical presentation and if missed and not treated is likely to be fatal within 5 days. Projectile vomiting is typically associated with hypertrophic pyloric stenosis although the association is by no means exclusive. l1 Affected infants, usually males, typically present at 3 weeks of age with vomit-
VOMITING
ing which occurs once or twice a day, but as the obstruction increases, the vomiting becomes more forceful and more constant. Dehydration may ensue accompanied by metabolic alkalosis and profound weight loss. The diagnosis is confirmed most reliably by barium swallow and ultrasonography is used increasingly as a non-invasive diagnostic aidI although it has a relatively high (12%) false negative rate.r3
Food allergy or intolerance Food allergy is increasingly being blamed for a wide variety of paediatric ailments, frequently with little or no evidence. It is, however, clearly established that vomiting alone or in association with diarrhoea may be a manifestation of food intolerance14 and in the acute phase this may be indistinguishable from gastroenteritis. The commonest example of this is cow milk protein intolerance (CMPI) which usually presents in the first 2 years of life. This has a prevalence of between 1% and 3% and occurs more commonly in infants from atopic families; affected babies often have other signs of allergic disease such as wheezing, eczema or urticaria. Diagnosis is based on remission of symptoms upon withdrawal of cow milk followed by a relapse after cow milk challenge. Most patients have recovered by 18 months to 2 years of age. Soya formula is frequently given as a substitute for cow milk but it is important to know that about a quarter of children with CMPI will develop intolerance to soya. Several other foods have been demonstrated to produce similar symptoms of intolerance to cow and soya milk including egg, rice, fish and chicken.r5 Coeliac disease may present as vomiting when glutencontaining foods are introduced for the first time.
Raised in&a-cranial pressureand post-traumatic emesis In the older child persistent vomiting should always be regarded as due to raised intra-cranial pressure until proved otherwise. Thus vomiting may be an important symptom of cerebral oedema, intra-cranial haemorrhage (e.g. a sub-dural haematoma), intracranial tumour or hyper tension. Vomiting not caused by central nervous system pathology is usually part of a symptom complex that includes fever and severe abdominal pain, or a notable alteration in bowel pattern. The recurrence of a pattern of effortless vomiting with minimal systemic complaints may distinguish vomiting due to an intra-cranial mass from most other causes.“j Many children vomit following a head injury and Hugenholz et al (1987) have shown that post-traumatic emesis occurs more frequently in children over 2 years and in children within an hour of intake of food or drink and that there is no significant difference in the incidence of vomiting between children with minor head injuries with a skull fracture and those without.”
IN INFANTS
AND CHILDREN
15
Drugs and poisoning Nausea and vomiting are very common adverse reactions to drugs and it is likely that virtually all groups of drugs are capable of causing them under appropriate conditions. Cytotoxic drugs, opiates, digoxin, theophylline, potassium salts, iron salts and antibiotics can all cause vomiting. It is important to remember that vomiting may be a sign of poisoning (e.g. lead poisoning) in children and this should always be considered when a previously well child begins to vomit without an identifiable cause. Such poisoning may be accidental or deliberate in a case of child abuse. The causes of vomiting in children are of course legion and it is impossible to provide a comprehensive list. Nevertheless, the above outlines the major framework within which the majority of cases will fall. Rarer causes include extraintestinal abdominal disorders (e.g. hepatitis, cholecystitis and pancreatitis) and metabolic disorders (e.g. congenital adrenal hyperplasia, galactosaemia, phenylketonuria, hypercalcaemia, diabetic ketoacidosis). The encephalopathy of Reye’s syndrome is often preceeded by recurrent vomiting. Vomiting has recently been reported as an ictal manifestation of epileptic syndromes in childhood.’ 8 Treatment of vomiting is initially directed towards correction of any underlying disorder and then alleviation of the symptoms. l9 Intravenous fluids may be required until the vomiting settles. Anti-emetics are ineffective in the treatment of vomiting caused by gastroenteritis and should not be prescribed. Phenothiazines act on the chemoreceptor trigger zone to depress vomiting but they have a number of side effects including extra-pyramidal reactions and seizures. Anti-histamines are effective antiemetics for motion sickness, but they commonly cause drowsiness. As a result of their sedative effects, the anti-emetics may mask serious causes of vomiting such as diseases of the central nervous system. One instance in which anti-emetic drug therapy plays an important part in patient management is in the treatment of vomiting induced by cytotoxic drugs.20 Commonly used anti-emetics as an adjunct to chemotherapy include phenothiazines, metoclopramide and domperidone all of which block dopamine stimulation of the chemoreceptor trigger zone. In the treatment of cyclical vomiting chlorpromazine, phenobarbitone, propanolol and clonidine have been used effectively in some patients.
References 1. Winton ASW, Singh NN. Rumination in pediatric populations: A behavioral analvsis. J Am Acad Child Psvch i983;
22: 269-275.
2. Reinhart JB, Evans SL, McFadden DL. Cyclic vomiting in children: Seen through the psychiatrist’s eye. Pediatr 1977; 59: 371-77. 3. Oderda G, Forni M, Poli E et al. Helicobacter pylori gastritis in children: Wide spectrum of symptoms. Presented at
I6
4. 5.
6. 7. 8.
9.
10. 1 I.
CURRENT
PAEDIATRICS
XXIIIrd annual conference of European Society of Paediatric Gastroenterology and Nutrition, Amsterdam, April, 1990. Rbbb JDA, Thomas PS, Orszulok J et al. Duodenal ulcer in Children. Arch Dis Child 1972: 47: 688-696. Drumm B, Sharman P, Chiasson D et al. Treatment of Campylobacter pylori associated autral gastritis in children with bismuth subsalicylate and ampicillin. J Pediatr 1988; 113: 908-912. Balistreri WF, Farrell MK. Gastroesophageal reflux in infants. New Eng J Med 1983; 390(13): 790-792. Paton JY, Nanayakkhara CS, Simpson H. Vomiting and gastro-oesophageal reflux. Arch Dis Child 1988; 63: 837-856. Vandenplas Y, Sacre-Smits L. Seventeen-hour continuous esophageal pH monitoring in the newborn: Evaluation of the influence of position in asymptomatic and symptomatic babies. J Pediatr Gastroenterol Nutr 1985; 4: 356-361. Cucchiara S, Staiano A, Boccieri A et al. Effects of cisapride on parameters of oesophageal motility and on the prolonged intraoesophageal pH test in infants with gastro-oesophageal reflux disease. Gut 1990; 31: 21-25. See CC, Newman LJ, Berezin S et al. Gastroesophageal reflux-induced hypoxemia in infants with apparent lifethreatening events. Am J Dis Child 1989; 143: 951-4. Benson CD. Infantile hypertrophic pyloric stenosis. In: Pediatric Surgery eds. Welch KJ. Randolph JG.
12. 13. 14. 15. 16. 17. 18. 19. 20.
Ravitch MM. G’Neill JA and Rowe MI. 1986. Year Book Medical Publishers Inc. Chapter 8 1; 8 1 l-8 15. A’Delbert Bowen. The vomiting infant: Recent advances and unsettled issues in imaging. Radio1 Clin North Am 1988; 26; 377-392. Foley LC, Slovis TL, Campbell JB et al. Evaluation of the vomiting infant. Am J Dis Child 1989; 143: 660-661. Hill DJ, Firer MA, Shelton MJ, Hosking CS. Manifestations of milk allergy in infancy: clinical and immunologic findings J Pediatr 1986; 109: 270-276. Vitoria JC, Camarero C, Sojo et al. Enteropathy related to fish, rice and chicken. Arch Dis Child 1982; 57: 44-8. Squires RH. Intracranial Tumors: Vomiting as a presenting sign. A gastroenterologist’s perspective. Clin Pediatr 1989; 28: 251-4. Hugenholtz H, Izukawa D, Shear P et al. Vomiting in children following head injury. Child’s Nerv Syst 1987; 3; 266-270. Panayiotopoulos CP. Vomiting as an ictal manifestation of epileptic seizures and syndromes. J Neurol Neurosurg Psych 1988; 51: 1448-1451. Jaudes PK. Christoffel KK. Differences among physicians in the treatment of children with vomiting. Fam Pratt Res J 1986; 6: 47-53. Cunningham D. Treatment of emesis induced by cytotoxic drugs. Hosp Update 1990; 16: 99-108.