PE23.1 | Vomiting — Summary & Reflection

KEY TAKEAWAYS

Vomiting in children spans a wide spectrum from benign physiological regurgitation in infants to life-threatening surgical emergencies. The key clinical approach:

• First: identify surgical emergencies — bilious (green/yellow-green) vomiting = surgical emergency (malrotation/volvulus, atresia, obstruction) until proven otherwise; projectile non-bilious vomiting in a 2-8 week infant = hypertrophic pyloric stenosis

• Age-stratify the differential: Neonates (atresia, malrotation, HPS, sepsis, CAH); Infants (GERD, HPS, intussusception, gastroenteritis); Older children (gastroenteritis, appendicitis, raised ICP, metabolic, CVS)

• Pyloric stenosis investigations: Ultrasound is gold standard — muscle thickness >3-4 mm, channel length >14-16 mm; metabolic profile shows hypokalaemic hypochloraemic metabolic alkalosis. Correct electrolytes BEFORE surgery.

• Management principles: Bilious vomiting → nil orally, IV access, surgical referral; dehydration → IV fluid resuscitation (20 mL/kg bolus) or ORS (Plan B: 75 mL/kg/4h for some dehydration); gastroenteritis vomiting → single-dose oral ondansetron (0.15 mg/kg) + ORT with reduced-osmolarity ORS 245 mOsm/L; GERD → positioning + thickened feeds first, PPI only for GERD disease

• Key red flags: Bilious vomiting; projectile nature; haematemesis; neurological signs; abdominal distension; failure to pass meconium; poor weight gain

REFLECT

Think about the last child you have seen (or read about) presenting with vomiting. What was the first question you asked — or should have asked — about the colour and character of the vomiting? How would the assessment and management pathway have differed if the vomitus had been green?

Consider the tension between reassuring an anxious parent of a thriving infant who regurgitates frequently and identifying the rare infant whose vomiting signals a surgical emergency. What clinical features would shift your confidence from 'reassure' to 'investigate urgently'? How would you explain this distinction to a junior colleague during a ward round?