INTRODUCTION
The subject for discussion
Is the little child who vomits,
Who throws up all her food with the
Trajectory of comets.
But first we must distinguish,
As you’re sure to come across it,
The differences between this and
The gently brought up posset.
The child who only possets
Never puts you in a spin
For she deposits but a drop
Or two upon her chin.
The vomiter however is
A child you can’t ignore
As her most recent meal ends up
Upon the kitchen floor.
A posseter you reassure;
A vomiter – find out more.
Why do children vomit?
Well, like you and me,
When the stimulus is there
It’s a reflex, don’t you see?
Signals from the gut
Or deep within the brain
Go to the medulla
To initiate a chain
Of events that are directed
By a centre that is known
By the sweet nonscanning title of
Chemo-emetic trigger zone.
What follows? Need I tell it?
The stomach will expel it.
It’s vital to remember that,
Like fits or halitosis,
                                   Vomiting’s a symptom and
                                   Is not a diagnosis.
I’ll say it once again
Though it might induce hypnosis:
                                   Vomiting’s a symptom and
                                   Is not a diagnosis.
So don’t be tempted just to give
The mother’s head a pat
And dose the kid with Stemetil
Or nostrums such as that.
A CLINICAL APPROACH
A good history and examining
Will help you find the pieces
That fit together giving you
The cause of the emesis.
Thus a clinical approach will in all
Cases give the answer
Which may vary from a sore throat to
A cerebellar cancer.
Yes, causes may be minor
Like an earache or a cold
But miss a mass within the brain
And there’ll be strife untold.
The most helpful thing to aid you
As you search to find the reason
Is the age at which the child
NEONATEÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Has now presented. In the season
Of the first week of the neonate
What they swallow during labour
Gastric                       May cause some irritation and
irritation                     Get tossed out like a caber.
Liquor, blood, meconium
Upset the stomach lining
And make the baby puke
And vomit after dining.
Feeding                      Also difficulties feeding may
problems                    Upset the infant gut.
These symptoms usually settle and
The baby then thrives, but
Don’t forget that in this period when
The baby very light is
Infections                    She’s prone to get infections:
Septicaemia, meningitis.
Here the septic babe
May cry too much or go
Too quiet and apathetic,
Her temp is high or low.
Should these things occur,
Then you must be quick
To do your cultures and begin
An antibiotic.
Congenital                  Also at this time the gut is
gut                              New and is untried
anomalies                   And there may be an atresia or
Stenosis deep inside.
Many’s the congenital
Obstruction that may show
Soon after birth with vomiting.
So don’t be slow
To think of duodenal or other atres-
ia, meconium ileus or Hirschsprung’s disease.
If you’re in a bind
And just can’t find
Which part of the babe the trouble is in
There’s a chance it may
Be the DNA:
An inborn error of metabolism.
So at the end of the list
And not to be missed
Some rare faults exist
For the biochemist
Such as hyperammonaemia
Where blood ammonia’s high
And, if treatment isn’t given,
The baby may well die.
EARLYÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Vomiting’s a common symptom in the
INFANCYÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â First few months of life
And it causes much alarm to many a
Mother or a wife.
Feeding                      Commonly it’s met where feeding
problems                    Isn’t going well.
The baby’s swallowing air and is
Creating merry hell.
She eructates or burps
And the milk returns at speed.
The whole thing is repeated then
With each and every feed.
Or perhaps the hole that’s in the teat
Is made too big and wide;
Gulped air and milk distend her gut –
She can’t keep them inside.
Thus careful note you need to make
Of mum’s technique of feeding
So you can find the faults and change
Disaster to succeeding.
GORÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Quite common too is GOR,
That’s gastro-oesophageal
Reflux where the babe returns
A portion of each meal.
She brings her milk up with no strain,
Of bile there’s not a trace,
But on the carpet there’s a stain;
Despair is in mum’s face.
But your job is to reassure.
“She’ll grow out of it”, you say
But check first that she’s growing well
And that her chest’s OK.
For reflux may result in a
Failure to gain weight
And, in others, food’s return
May make them aspirate.
A variation on this theme
Of GOR is seen when haem-
atemesis gives mum a fright. This
Brings to light oesophagitis:
Acid burn of the gullet
Needs antacid to dull it.
Infections                    Also you will often see
An infant with otitis me-
dia, the common cold or such
Presenting ‘cos she vomits much.
Infections present commonly
                                   With vomiting in infancy.
This aphorism’s worth repeating
Over and over if kids you’re treating:
Infections present commonly
                                   With vomiting in infancy.
Always thus you must consider
Maybe bugs will give a kid a
Gastro or a meningitis,
Chest infection, hepatitis.
Don’t forget the UTI
Lurking unsuspected by
Those not versed in little tricks,
Eg. the using of dipstix.
These causes – feeding, GOR, infection
Are the commonest in this section
Less common but now needing introduction
Intestinal                     Are some syndromes of intestinal obstruction.
Obstruction
Firstly and most common is a
Major diagnosis:
That’s infantile hypertrophic
                                   pyloric stenosis.
The cause of this phenomenon,
The pundits now assure us
Is that nitric oxide synthetase is
Low in the pylorus.
This is four times commoner
In boys than little girls.
It can run in a family. The
Firstborn often hurls
His milk across the room in
A projectile fashion.
It’s sudden and complete – he
Then wants his next ration.
The vomiting is not always projectile,
Don’t be caught,
But it occurs soon after feeds;
His mother’s overwrought.
The baby doesn’t thrive, he
May go slightly yellow
And it is quite obvious he’s a
Hungry little fellow.
The clue, apart from hist’ry, you will
Find if you can feel
A round mass, olive-shaped, as the
Baby takes a meal.
Here is how
To do it now:
The baby feeds on mother’s breast, re-
laxed (there is no hustle).
You gently get you fingers to the
Right of rectus muscle.
You’ll feel it then. Your eye may catch, as
It so smoothly pulses
Across the epigastrium, the
Gastric peristalsis.
The other helpful clue to
Make the diagnosis
Is a hypochloraemic hypokalaemic
Metabolic alkalosis:
For –
Although he’s dehydrated, it’s
Acid that he’s lost
And trying to correct, potassium into
Cells has crossed.
The diagnosis is confirmed with
Ultrasound or barium
And with a pyloromyotomy you’ll
Get your honorarium.
The name of the operation I’ll repeat now
Nice and slowly:
You cut the muscle lengthways –
Pyloromyotomy.
OLDER
INFANTSÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â In older infants it’s the in-
fections that are major
Infections                    Causes of the vomiting in
Children at this stage. A
Child of this age also tends to
Pick things up and swallow
Poisoning                   All sorts of things that do no good.
Emesis may well follow.
A tablet, insect, leaves and sticks
Enter the oral cavity
So think of poison when she throws up,
Defying gravity.
Rumination                 The ruminator brings it up in
to his mouth, rechews it,
Swallows it again or, at
Times, will choose to spew it.
This can be normal but may show a
Child who’s life is boring;
Who’s parents do not stimulate or
Actively ignore him.
Stress                          Likewise the infant who has had an
Early life of tension
At times of stress may make a mess;
Vomits to get attention.
If you have been sleeping
Please wake up and listen
As I introduce
Some important conditions.
Concentrate now! Do not doze
As words of wisdom I propose:
Surgical                      In the first two years there occurs
causes                         A vomit which the surgeon
Would maintain is his terrain.
One is an emergen-
cy, the midgut volvulus.
Here there will exist
A malrotation of the gut which
Gets into a twist.
The circulation to the bowel is
Compromised and should
This state continue long that
Bowel will be no good.
The child with this will vomit bile, goes
In and out of shock, but
Distension’s rare, the stomach’s soft, not
Much to point to rotgut.
To diagnose the midgut volvulus
Make it certain that
A child who brings up bile must have a
Barium meal and that stat.
To be complete,
I must repeat:
To diagnose the midgut volvulus
Make it certain that
A child who brings up bile must have a
Barium meal and that stat.
The other thing that’s surgical and
Vomits at inception
Is telescoping of the bowel that’s
Called intussusception.
This occurs at many sites, is
Often ileocolic.
The baby has a bloody stool and
Pain that’s diabolic.
These times of pain are episodes of
Gut contraction when
Ischaemia is occurring at the
Site of obstruction.
Apart from the history and the
Pain, the sign you try to find
Is a sausage-shaped abdominal lump
Either ill- or well-defined.
The management, I’ll briefly say, is
To attempt reduction,
Under X-ray control,
with careful introduction
Of air under pressure
In the colon with a pump:
And with a bit of luck
You’ll get rid of the lump.
Should this fail
It will entail
A surgeon’s knife
To end the strife.
Please make it a rule – if
Money you would earn – you
Must never, never miss an in-
                                   carcerated hernia.
You’ll be alright
If in each mite
You carefully check
Each hernial site.
CHILDHOODÂ Â Â Â Â Â Â Â Â Â The older child she vomits less. The
Causes are not many.
Once more infections dominate and
Basically are any.
Infections                    Some are less than obvious, re-
quire a little looking
To find the underlying germ, to
Ascertain what’s cooking.
Examples here are hepatitis
That is anicteric
And once again the UTI. And
Then there’s mesenteric
Adenitis that presents with
Pain that on the right is,
Similar to that found in
Acute appendicitis.
Binges                        Don’t forget that little kids are
Greedy little devils
And often bring up after being at
Birthday party revels.
Poisoning                   Now, to those children with a fixation that is oral,
                                   Here are some statements; each one with a moral:
The child that reaches for green peaches
Learns the lesson that this teaches.
Likewise she who chews dad’s pills
May go green about the gills.
Nausea and vomits follow
Kids who sundry poisons swallow.
Raised                        A group we must not fail to mention
ICPÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Have intracranial hypertension.
Infections, tumours – all may cause a
Puke with no preceding nausea.
So always probe for symptoms that
Point to trouble ‘neath the hat.
Headache, squint, a change in form, a
Fit, ataxia or head trauma.
Cyclical                      Now, cyclical vomiting. I’ll
vomiting                     Try to give you a notion of it:
A child who’s well will, like hell,
Suddenly, profusely vomit.
She may get so dry
She may need I
V for rehydration
Yet in a day or so
She’ll want to go
Back to school and her education.
She’s well again, as right as rain
Yet she will be back
Puking like a drain, sunken-eyed again
In the midst of another attack.
The reason why this happens
I wish I could explain
But we know the child may go
On to suffer from migraine.
The recurrent nature of these bouts,
The rude health in between
Should rule out most of your doubts
And keep tests to the routine.
Psycho-Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Some problems with the psyche
logical                        And certain states of mind
problems                    May make a child quite likely
To vomit be inclined.
A sight, a smell, excitement, joy,
The fear of a needle’s prick
May make a little girl or boy
Quite literally sick.
If an older child comes with vomiting
And the reason seems something of a poser
Just take note
Of the finger in the throat:
It’s a case of anorexia nervosa.
I’ll go on now we’ve been through
Causes and ages
And take a trip through all the
Clinical stages.
HISTORYÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â History first. We want to know
More about the vomiting so
Quantity                     We ask a few questions. Quantity first.
Is it enough to cause a thirst?
Does it dehydrate the child?
Is this major or only mild?
What proportion of each feed
Is returned and at what speed?
Character                   We’ve partly discussed this –
Projectile or posset?
Is it forceful or with ease
That she manages to toss it?
Contents                     And what’s in the stomach contents as they’re
Ejected or released?
Is it bile or blood or old food or what re-
mains of her last feast?
If blood, think first it’s swallowed
Eg. when a nipple cracks. This
Is like the older child who
Has an epistaxis.
But, as in older folk,
Vomiting blood may be no joke.
It may be from burst varices
Or bleeding peptic ulcer disease.
The presence of a green tint, bile,
Should make you think obstruction;
It may be paralytic il-
eus – needs drip and suction.
But it could be mechanical
Below ampulla of Vater
Where surgery is called for and
Medicine’s a non-starter.
Associated                  Nausea we’ve discussed. It’s
symptoms                   Presence is suggestive
Of trouble that relates to part
Of the tract digestive.
In its absence, don’t be dull —
Think of trouble in the skull.
Associated symptoms
You need to find to sew up
The underlying cause that
Makes a little child throw up.
Diarrhoea would suggest the
Cause is enteritis.
Fever, stiff neck, crying point to
Likely meningitis.
A little trick- if a child is sick
As each new day is dawning
She may be in the grip of a postnasal drip
With a gut full of snot every morning
EXAMINATIONÂ Â Â Â Â Examination. There are two
Questions to select:
One: what caused the vomiting? and
Two: what’s its effect?
Hydration                   Two first: Check the child for the de-
and                             gree of dehydration.
nutrition                      Is she still well nourished or
Showing emaciation?
A weak child may be short of
Ions: potassium, sodium, chloride
And may need their replacement intra-
venously supplied.
General                      Examination takes the form that
You’ve been taught so well:
All systems of the body may
Have a tale to tell.
Jaundice – that’s the liver;
Fever – that’s a bug;
Neonate, distension that could
Be meconium plug.
Abdomen                    The abdomen’s the focus of your
Int’rest like as not.
Can you palpate an organ?
Is there a tender spot?
Gaseous distension an
Obstruction would suggest
And peristalsis you can see will
Help you in your quest.
Don’t forget the rectal – it can
Help you when one sees
A low intussusception or per-
haps Hirschsprung’s disease.
Other                          Don’t ignore the ENT,
systems                       Otitis you may miss
But I can’t talk of everything in a
Paper such as this.
SPECIALÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Investigations are dictated very
TESTSÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Much by what you find
But here are some remarks which you
Ought to keep in mind.
Always test the urine; Acid–
Base if weak or dry
Along with the electrolytes which
May be low or high.
X-rays may be plain or contrast,
Use mainly in obstruction –
Barium can go in the top or by
Rectal introduction.
Ultrasound has got a place for
Seeking out of masses
That may cause copious vomiting in
Little lads and lasses.
These days its use for intussus-
ception or pyloric
Stenosis, GOR is nothing
Short of meteoric.
Other tests you order will re-
late to your conclusion
As to where you think the trouble is – of
These there’s a profusion.
But all in all our main help is
                                   Always to be found
                                   When hist’ry and examination
                                   Are complete and sound.
Now remember at the start
Of this great work of art
A sentence that I’d like you
To learn off by heart.
Open your eyes
And lift that drooping ptosis:
Vomiting’s a symptom and is
                                   NOT a diagnosis.
TREATMENTÂ Â Â Â Â Â Â Â Â So – Management is One: General (re-
plenish body stores
of fluid and electrolytes);
Two: Specific (treat the cause).
Just one more thing: resist the urge,
Though mother may be keen,
To stop the kiddy’s vomit with a
Phenothiazine,
For Stemetil or Valoid
Are toxic to a baby
Or child and could produce a
Dyskinesia maybe.
So treat the cause and you will win
And baby’ll keep her dinner in.
So ends this thesis
On childhood emesis.