Nausea and vomiting are very common symptoms in the pediatric population. Whether presenting in the emergency department or in an outpatient clinic, they are a frequent reason for parents and caregivers to seek medical attention.
Nausea is the subjective unpleasant sensation of imminent vomiting. It is frequently accompanied by autonomic symptoms such as dizziness, pallor, and sweating.
According to the Rome foundation, chronic nausea is defined as bothersome nausea occurring several times per week, not usually associated with vomiting, in the absence of endoscopic or metabolic disease. These criteria must be fulfilled for the last 3 months, with the symptom onset at least 6 months prior to diagnosis. In the latest Rome IV consensus, a specific definition of chronic nausea for young children or adolescents was not included.
Nausea is not always followed by vomiting, as in conditions such as chronic functional nausea, postural nausea, and functional dyspepsia.
Vomiting is defined as the vigorous oral expulsion of the gastric or intestinal contents associated with increased intra-abdominal pressure. Oral regurgitation refers to the effortless, usually postprandial, emesis of food content.
Vomiting is usually preceded by nausea; the only exceptions are rumination syndrome, in which oral regurgitation is not preceded by nausea, and possibly gastroesophageal reflux disease.
There are various established mechanisms that are known to cause nausea and vomiting, including:
Stimulation of chemoreceptors situated in the area postrema (medullary structure located in the fourth ventricle of the brain)
Movement-induced stimulation of the labyrinth
Irritation or over-distension of the mechanically sensitive vagal afferents in the gastrointestinal tract.
The etiology of nausea and vomiting is often age-dependent, with a wide spectrum of gastrointestinal, nongastrointestinal, and environmental causes, including:
Inflammatory changes causing infection of the gastrointestinal system or other body systems
Anatomical abnormalities resulting in bowel obstruction
Functional disorders or malignancy of the gastrointestinal tract
Neurologic causes, which can be one of the most ominous causes, particularly in the presence of increased intracranial hypertension or central nervous system infection
Metabolic or endocrine abnormalities such as diabetic ketoacidosis, adrenal insufficiency, and protein or carbohydrate metabolism disorders
Urologic/gynecologic or renal causes such as gonadal torsion
Renal causes such as hemolytic uremic syndrome and nephrolithiasis
Psychiatric causes such as eating disorders, rumination, or factitious disorder
Environmental causes such as toxic ingestions and adverse effects associated with the use of medications or illicit drugs.
A complete history and meticulous physical examination is essential and provides the clues for appropriate diagnosis and management. Diagnostic testing should be directed by the clinical picture.
Urgent considerations, particularly neurologic compromise, need to be addressed first and may prompt more immediate therapeutic management. Red-flag symptoms that may require urgent management include: lethargy, fever, volume depletion, weight loss, bilious vomiting, hematemesis, papilledema, abdominal tenderness, or the presence of a mass.
- Viral gastroenteritis
- Bacterial gastroenteritis
- Motion/travel sickness
- Concussion (mild traumatic brain injury)
- Brain tumor
- Pyloric stenosis
- Intestinal malrotation
- Small bowel atresia
- Diabetic ketoacidosis
- Gastroesophageal reflux disease (GERD)
- Cyclic vomiting
- Functional dyspepsia
- Testicular torsion
- Urinary tract infection
- Peptic ulcer disease
- Acute appendicitis
- Acute pancreatitis
- Hepatitis A
- Lactose intolerance
- Food allergy
- Eosinophilic disease
- Bulimia nervosa
- Toxic ingestion
- Medication adverse effects
- Benign paroxysmal positional vertigo
- Pseudotumor cerebri (benign intracranial hypertension)
- Superior mesenteric artery syndrome
- Addison disease
- Congenital adrenal hyperplasia
- Protein metabolism disorders
- Carbohydrate metabolism disorders
- Postural orthostatic tachycardia
- Hirschsprung disease
- Ovarian torsion
- Hemolytic uremic syndrome
- Ureteropelvic junction obstruction
- Small bowel lymphoma
- Factitious disorder
- Cannabis hyperemesis syndrome
- Otitis media
John E. Fortunato, MD
Professor of Pediatrics
Neurointestinal and Motility Program Director
Ann & Robert H. Lurie Children’s Hospital of Chicago
JEF is on the advisory board (non-compensated) for the Gastroparesis Patient Association for Cures and Treatments (G-PACT).
Dr John E. Fortunato would like to gratefully acknowledge Dr Mary K. Rogers Boruta and Dr Roberto A. Gomez-Suarez, previous contributors to this topic. MKRB is a consultant for Medspira on pediatric integration for anorectal manometry by assisting with training providers on device use, for which she receives no compensation. There is no contractual agreement to disseminate product information. RAG-S declares that he has no competing interests.
David A. Bergman, MD
Division of General Pediatrics
Stanford School of Medicine
DAB declares that he has no competing interests.
Prateek D. Wali, MD
Golisano Children's Hospital
Upstate Medical University
PDW declares that he has no competing interests.
Alistair G. Sutcliffe, MB ChB, MD, PhD, FRCP, FRCPCH, PG DIP CT
Reader in General Paediatrics
Honorary Consultant Paediatrician
University College London Hospitals and Great Ormond Street Hospitals
Institute of Child Health
University College London
AGS is developing a project on the use of an antiemesis drug for gastroenteritis but has no other connection with the topic per se.
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