Pediatric Vomiting/Diarrhea/Dehydration

Vomiting DDx by Age Group

Baby (1 mo – 1 yr)

Malrotation – Volvulus – NEC – Intestinal atresia – Incarcerated inguinal hernia – UTI – Intussusception – Inborn error – CAH – Tox – NAT – pyloric stenosis – sepsis

Toddler (1 – 2 yo)

Viral – DKA – UTI – Appy – Intussusception – Incarcerated inguinal hernia – Tox – NAT – Sepsis – Hirschsprung – Inborn error

Pre-school (3-5 yo)

Viral – Appy – Intussusception – UTI – DKA – Tox

School age (5 – 8 yo)

Viral – Appy – DKA – UTI – IBD

Pre-pubertal (8 – 12 yo)

Viral – Appy – DKA – UTI – IBD – pregnancy – ovarian/testicular torsion – Bulimia – Cholecystitis – Eosinophilic esophagitis – Constipation – Mass – Celiac

 

H&P

  • Feeding schedule (3 oz q 3h is good rough estimate of normal)
  • Gestational age at birth
  • Breast vs bottle fed
  • Head size (macrocephaly and hydrocephalus)
  • Hydration (fontanelle, eyes, MMM, tears, tachypnea, turgor)
  • GU exam (inguinal hernias)
  • Maybe rectal (if Hirschsprung concern)

 

HPI Red Flags

  • Vomiting alone
  • Bilious/Bloody emesis – bilious is an obstruction (e.g. malro, atresia) and surgical emergency
  • Fever
  • Projectile
  • H/o meconium delayed >48 hrs s/p birth
  • < 3 wet diapers/24h
  • AMS
  • H/o abdominal surgery

 

Diagnoses

NEC – < 2 wks

  • Vomiting, decreased feeds, +/- bloody stool and abdominal distention
  • Can occur in term babies too
  • Pneumatosis on AXR shows as railroad tracking along bowel wall

Pyloric stenosis – 2 wks-12 wks

  • Highest risk in males
  • If prolonged, hypochloremic, hypokalemic metabolic alkalosis
  • US very sensitive and specific if pylorus ≥15mm long, ≥3mm thick

Intussusception 3 mo-5 yrs

  • Colicky abdominal pain, AMS w/ or w/o abdo pain, maybe guaiaic pos stool
  • US has good sensitivity and specificity
  • Air enema for dx and tx

NAT – Pre-verbal children are high risk

  • Be vigilant
  • Abdominal XR can pick up fx

Incarcerated inguinal hernia

  • Increased risk in preemies
  • GU exam important

Inborn errors and CAH

  • If hypoglycemia, these should rise up on DDx
  • If inborn error suspected start w/u w/ UA, ketones, NH3 and lactate

 

Workup

  • CBG (especially if < 2 yo or any kind of AMS)
  • Ondansetron 0.1 mg/kg up to 4 mg
  • Start PO challenge 15 min after ondansetron
  • UA if: fever or hypoglycemia
  • Chem panel if: < 6 mo, projectile, hypoglycemia, AMS, severe course
  • AXR if: Bilious emesis
  • Consider US for appy, pyloric stenosis, intussusception etc.

 

Treatment

ORT

  • 5 ml aliquots of fluid q 2-5 minutes
  • Set parental expectations that meds help but do not eliminate vomiting

ORT for Loss Replacement

  • 2 cc/kg per emesis
  • 10 cc/kg per watery diarrhea
  • Calculate these into ounces for parents (30cc/1 oz)

1/2 Apple Juice and Preferred Fluids Better than Elyte Drinks (Effect of Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Fialure Among Children w/ Mild GE. Freedman et al. JAMA. 2016.)

  • Excluded kids < 6 mo and those w/ severe dehydration or significant comorobidities
  • Elyte drinks taste so bad, 60% of parents would rather their kids had an IV!
  • NNT of 12 to prevent combined outcome of ORT treatment failure
  • Most of difference was in kids > 2 yo who had developed taste preferences
  • Difference was not just in representation but also in need for IVF and maybe even hospitalization needed at the index ED visit

Peds IVF

Bolus NS/LR – 20 cc/kg

Maintenance D5NS – 4 ml/kg/hr – 1st 10 kg; 2 ml/kg/hr – 2nd 10 kg; 1 ml/kg/hr – >20 kg