Vomiting

Dear Lisa,

My 3 year old niece complains of her tummy burning then she vomits up white foamy looking stuff. My sister took her to the Dr. they put her on Pepcid but the problem continues. HELP!!!!

“Auntie”

Dear “Auntie”,

In order to treat vomiting it is necessary to know the underlying cause. Since there are so many possible causes of vomiting in a three year old child the treatment can vary from case to case. Unfortunately, vomiting is a symptom that can be found in many disorders ranging from something as simple as a virus to diseases that are quite serious such as central nervous system disorders. In deciphering the cause of a child’s vomiting it is important to know the length of time that the vomiting has been occurring and any associated symptoms. (1)

The most common cause of acute vomiting in young children is a Viral infection of the gastrointestinal tract. (1) Viral Gastroenteritis is usually associated with diarrhea and a low-grade fever. Viral Gastroenteritis can be complicated by dehydration; therefore any child with prolonged symptoms needs to follow up by their Physician.

Some children with Viral Gastroenteritis symptoms may actually have a Urinary Tract Infection. Children typically do not display the classic symptoms of a Urinary Tract Infection the same way that adults do. Instead of complaining about pain or burning with urination, a child with a Urinary Tract Infection can present with vomiting, diarrhea, fever and abdominal pain.(1) Therefore a child with persistent vomiting may need to be tested for a Urinary Tract Infection.

Another gastrointestinal cause for vomiting is a parasitic infection. Parasitic infections found in the pediatric population include; giardiasis, amebiasis, ascariasis and hookworm. Other symptoms of a parasite include poor weight gain, abdominal pain and bloody diarrhea.

Infections outside of the gastrointestinal tract can also cause vomiting. Children with respiratory tract infections many times have vomiting. (1) Young children frequently complain of a “belly ache” when they really have pain in their chest. This occurs because their stomach and their chest are in such close proximity that they are not able to differentiate between the two.

In other cases children cannot adequately localize and verbally describe pain.
Many of the children that I took care of with vomiting and abdominal pain actually had Pneumonia or Asthma. It is important to consider a respiratory condition such as Asthma, Pneumonia, Bronchiolitis or Bronchitis in a child with persistent abdominal pain, vomiting or fever. Upper Respiratory Tract infections can cause vomiting when a child has post nasal drip and swallows their mucus.(1) Otitis Media or an inner ear infection is also a common cause of vomiting. (1,2)

Infections of the abdominal organs usually begin with vomiting along with a decrease in appetite and progresses to severe abdominal pain. Appendicitis begins with nausea, vomiting, low grade fever and pain around the belly button area. As inflammation of the appendix progresses the pain shifts to the right lower quadrant of the abdomen.(1) Hepatitis is an infection of the liver that also presents with vomiting. Children with Hepatitis develop jaundice in addition to nausea, vomiting and right upper quadrant tenderness.

Vomiting due to Central Nervous System disorders is often forceful and not necessarily preceded with nausea. Any process that causes irritation of the central nervous system may cause hypersensitivity of the vomiting center and lead to vomiting. A child with Meningitis often has vomiting, irritability and lethargy before they develop meningeal signs such as a stiff neck. (1) Children with Metabolic Disorders may present with similar symptoms. The vomiting in a child with a Metabolic Disorder is usually forceful and persistent. In this case the symptoms typically progress to lethargy, seizures and coma.(1)

Another common cause of vomiting in children is Cyclic Vomiting. Cyclic Vomiting is recurrent episodes of severe vomiting with intervals of wellness in between.(3) Children with cyclic vomiting tend to vomit many times per hour during an attack. The attack frequency is approximately every 2 to 4 weeks and the duration of the attacks last about 24 to 40 hours.(3) Cyclic vomiting is an early childhood form of migraine which may evolve into abdominal migraine and later into the typical adult-type migraines.(3)

As you see, the list goes on and on and the conditions associated with vomiting are numerous. This is not intended to scare you, or make you think that your niece is suffering from all of these conditions. Instead it is meant to show you the importance of close follow-up with a physician when a child’s vomiting is persistent. Follow-up appointments are necessary in order to monitor for complications and to rule out underlying disorders when needed.

In regards to your niece’s medication, Pepcid is frequently prescribed for children with GI symptoms such as heartburn and vomiting. Pepcid is an H2 receptor antagonist which decreases the acid secretion in the stomach. (4) It relieves heartburn associated with acid indigestion and sour stomach (5) The medication should be taken one hour prior to or two hours after eating for maximal effectiveness.(4) Acid Suppressants such as Pepcid are also commonly prescribed for children with Gastroesophageal Reflux (GER). (6)

If your niece is receiving the Pepcid as recommended and is still experiencing symptoms, she may need an adjustment in her dosage. In some cases the addition or change of medication may be necessary. Children with GER many times need their acid suppressant therapy increased or changed in order to better control their symptoms. In some cases a Proton Pump Inhibitor is recommended when an H2 receptor antagonist fails. (6) This class of medication is preferred because clinical trials have demonstrated the superiority of Proton Pump inhibitors when compared with H2 Receptor antagonist in treating GERD symptoms.(6)

Concerning symptoms include bilious vomiting (foamy greenish vomiting), abdominal pain, abdominal distention, fever, weight loss, yellow eyes, diarrhea or signs of dehydration. If your niece develops any of these symptoms along with her vomiting a visit to her Doctor would be needed in a timely manner.

For more information about topics discusses read other Pediatric Advice Stories:

Gastroesophageal Reflux

Toddler with Yellow Skin

Vomiting

Vomiting and Weight Loss

Gastroenteritis

I hope your niece is feeling better soon.

References:
(1)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:352-353.
(2)Alper B, Fox G. Acute Otitis Media. The Clinical Advisor. 2005. April:78-86.
(3)Lewis D, Pearlman E. The Migraine Variants. Pediatric Annals. 2005. 34(6):486-500.
(4)Schwartz R, Guthrie K. GERD: the lessons my new grandchild taught me. Infectious Diseases in Children. 2006. April:14.
(5) Physician’s Desk Reference. 2004. Montville, NJ. Thomson PDR at Montville:1781.
(6)Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006. 35(4):259-266.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Keeping Kids Healthy