Vomiting in Infants

Name: Vomiting in Infants - Pulse Reference
Published: 2022-08-01T18:17:27+00:00

Differential Diagnosis

URTI (Vomiting Secondary to Coughing)
Gastro-Oesophageal Reflux/GORD
Gastroenteritis
Any Acute Febrile Illness (e.g. Otitis Media, Tonsillitis, UTI, Meningitis, Pneumonia)
Cow’s Milk Protein Intolerance

Key distinguishing features of the most common diagnoses

	URTI	Gastro-Oesophageal Reflux/GORD	Gastroenteritis	Acute Febrile Illness	CMPI
Recurrent	No	Yes	No	No	Yes
Fever	Possible	No	Possible	Yes	No
Diarrhoea	Possible	No	Yes	Possible	Possible
Positional	No	Yes	No	No	No
Infant off Feeds	Possible	No	Yes	Yes	No

It is highly unlikely that the GP would arrange any investigations in this scenario. If the level of concern or diagnostic uncertainty is such that the child needs investigating, then it would need referral (usually urgently). Even if a UTI is suspected as the cause, then investigations in primary care become academic – if the child is unwell enough to be vomiting with a UTI, then it needs hospital assessment.

Take time to clarify the clinical picture. Many parents will describe florid vomiting when they actually mean retching after bouts of coughing. They also have a tendency to call many episodes of vomiting ‘projectile’, so take time to get them to describe what they mean.
In the acute situation, a precise diagnosis may be difficult and the consultation is more about whether observation or admission is required. Work through the most relevant issues systematically. Is the child dehydrated? Is this sepsis? Is it an acute abdomen? And, if all the above are negative, is the child ill enough to require admission anyway?
Bear in mind that gastro-oesophageal reflux and GORD are not the same thing. The former can be considered normal and self-limiting; the latter shares some features with simple reflux but also causes distress or other symptoms.
In ongoing vomiting in an otherwise well child, the likely diagnoses are feeding mismanagement, GORD or CMPI.

In the acutely ill child, use the NICE traffic light system and sepsis screens early in your assessment – if the child is seriously ill then it needs admission regardless of precise diagnosis.
Genuinely projectile vomiting in infants up to 2 or 3 months of age should be taken seriously – pyloric stenosis needs excluding.
Bile stained vomiting, particularly with abdominal swelling, suggests intestinal obstruction.
Beware the vomiting infant with screaming episodes associated with pallor – this could be intussusception.
Recurrent vomiting with failure to thrive requires a specialist opinion.
A bulging fontanelle, decreased responsiveness or rapidly increasing head circumference associated with vomiting suggests raised intracranial pressure – this needs urgent assessment.