• Vomiting for less than two weeks
• Corroborating findings of infectious cause
• Responsive to therapy for gasto-oesophageal reflux
• No associated worrying features
Action
Reassure
Review/refer
• Vomiting for less than two weeks
• No corroborating findings of infectious cause
• Unresponsive to reflux therapy
• Any worrying features
Action
Observe and review two weeks after vomiting onset
Repeat history and examination
Scan
• Persistent (occurring on most days over a two week period) vomiting
• No corroborating findings of infectious cause
• Unresponsive to therapy for gasto-oesophageal reflux
• Any worrying features
Action
Refer for an MRI scan
Diagnostic pitfalls
• Vomiting is attributed to an infective cause without supportive findings e.g fever, diarrhoea or contact with others with recent similar symptoms.
• Head circumference has not been monitored in a baby with persistent vomiting, where the vomiting was due to raised intracranial pressure.
Examination/assessment
• Determine duration and characteristics of nausea and vomiting.
• Ask specifically about associated symptoms and risk factors:
• Personal or family history of a brain tumour
• Leukaemia
• Sarcoma and early onset breast or bowel cancer prior therapeutic CNS irritation
• Neurofibromatosis types 1 and 2
• Tuberous Sclerosis
• Li Fraumeni Syndrome
• Family history of colorectal polyposis
• Assess hydration and need for oral or intravenous hydration.
• Neurological examination (include assessment of vision (including acuity), gait and coordination)
• Plot growth in all children and pubertal status if applicable
• Plot head circumference in children under two
Worrying features
• Vomiting that wakes a child/young person from sleep or occurs on waking
• Vomiting that is worse in the morning (exclude pregnancy where appropriate)
• Vomiting with a headache
• Vomiting with an increasing head circumference (crossing centiles)
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