• Vomiting for less than two weeks
• Corroborating findings of infectious cause
• Responsive to therapy for gasto-oesophageal reflux
• No associated worrying features




• Vomiting for less than two weeks
• No corroborating findings of infectious cause
• Unresponsive to reflux therapy
• Any worrying features


Observe and review two weeks after vomiting onset Repeat history and examination


• 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


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.


  • • 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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