Persistent / Recurrent vomiting
Reassure
- 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
- Persistent vomiting with one or more other symptoms that may occur with a brain tumour
Action
Refer for an MRI scan
Diagnostic Pitfalls
- Vomiting is attributed to an infective cause without corroborating 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
- Assess hydration and need for oral or intravenous hydration
- 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
- Gorlins Syndrome
- Other familial genetic syndromes
- 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)