Concerning signs | Comments or diagnostic considerations |
Nonspecific symptoms |
Prolonged vomiting - >12 hours in a neonate
- >24 hours in children <2 years
- >48 hours in older children
| - Concerns for fluid and electrolyte abnormalities
- Increased possibility of underlying systemic or metabolic disorder
|
Profound lethargy | - Increased possibility of an underlying systemic or metabolic disorder
|
Significant weight loss | - Increased possibility of an underlying systemic or metabolic disorder
|
Symptoms of gastrointestinal obstruction or disease |
Bilious vomiting | - Intestinal obstruction, especially in a neonate
|
Projectile vomiting | - Pyloric stenosis in a young infant (<12 weeks of age)
- Intestinal obstruction, cyclic vomiting syndrome
|
Hematemesis | - Severe hematemesis suggests esophageal varices
- Milder hematemesis may be due to injury to the esophagus (Mallory-Weiss tear) or stomach (prolapse gastropathy), due to recurrent vomiting
|
Hematochezia | - Intussusception (especially in infants and toddlers), infectious colitis, or IBD
|
Marked abdominal distension, peritoneal signs | - Intestinal obstruction or intra-abdominal process (eg, appendicitis)
|
Symptoms or signs suggesting neurologic or systemic disease |
Bulging fontanelle (infant) | - Hydrocephalus or meningitis
|
Headache, positional triggers for vomiting or vomiting on awakening, lack of nausea | - Increased intracranial pressure (eg, CNS mass, hydrocephalus, or idiopathic intracranial hypertension)
|
Altered consciousness, seizures, or focal neurologic abnormalities | - Toxic ingestion, diabetic ketoacidosis, CNS mass, or inborn error of metabolism
|
History or physical signs of trauma | - Subdural hematoma or intra-abdominal injury (eg, duodenal hematoma)
|
Hypotension disproportionate to apparent illness and/or hyponatremia with hyperkalemia | |