Nausea and Vomiting in Childhood and Pregnancy

Responding to Symptoms: Gastrointestinal Problems - Nausea & Vomiting

• Nausea is a symptom of feeling near to vomiting.
• Vomiting is the process where stomach contents are expelled through the mouth.
• Retching is an effort to vomit, but nothing is expelled.
• Regurgitation is the return of swallowed food back up the oesophagus.
• Reflux is the return of stomach acid back up the oesophagus.

Other Symptoms

• Sweating and cold sweats.
• Increased saliva production.
• Headaches.
• Feeling cold.
• Going pale (pallor).
• Feeling weak.

Nausea & Vomiting - Epidemiology

• Nausea and vomiting is common, especially in childhood.
• Any age group can be affected.
• Nausea and vomiting can be symptoms of other conditions.
• Epidemiology might thus be determined by the condition.
• Gastroenteritis is the most common cause.
• Norovirus is the most common cause of gastroenteritis, (50%).
• Rotavirus is a common cause in children (20%).
• Adenovirus and Astrovirus can also cause gastroenteritis.

Nausea & Vomiting - Aetiology

• The chemoreceptor trigger zone (CTZ) in the brain is stimulated by toxic substances.
• The CTZ stimulates chemoreceptors.
• The vomiting centre in the brainstem receives nerve signals from the CTZ and other pathways (such as the gut and liver).
• The vomiting centre sends impulses to the pharynx, larynx, and gut, causing nausea and vomiting with other symptoms.

Nausea & Vomiting - Causes

• Gastrointestinal causes include food poisoning, acute appendicitis, gastroesophageal reflux disease (GORD), blockages, and overindulgence.
• Metabolic causes include diabetic ketoacidosis, and hypercalcaemia.
• Neurological causes include head injury, meningitis, migraines, pain, and stress.
• Ear disorders like labyrinthitis and infections.
• Drug and chemical exposure (e.g., chemotherapy).
• Post-operative effects (e.g., general anesthetic).
• Psychiatric disorders like bulimia nervosa.
• Pregnancy.
• Movement (e.g., motion sickness).

Pregnancy

• Nausea and vomiting usually starts between weeks 4-7 of pregnancy.
• It typically peaks between weeks 9-16 and resolves between weeks 16-20.
• “Morning sickness” is a misnomer, since nausea and vomiting can occur at any time of the day.
• Hyperemesis gravidarum is a more severe form of morning sickness.

Pregnancy - Causes

• Human chorionic gonadotropin (hCG) -originating from the placenta- and high oestrogen levels.
• Evolution of increasing hormone levels.
• The prevention of eating harmful foods.
• Gastric dysfunction.
• Increased progesterone levels lead to smooth muscle relaxation, this impairs the small bowel motility, leads to delayed gastric emptying.
• It is often multifactorial, with various factors involved.

Motion Sickness

• Motion sickness is caused by repeated movements.
• Examples are: going over bumps in a car, moving up and down in a boat or aeroplane, train rides, or going in circles.
• Inner ear sends different signals to the brain than those the eyes see/perception.
• This confusion causes nausea.
• It can affect everyone but is more common in children and women.
• Nausea may continue post-motion, sometimes called "mal de debarquement".

N & V - Questions & Relevance - Age

• Common in children.
• Refer under 1 year.
• Risk of dehydration in very young and very old.
• Refer to a medical professional if needed

N & V - Questions & Relevance - Onset

• Gastroenteritis - within 48 hours of eating contaminated food, some cases appear within hours.

N & V - Questions & Relevance - Time

• Early morning (pregnancy).
• Immediately after eating (gastritis).
• 1-2 hours after eating (gastroenteritis, peptic ulcer).

N & V - Questions & Relevance - Other Symptoms

• Viral infection (presence of blood in vomit).
• Middle ear (tinnitus/dizziness).
• Migraine (headache/aura).

Referral

• Symptoms suggesting a heart attack (chest pain, radiating pain, shortness of breath) accompanying nausea and vomiting warrant referral.
• Pregnancy-related nausea (hyperemesis gravidarum)
• Suspected GI bleed (blood in vomit).
• Bilious vomiting (dark green vomit - possible GI obstruction, appendicitis).
• Severe dehydration
• Possible secondary cause (e.g., head injury, sepsis, eating disorder).

Vomiting - Treatment

• Not much can be done once vomiting has started.
• Stay hydrated.
• Rehydration therapy may be needed.
• Treatment depends on the cause.
• Anti-emetics potentially harmful if cause is unknown).
• Over-the-counter medications (e.g., Pepto-Bismol, aspirin-like salicylates).
• Prokinetic medications (POMS).

Anti-emetics

• Prochlorperazine (dopamine antagonist, phenothiazine).
• Buccal tabs only in cases related to migraine.
• Can be prescribed in other cases.

Anti-emetics - Motion Sickness

• Prophylaxis (e.g., Hyoscine, which is an anti-muscarinic agent with central and peripheral actions.

• Available as patches or tablets for motion sickness.

• Often a sedative effect, ADR's need consideration.

• Alternative sedative antihistamines are: -Cinnarizine (e.g., Stugeron®) -Promethazine (e.g., Phenergen®)

  • Cyclizine - slightly less effective than hyoscine, better tolerated.

Practical Measures (Nausea)

• What to do: Fresh air, distractions (music, TV), regular sips of cold drinks, ginger or peppermint tea, ginger foods, smaller more frequent meals, avoid strong smells.
• What not to do: Eat or cook strong-smelling food, hot, fried, greasy food, eat too quickly, have a large drink or meal, lie down immediately after meals, tight clothes.

N & V - Treatment - Motion Sickness - Prevention

• Strategies for motion sickness include sitting in the front of the car or in the middle of the boat, not reading or watching a film, looking at a fixed point ahead on the horizon, closing your eyes, sleeping, and breathing slowly.
• Other strategies are focusing on breathing, being in the fresh air (open window), avoid heavy meals or alcohol, avoid long journeys, get fresh air/drink water/walk, take anti-emetics, try acupressure or ginger.

N & V - Treatment - Pregnancy

• Strategies for pregnancy-related nausea and vomiting include rest and frequent, small meals that include bland, protein-rich foods that are low in carbohydrates and fat.
• Avoid caffeine, alcohol and foods/smells that trigger nausea.
• Try ginger, acupressure devices and other therapies as appropriate, as first-line treatments.
• Refer if necessary.

Explore the key factors and physiological mechanisms behind nausea and vomiting, particularly in children and pregnant women. This quiz covers common triggers, symptoms, and medical considerations related to this condition. Test your knowledge on the underlying causes and related risks associated with nausea and vomiting.