Children in the sensorimotor stage (birth 2 years of age) experience the world and

act through sensations and motor acts. They are developing the concepts of object
permanence, causality, and spatial relationships. Children in the preoperational
stage (2 6 years)

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Birth to 6 Months Examination of children of this age is usually pleasant. Although
verbal interaction is limited, it is important to play with children, hold them, and talk
to them. By watching physicians interact with their children, new parents have an
opportunity to learn how to behave with their infants. Infants have not yet
developed a fear of strangers and can usually be easily examined either in parents
arms or on the examination table.

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Birth to 6 Months Examination of children of this age is usually pleasant. Although
verbal interaction is limited, it is important to play with children, hold them, and talk
to them. By watching physicians interact with their children, new parents have an
opportunity to learn how to behave with their infants. Infants have not yet
developed a fear of strangers and can usually be easily examined either in parents
arms or on the examination table.

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Techniques The Interview Open-ended questions Closed-ended questions Repetition

of important phrases Clarification Pauses and silent periods Limit medical jargon
Guide the interview Be aware of nonverbal communication Acknowledge parental
concerns Empathize Remember common courtesies Recognize personal limitations
Summarize The Physical Examination Show consideration for the child Inform
Explain procedures Avoid exclamations Concluding Remarks Provide closure
Minimize discharge instructions Be specific Praise Confirm parental understanding
Table 5-1. Communication Guidelines and Techniques Examples How is Susie?
Does she have a cough? She has had a high fever for four days now? What do
you mean by Susie was acting funny? Susie has an ear infection. vs Susie has
otitis media. Right now I am most interested in hearing about the symptoms of
this illness. Use eye contact and phrases such as I see. Worrying about hearing
loss is understandable. A fever of 104F can be very frightening. Knock before
entering. I am not an expert in this area. I would like to consult with a colleague.
So she has had fever for four days but the rash and cough began one week ago?
Its OK to be afraid. That took me some time, but her heart sounds normal. You
may feel a little uncomfortable during the rectal examination. Wow! I have never
seen anything like this. Our time is over today. May we discuss this at the next
visit? I am going to treat her with amoxicillin. vs Ill prescribe an antibiotic.
Youre doing a great job. Please repeat for me Susies diagnosis and treatment
instructions so Im sure Ive been clear in explaining them to you. follow 4
principles (Table 5-2). Operationally, open-ended questions (eg, How do you feel
about smoking?), affirmations (eg, You are tired of having to monitor your blood
sugar every day and stick to your diet.), and reflective listening (eg, You are
worried about your daughters behavior and are concerned that if it persists, she
may be expelled from school.) are important tools of MI. In addition, MI
practitioners ask permission before giving advice (eg. Would it be OK if I shared
some information with you?), or the practitioner may state the facts but let the
parent interpret the information (eg, What does this mean to you?). Motivational
interviewing is not only effective with adults, but research with adolescents has
shown MI to be an effective tool to increase self-efficacy to enact change (eg,
adolescent smoking cessation). The Physical Examination Parents keenly observe
physicians interactions with their children during the examination. It is an
important time for physicians to Table 5-2. Principles of Motivational Interviewing
Principle Example Express empathy. Use reflective listening. Develop discrepancy
between Patient, not practitioner, presents patients current behavior and his
arguments for change. treatment goal. Roll with the patients resistance. Support
the patients self-efficacy. a a Avoid arguing for change. Patients own belief in the
possibility

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A 6-week-old male infant who has been vomiting after each meal for 3 days is
brought to the office. He is breastfed, afebrile, and otherwise well. The history of the
pregnancy and birth are normal. His birth weight was 3,500 g, and his current
weight is 4,500 g. The physical examination is unremarkable. The mother nurses
the infant in the office. Although he feeds hungrily and well, he vomits about 5
minutes after the feeding. The vomiting is projectile, and the vomitus shoots across
the room. The vomitus contains curdled milk. On reexamination of the abdomen, a
small mass is felt in the right upper quadrant.

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Vomiting is a common complaint of infants and children, and led Thomas Phaire to
write, Many times the stomake of ye child is so feble that it cannot retayne eyther
meate or drynke ( The Boke of Chyldren , 1553). Vomiting is defined as the forceful
ejection of the stomach contents through the mouth. The mechanism involves a
series of complex, neurologically coordinated events under the control of the
central nervous system (CNS). In contrast, regurgi tation is the effortless bringing up
of 1 or 2 mouthfuls of food without distress or discomfort. This is a frequent
symptom of gastroesophageal reflux in infants (see Chapter 108). Rumination, a
form of autostimulation, is the voluntary induction of regurgitation. It is most often
noted in infants between the ages of 3 and 6 months. Rumination occurs in infants
with developmental retardation or with a disturbed mother infant relationship. It is
said that affected infants always smell like vomitus, which is on the clothing, but
that the vomiting is rarely seen because the presence of another person provides
distraction. Rumination should be considered in infants from deprived environments
(eg, neglectful homes). Cases of rumination have been described in premature
infants who were maintained in a neonatal intensive care unit after they no longer
needed vigilant care from the nursing staff. Incubators, which were cut off from the
outside environment, contributed to the isolation and subsequent rumination. The
condition resolved once the infants were held and nurtured. Epidemiology Fifty
percent of infants have spitting up or vomiting as an isolated complaint and less
than 5% of these infants have significant underlying disease. Vomiting occurs less
frequently in older children, who often experience acute, self-limited illnesses, such
as gastroenteritis. Clinical Presentation Infants and children may present with

vomiting as an isolated complaint or in association with other symptoms, including

faintness, diaphoresis, sweating, pallor, tachycardia, fever, anorexia, abdominal
pain, or diarrhea (Dx Box). When vomiting has persisted over a period, weight loss
or failure to thrive (FTT) may occur. Neurologic symptoms, including headache and
gait disturbances, may be noted in children with CNS problems. Other neurologic
symptoms of altered muscle tone, lethargy, seizures, or coma in young infants
suggest inborn errors of metabolism. Dx Vomiting Vomiting Nausea
Abdominal pain Anorexia Diarrhea Headache Fever Lethargy Pathophysiology
Vomiting is a reflex reaction that occurs in response to numerous stimuli: enteric
infections, toxins, drugs, chemotherapy, radiation, etc. The final common pathway
involves expulsion of food from the relaxed stomach into the mouth due to
coordinated contraction of the abdominal wall, respiratory muscles, increased intraabdominal 679
and thoracic pressure, and relaxation of the lower and upper esophageal sphincters.
Anything that delays gastric emptying may be associated with vomiting. Gastric
emptying may be retarded by a high-fat meal, swallowed mucus (eg, maternal
mucus after birth, nasal mucus with an upper respiratory infection), fever, infection,
and malnutrition. Delayed gastric emptying may develop with long-standing
diabetes mellitus. Vomiting can be divided into 3 phases: nausea, retching, and
emesis. However, nausea may occur without retching and vomiting, and retching
may occur without vomiting. Nausea is a significant and difficult to define
discomfort related to the sensation of a need to vomit. It can be produced by
various stimuli (eg, bacterial toxins, drugs, intestinal distention, visceral pain,
unpleasant memories, labyrinthine stimulation, noxious odors, visual stimulations,
unpleasant taste, and increased cerebral pressure). Peripheral receptors in the
stomach and the small and large intestines detect emetic stimuli; distention and
contracrecognized tions are by mechanoreceptors and toxins are sensed by
chemoreceptors. Emetic stimuli may also originate from the obstructed or inflamed
bile ducts, peritoneal inflammation, mesenteric vascular occlusion, the pharynx, and
the heart. Vagal pathways mediate emetic responses to a variety of peripheral
stimuli. Most afferent vagal fibers project to the nucleus tractus solitarius and some
to the area of postrema or the dorsal vagal motor nucleus. The serotonergic
pathway plays the central role in nausea induced by peripheral stimuli. The area
postrema on the dorsal surface of the medulla close to the fourth ventricle is
considered the chemoreceptor trigger zone to a variety of neurochemical stimuli.
Bacterial toxins, drugs, toxic products of metabolic disorders, and radiation therapy
may induce nausea by stimulation of numerous central receptors: dopamine D 2 ,
muscarinic M 1 , histaminergic H 1 , serotonergic 5-HT3, and vasopressinergic
subtypes located in the area postrema. However, afferent excitation of multiple
brain sites, including nucleus tractus solitarius, the dorsal vagal and phrenic nuclei,
the medullary nuclei controlling respiration, the hypothalamus, and the amygdala, is
responsible for coordinated activities of various organs and muscles and the
induction of retching and emesis. Retching is the second phase of vomiting. It is

produced by concurrent contractions of inspiratory thoracic, diaphragmatic, and

abdominal muscles against the closed glottis. The generated high positive intraabdominal pressure forces gastric contents into the esophagus and herniates the
gastric cardia into the thorax. At this phase, the high negative thoracic pressure
prevents emesis of gastric fluids. Emesis is the final stage of vomiting. Synchronous
contractions of the inspiratory and expiratory muscles generate high positive
intrathoracic pressure sufficient to produce expulsion of gastric contents into the
mouth. Oral propulsion of the vomitus is facilitated by the elevation of the hyoid
bone and larynx. Airways are protected from aspiration by glottis closure. Elevation
of the soft palate prevents passage of the vomitus into the nasal cavities.
Hyperventilation may occur before emesis. During vomiting, breathing is
suppressed. With emesis, retrograde giant contractions originate from the middle of
the small intestine. Intestinal contents move into the stomach causing enterogastric
reflux. Within the stomach, the fundus remains flaccid, but the antrum and pylorus
contract. Relaxation of the lower esophageal sphincter also occurs. In children with
pyloric stenosis, enterogastric reflux is prevented by hypertrophy of the pylorus.
Projectile vomiting is facilitated by giant, often-visible contraction of the antrum and
relaxation of the proximal stomach and low esophageal sphincter. Nausea is not
associated with vomiting related to pyloric stenosis, and affected infants are
frequently eager to eat immediately after vomiting. Vomiting induced by increased
intracranial pressure (ICP) is also not associated with nausea. In addition, such
vomiting frequently occurs first thing in the morning on awakening and on an empty
stomach. Regurgitation is a return of undigested food back up the esophagus to the
mouth without the force and displeasure associated with vomiting. It could be
manifested by visible spitting up after feeding or could be silent. Clinical evidence of
regurgitation is not always associated with gastroesophageal reflux disease (GERD).
Differential Diagnosis Vomiting could be a manifestation of gastrointestinal (GI),
renal, metabolic, allergic, and CNS disorders. Some of them respond to medical
management, and others mandate surgical intervention (Box 107-1). The presence
of bile in the vomitus, referred to as bilious vomiting, is a serious sign, usually
indicative of intestinal obstruction distal to the major duodenal papilla and of the
need for surgical intervention. Bilious vomiting can also occur in children with
pseudo-obstruction syndrome or acute pancreatitis and other conditions leading to
paralytic ileus. The presence of blood in the vomitus is another ominous sign and is
discussed in Chapter 109. The most common cause of vomiting is acute viral or
bacterial gastroenteritis. Acute gastroenteritis is discussed in greater detail Box
107-1. Differential Diagnosis of Vomiting in Infancy Medical Conditions
Gastroenteritis Ingestion of maternal blood or mucus Overfeeding Food
allergies Parenteral infections (eg, otitis media, urinary tract infection)

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Conditions Atresia/stenosis of gastro intestinal tract Pyloric stenosis Ulcers
Inborn errors of metabolism Congenital adrenal hyperplasia

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