1 yr old with fever vomiting differentials ?

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Based on my textbook searches, here is a structured answer on differentials for a 1-year-old with fever and vomiting.

Differentials: 1-Year-Old with Fever + Vomiting

A 1-year-old (toddler) presenting with fever and vomiting is a common but potentially serious clinical scenario. The differential is broad and must be organized systematically - never assume the cause is benign until dangerous causes are excluded.

URGENT / MUST-NOT-MISS (Red Flag Diagnoses)

Diagnosis	Key Features
Bacterial Meningitis	Fever, vomiting, irritability, bulging fontanelle (may still be open at 12 months), photophobia, neck stiffness (often absent in infants). Between 1 month and 3 years, fever, irritability, and vomiting are the most common signs.
Intussusception	Episodic colicky crying, drawing up of knees, current-jelly stool, palpable sausage-shaped mass. Peak age 3 months - 3 years. Vomiting + intermittent pain is classic.
Meningococcal Sepsis	Fever, vomiting, non-blanching petechial/purpuric rash, rapid deterioration.
Urinary Tract Infection (UTI)	One of the most common hidden causes at this age - fever often the only sign; vomiting and poor feeding frequently accompany it.
Encephalitis	Fever, altered consciousness, seizures, vomiting.
Raised Intracranial Pressure / Hydrocephalus	Vomiting (often projectile), bulging fontanelle, sunsetting eyes, seizures. - Adams & Victor's Neurology

COMMON INFECTIOUS CAUSES

Diagnosis	Key Features
Viral Gastroenteritis (Rotavirus, Norovirus, Adenovirus)	Most common cause at this age. Diarrhea typically accompanies fever + vomiting. Day-care exposure is a clue.
Otitis Media	Ear pulling, irritability, decreased hearing. Fever and vomiting common at this age.
Tonsillitis / Pharyngitis	Throat erythema, refusal to eat, drooling.
Pneumonia	Fever, tachypnea, recessions, grunting. Vomiting may be the presenting symptom.
Sepsis	Any source. Tachycardia, poor perfusion, capillary refill >2 sec.

IMPORTANT MIMICS

Diagnosis	Key Features
Kawasaki Disease	Fever >5 days, conjunctival injection, strawberry tongue, rash, swollen hands/feet, lymphadenopathy. Can present with vomiting and abdominal pain mimicking a surgical abdomen. CSF pleocytosis can mimic viral meningitis. - Rosen's Emergency Medicine
Pyloric Stenosis	Typically presents at 2-8 weeks but late presentations possible; projectile non-bilious vomiting.
Diabetic Ketoacidosis (DKA)	Rare at 1 year but possible (new-onset T1DM). Vomiting, dehydration, Kussmaul breathing.
Intoxication / Ingestion	At 1 year, toddlers explore and ingest household substances.

LESS COMMON BUT IMPORTANT

Appendicitis - rare under 2 years but high mortality when it occurs (often perforated)
Volvulus / Malrotation - bilious vomiting, abdominal distension
Henoch-Schonlein Purpura (IgA Vasculitis) - purpura, arthritis, abdominal pain
Febrile Seizure - post-ictal vomiting in a febrile child
Reye Syndrome - rare; ASA use history

Approach in ED

Vitals + Triage severity - temperature, HR, RR, SpO2, capillary refill
Assess hydration - sunken fontanelle, eyes, skin turgor, urine output
Look for source - examine ears, throat, chest, abdomen, skin (rash?), fontanelle
Key investigations:
- Urine dipstick/MC&S (urine dipstick alone is unreliable at this age - catheter sample preferred)
- FBC, CRP, blood culture if unwell
- LP if meningitis suspected (after fundoscopy/clinical assessment)
- Abdominal ultrasound if intussusception considered
- Blood glucose (exclude DKA/hypoglycemia)

Clinical Pearl: At 1 year, fever + vomiting without an obvious source = UTI until proven otherwise. A normal-appearing child with only fever and vomiting still warrants urine culture.

Sources: Rosen's Emergency Medicine; Roberts & Hedges' Clinical Procedures in Emergency Medicine; Adams & Victor's Principles of Neurology; Tintinalli's Emergency Medicine; Campbell-Walsh Urology

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