What is the recommended treatment for a child with a history of vomiting?

Treatment for a Child with Vomiting

For a child with vomiting, the recommended treatment is oral rehydration therapy (ORT) with small, frequent volumes (5 mL every minute) of reduced osmolarity oral rehydration solution (ORS), gradually increasing the amount as tolerated. 1

Assessment of Hydration Status

First, assess the child's hydration status to guide treatment approach:

• Mild to moderate dehydration (5-9% fluid deficit):

  • Signs: Dry mucous membranes, decreased urine output, increased thirst, sunken eyes
  • Treatment: ORS 50-100 mL/kg over 3-4 hours 1

• Severe dehydration (≥10% fluid deficit):

  • Signs: Altered mental status, poor perfusion, weak pulse
  • Treatment: Immediate IV rehydration with isotonic fluids (20 mL/kg boluses) until vital signs normalize 1

Oral Rehydration Protocol for Vomiting

1. Initial approach for vomiting:

   • Start with small volumes (5 mL every minute)
   • Administer via spoon or syringe under close supervision
   • Gradually increase volume as tolerated 1

2. Replacement of ongoing losses:

   • Replace each vomiting episode with 2 mL/kg of ORS 1

3. If vomiting persists despite proper ORT technique:

   • Consider ondansetron for children >4 years (0.15 mg/kg IV or 0.2 mg/kg oral; maximum 4 mg) 1, 2, 3
   • Ondansetron has been shown to reduce gastroenteritis-related vomiting and facilitate ORT 4

Dietary Management

• Breastfed infants: Continue nursing on demand throughout illness 1
• Bottle-fed infants: Resume full-strength formula immediately upon rehydration 1
• Older children: Continue regular diet with emphasis on starches, cereals, yogurt, fruits, and vegetables 1
• Avoid: Foods high in simple sugars and fats 1

When to Escalate Care

Escalate to IV therapy if:

• Severe dehydration is present
• Child cannot tolerate oral fluids after appropriate ORT attempts
• Altered mental status or shock develops
• Serum bicarbonate ≤13 mEq/L (strong predictor of ORT failure) 5

Important Cautions and Pitfalls

1. Do not use antimotility drugs (e.g., loperamide) in children <18 years with acute diarrhea and vomiting 1

2. Avoid common household beverages like apple juice, sports drinks, and soft drinks for rehydration as they have inappropriate electrolyte content and osmolarity 1

3. Watch for red flag signs requiring immediate medical attention:

   • Bilious or bloody vomiting
   • Altered mental status
   • Severe dehydration
   • Persistent vomiting despite proper ORT 3

4. Recognize that ORT has a small failure rate: For every 25 children treated with ORT, one may fail and require IV therapy, but this should not discourage its use as first-line therapy 6

The evidence strongly supports ORT as the first-line treatment for vomiting in children, with IV therapy reserved for severe cases or when ORT fails. Proper technique with small, frequent volumes is critical to success, and addressing dehydration often helps resolve the vomiting itself.