What is the treatment for vomiting in a pediatric patient?

Treatment of Vomiting in Pediatric Patients

For pediatric patients with vomiting, oral rehydration therapy with small, frequent volumes (5 mL every minute) should be the first-line approach, with antiemetics like ondansetron reserved for cases where persistent vomiting impedes oral intake. 1

Initial Assessment and Red Flags

When evaluating a child with vomiting, assess for:

• Hydration status (dry mouth, decreased urine output, lethargy)
• Red flags requiring immediate attention:
  • Bilious or bloody vomiting (surgical emergency)
  • Altered mental status
  • Signs of severe dehydration
  • Bent-over posture (suggesting peritonitis)
  • Unstable vital signs

Treatment Algorithm

1. Oral Rehydration Therapy (First-Line)

• Administration technique: Start with small, frequent volumes (5 mL every minute) 1
• Delivery method: Use a spoon or syringe with close supervision
• Gradual progression: Slowly increase the amount as tolerated
• Rationale: Correcting dehydration often reduces vomiting frequency

2. Antiemetic Medications (For Persistent Vomiting)

For children unable to maintain oral intake due to persistent vomiting:

• First choice: Ondansetron 2

  • Dosing: 0.15 mg/kg IV or 0.2 mg/kg oral (maximum 4 mg)
  • Particularly effective for preventing hospital admission in acute gastroenteritis

• Alternative options:

  • For children >2 years: Promethazine 3
    • Dosing: 0.5 mg/pound of body weight
    • 12.5-25 mg doses repeated at 4-6 hour intervals as needed
    • CAUTION: Contraindicated in children under 2 years

3. Specific Situations

Acute Gastroenteritis

• Focus on oral rehydration
• Avoid antimotility agents (may prolong viral shedding) 4
• Consider ondansetron only if vomiting prevents oral rehydration 5

Chemotherapy-Induced Vomiting

• For high-emetic-risk agents: Three-drug combination of 5-HT3 receptor antagonist, dexamethasone, and aprepitant 1
• For moderate-emetic-risk agents: Two-drug combination of 5-HT3 receptor antagonist and dexamethasone 1
• For low-emetic-risk agents: Ondansetron or granisetron alone 1

Dietary Management

• Breast-fed infants: Continue nursing on demand 1
• Bottle-fed infants: Use full-strength, lactose-free or lactose-reduced formulas immediately upon rehydration 1
• Older children: Continue usual diet including starches, cereals, yogurt, fruits, and vegetables 1
• Avoid: Foods high in simple sugars and fats 1
• Temporary approach: BRAT diet (bananas, rice, applesauce, toast) may help reduce symptoms 4

Common Pitfalls to Avoid

1. Treating vomiting without identifying the cause: Vomiting may be a symptom of serious conditions requiring specific treatment (intussusception, appendicitis, increased intracranial pressure)

2. Overuse of antiemetics: Antiemetics should not be used for vomiting of unknown etiology in children 3

3. Allowing dehydration to worsen: Parents should be instructed to seek medical attention if the child becomes irritable/lethargic, has decreased urine output, or develops intractable vomiting 1

4. Inappropriate fluid administration: Allowing a thirsty child to drink large volumes of fluid at once can worsen vomiting; small, frequent amounts are more effective 1

5. Overlooking metabolic causes: Children with serum bicarbonate ≤13 mEq/L often require more aggressive management and may not tolerate oral rehydration 6

Most cases of vomiting in children are due to self-limiting conditions like gastroenteritis. With proper oral rehydration techniques and judicious use of antiemetics when necessary, most children can be managed successfully without complications.