What is the best approach to manage vomiting in infants?

Management of Vomiting in Infants

The best approach to manage vomiting in infants is to provide small, frequent volumes of oral rehydration solution (ORS), starting with 5 mL every minute, administered via spoon or syringe under close supervision, while maintaining appropriate nutrition. 1

Assessment of Vomiting Infant

Initial Evaluation

• Assess for red flag signs requiring immediate medical attention:
  • Bilious or bloody vomiting
  • Altered mental status
  • Toxic or septic appearance
  • Inconsolable crying
  • Severe dehydration
  • Signs of hypoglycemia 2

Hydration Status Assessment

• Early signs of dehydration:
  • Thirst
  • Delayed capillary refill
  • Absence of tears
  • Mucosal dryness
  • "Sickly" appearance 3
• Monitor:
  • Number of wet diapers
  • Activity level and alertness
  • Ability to feed normally 4

Rehydration Strategy

Oral Rehydration Technique

1. Start with small volumes: 5 mL of ORS every minute 1
2. Gradual progression: Slowly increase volume as tolerated
3. Administration method: Use spoon or syringe with close supervision 1
4. Replace ongoing losses: 2 mL/kg after each vomiting episode 4

Key Points for Success

• Even vomiting infants can be successfully rehydrated orally in 95% of cases 5
• Simultaneous correction of dehydration often reduces vomiting frequency 1
• Avoid inappropriate fluids like cola drinks (too little sodium, hyperosmolar) 3
• Commercial ORS is preferred over homemade solutions for accuracy 4

Nutritional Management

For Breastfed Infants

• Continue breastfeeding on demand throughout the episode 1, 4
• Breastfeeding reduces severity of associated diarrhea 3

For Formula-Fed Infants

• Resume normal-strength formula immediately after initial rehydration 1
• Consider smaller, more frequent feedings to reduce vomiting 1
• For infants with NDI (nephrogenic diabetes insipidus), normal-for-age milk intake is recommended instead of water to ensure adequate calories 1

Solid Foods (Older Infants)

• Continue age-appropriate foods once able to tolerate
• Focus on starches, cereals, fruits, and vegetables
• Avoid foods high in simple sugars and fats 1, 4

When to Seek Medical Care

Instruct parents to seek immediate medical attention if the infant:

• Develops intractable vomiting
• Becomes irritable or lethargic
• Has decreased urine output
• Shows signs of dehydration despite home management 1

Home Management Instructions

• Keep ORS available at home at all times 1
• Offer increased fluids during episodes of vomiting
• Carefully space oral feeds to reduce risk of vomiting 1
• Practice proper handwashing and hygiene to prevent spread of infection 4

Medication Considerations

• Antiemetics like ondansetron (0.2 mg/kg oral; 0.15 mg/kg parenteral; maximum 4 mg) may be considered in cases of persistent vomiting that prevents oral intake 2
• Antibiotics are not routinely indicated unless specific criteria are met (high fever, bloody stools, etc.) 1, 4

Proper management of vomiting in infants focuses primarily on preventing dehydration through appropriate oral rehydration techniques while maintaining nutrition. The approach must be methodical and patient, with small, frequent volumes of appropriate fluids being the cornerstone of successful management.