What is the management for vomiting in children?

Management of Vomiting in Children

For children with vomiting, provide oral rehydration therapy with small, frequent volumes (5 mL every minute) administered via spoon or syringe, gradually increasing the amount as tolerated, while simultaneously correcting dehydration to reduce vomiting frequency. 1

Initial Assessment

• Assess hydration status - Look for:

  • Severe dehydration indicators: sunken eyes, disorientation, respiratory distress (>9% weight loss)
  • Altered mental status and poor perfusion
  • Abnormal capillary refill, skin turgor, and respiratory pattern (best predictors of ≥5% dehydration) 2

• Identify red flags requiring immediate attention:

  • Bilious or bloody vomiting (surgical emergency)
  • Altered mental status
  • Toxic/septic appearance
  • Severe dehydration
  • Inconsolable crying or excessive irritability 3

Management Algorithm

1. Mild Vomiting with No/Mild Dehydration

• Oral rehydration therapy (ORT):

  • Start with small volumes (5 mL every minute) 4
  • Use spoon or syringe for controlled administration
  • Gradually increase volume as tolerated
  • Replace fluid losses after each vomiting episode

• Fluid recommendations:

  • Commercial oral rehydration solutions (ORS) with reduced osmolarity (65-70 mEq/L sodium) 1
  • For children 3 years old: 100-200 mL of ORS after each stool 1

2. Persistent Vomiting or Moderate Dehydration

• Intensify oral rehydration:

  • Continue small, frequent volumes
  • Consider nasogastric administration if oral intake not tolerated 1

• Antiemetic therapy:

  • Ondansetron may be used if vomiting impedes oral intake:
    • Ages 4-11 years: 4 mg orally
    • Ages 12-17 years: 8 mg orally
    • Or 0.15 mg/kg parenteral (maximum 4 mg) 5, 3
  • Benefits include: less vomiting, greater oral intake, reduced need for IV fluids, and shorter emergency department stays 2

3. Severe Dehydration or Failed Oral Therapy

• Immediate IV fluid resuscitation:
  • Isotonic solutions (lactated Ringer's or normal saline)
  • Initial bolus of 20 mL/kg
  • Continue rapid infusion until clinical signs of hypovolemia improve 1

Nutritional Management

• Resume age-appropriate diet immediately after initial rehydration (within 4-6 hours) 1
• For infants:
  • Continue breastfeeding throughout illness
  • Formula-fed infants can resume regular formula quickly after initial rehydration
• For older children:
  • Continue usual diet including starches, cereals, yogurt, fruits, and vegetables
  • Avoid foods high in simple sugars and fats 4
• Offer food every 3-4 hours during recovery 1

Home Care Instructions

• Fluid replacement: Increase fluid intake to replace losses
• Diet: Continue regular feeding as tolerated
• Warning signs requiring medical attention:
  • Worsening symptoms despite treatment
  • Development of bloody stools
  • Persistent fever
  • Abdominal distention
  • Symptoms persisting >48 hours 1

Important Considerations

• Antimotility agents (e.g., loperamide) should NOT be given to children <18 years with acute vomiting or diarrhea 1

• Antibiotics are generally not indicated unless there is:

  • Blood in stool
  • High fever suggesting bacterial infection
  • Severe dehydration with systemic symptoms 1

• Ondansetron cautions:

  • Monitor for QT prolongation in patients with electrolyte abnormalities
  • Be aware of potential serotonin syndrome with concomitant serotonergic medications 5

The management of vomiting in children focuses primarily on preventing dehydration through appropriate fluid replacement while identifying and addressing any underlying causes. Most cases are self-limiting, but careful assessment for red flags is essential to identify serious conditions requiring specific interventions.