What is the best treatment for vomiting in a toddler?

Management of Vomiting in Toddlers

The best treatment for vomiting in a toddler is oral rehydration therapy (ORT) with small, frequent volumes (5-10 mL every 1-2 minutes) of oral rehydration solution (ORS), gradually increasing the amount as tolerated. 1

Initial Assessment

• Determine if vomiting is bilious or non-bilious, as bilious emesis suggests intestinal obstruction requiring urgent evaluation 2
• Assess for forceful (projectile) vomiting which may indicate pyloric stenosis or other obstructive conditions 2
• Evaluate hydration status through physical examination, which is the best way to determine severity of dehydration 3
• Look for red flag signs including altered mental status, toxic appearance, excessive irritability, severe dehydration, or bloody vomiting 4

Rehydration Approach

For Mild Vomiting Without Significant Dehydration:

• Administer small volumes (5 mL) of ORS every minute using a spoon or syringe under close supervision 1
• Gradually increase the volume as tolerated 1
• A common mistake is allowing a thirsty child to drink large volumes all at once, which can trigger more vomiting 1

For Moderate Dehydration:

• Continue with small, frequent volumes of ORS 1
• Replace ongoing losses (each episode of vomiting) with additional ORS 1
• Consider ondansetron (0.2 mg/kg orally or 0.15 mg/kg parenterally, maximum 4 mg) for children >4 years with persistent vomiting to improve tolerance of oral rehydration 1, 4

For Severe Dehydration:

• Intravenous fluids are indicated for children in shock, with severe dehydration (>10%), or those who fail oral rehydration therapy 3

Nutritional Management

• Breastfed infants should continue nursing on demand 1, 2
• For formula-fed infants, continue with full-strength formula if tolerated 1
• If formula intolerance is suspected, consider lactose-free or lactose-reduced formulas 1, 2
• For older toddlers on solid foods, continue their usual diet during episodes of vomiting 1
• Recommended foods include starches, cereals, yogurt, fruits, and vegetables 1
• Avoid foods high in simple sugars and fats 1

Medication Considerations

• Antiemetics should only be considered after adequate hydration is established 1
• Ondansetron may be given to children >4 years to facilitate oral rehydration when vomiting is persistent 1, 5
• Antimotility drugs (e.g., loperamide) should NOT be given to children <18 years with acute diarrhea and vomiting 1
• Antibiotics are generally not indicated unless there is evidence of bacterial infection (high fever, bloody diarrhea, or symptoms lasting >5 days) 1

Home Management

• Parents should be instructed to:
  • Offer small, frequent sips of ORS rather than large volumes 1
  • Continue appropriate nutrition as tolerated 1
  • Monitor for signs of worsening dehydration (decreased urine output, lethargy, persistent vomiting) 1
  • Return for medical care if the child becomes irritable or lethargic, has decreased urine output, develops intractable vomiting, or has persistent symptoms 1

When to Seek Emergency Care

• Bilious vomiting (green color) 2
• Projectile vomiting that persists 2
• Signs of severe dehydration not responding to oral rehydration 2
• Abdominal distension or tenderness 2
• Altered mental status or excessive irritability 4

ORT has been proven effective in over 90% of children with vomiting, even those with concurrent diarrhea, and is safer and more physiologic than intravenous therapy 1.