What is the treatment for pediatric vomiting?

Treatment for Pediatric Vomiting

The cornerstone of treating pediatric vomiting is oral rehydration therapy with small, frequent volumes (5 mL every minute) of oral rehydration solution (ORS), and ondansetron may be given to children >4 years of age to facilitate oral rehydration when vomiting is persistent. 1

Initial Assessment and Red Flags

Before initiating treatment, determine if vomiting is bilious (green-colored) or non-bilious, as bilious emesis suggests intestinal obstruction requiring urgent surgical evaluation. 2 Assess for projectile vomiting which may indicate pyloric stenosis or other obstructive conditions requiring emergency care. 2

Rehydration Strategy Based on Severity

Mild Vomiting Without Significant Dehydration

• Administer 5 mL of ORS every minute using a spoon or syringe under close supervision. 1, 2
• Gradually increase volume as tolerated—the key is small, frequent amounts rather than large volumes. 1, 2
• Simultaneous correction of dehydration often lessens the frequency of vomiting itself. 1

Moderate Dehydration with Persistent Vomiting

• Continue small, frequent volumes of ORS. 2
• Replace each episode of vomiting with additional ORS to account for ongoing losses. 1, 2
• Consider ondansetron (0.2 mg/kg orally or 0.15 mg/kg parenterally, maximum 4 mg) for children >4 years to improve tolerance of oral rehydration. 2

Severe Dehydration or Failed Oral Rehydration

• Hospitalization and intravenous fluids are indicated when oral rehydration therapy fails despite antiemetic use or when signs of shock are present. 3

Antiemetic Medications: Evidence-Based Approach

Ondansetron (First-Line for Children >4 Years)

• Ondansetron reduces immediate need for hospitalization and intravenous rehydration, though it may increase stool volume. 1
• Studies demonstrate more children receiving ondansetron had resolution of vomiting compared to placebo. 1
• The Infectious Diseases Society of America (IDSA) recommends ondansetron may be given to children >4 years and adolescents with acute gastroenteritis associated with vomiting (weak recommendation, moderate evidence). 1
• No recommendation can be made for routine use in children <4 years of age. 1
• Ondansetron is effective in decreasing vomiting rate, improving oral hydration success, and reducing ED length of stay with few serious side effects. 4

Medications to AVOID

• Antimotility drugs (loperamide) should NOT be given to children <18 years of age with acute diarrhea and vomiting (strong recommendation, moderate evidence). 1
• Deaths have been reported in 0.54% of children given loperamide, all occurring in children <3 years old. 1
• Promethazine is contraindicated in children under 2 years of age per FDA labeling. 5
• Metoclopramide has highly variable pharmacodynamics in pediatric patients and insufficient data to support efficacy. 6

Other Antiemetics

• Dimenhydrinate appears safe for pediatric use but has limited published evidence regarding effectiveness. 7
• Domperidone is commonly used but prescribed "off-label" in many settings. 8, 9

Nutritional Management During Vomiting

Infants

• Breastfed infants should continue nursing on demand throughout the illness. 1, 2
• Formula-fed infants should receive full-strength formula immediately upon rehydration. 1, 2
• If formula intolerance is suspected, consider lactose-free or lactose-reduced formulas temporarily. 1, 2

Older Children on Solid Foods

• Continue the child's usual diet during vomiting episodes—do not withhold solid food for 24 hours. 1, 2
• Recommended foods include starches, cereals, yogurt, fruits, and vegetables. 1, 2
• Avoid foods high in simple sugars and fats. 1, 2
• The BRAT diet (bananas, rice, applesauce, toast) and dairy avoidance are commonly recommended but have limited supporting data. 1

Critical Timing: When Antiemetics Should Be Used

Antiemetic agents should only be considered AFTER the patient is adequately hydrated—they are not a substitute for fluid and electrolyte therapy. 1 This is a crucial pitfall to avoid: never use antiemetics as first-line treatment before addressing hydration status.

When Antibiotics Are Indicated

Antibiotics are generally NOT indicated for vomiting alone. 1 Consider antibiotics only when:

• Dysentery or high fever is present 1
• Watery diarrhea lasts >5 days 1
• Stool cultures, microscopy, or epidemic setting indicate a specific bacterial pathogen requiring treatment 1

Home Management Instructions for Parents

Parents should be educated to:

• Offer small, frequent sips of ORS rather than large volumes 2
• Continue appropriate nutrition as tolerated 2
• Monitor for decreased urine output, lethargy, or persistent vomiting 1, 2
• Return for medical care if the child becomes irritable or lethargic, has decreased urine output, develops intractable vomiting, or has persistent symptoms. 1, 2

Common Pitfalls to Avoid

• Do not withhold oral intake or solid foods for 24 hours—early refeeding decreases intestinal permeability and improves outcomes. 1
• Do not give large volumes of fluid at once—this often triggers more vomiting; small frequent amounts are key. 1, 2
• Do not use antimotility agents in any child <18 years—risk of serious adverse events including death. 1
• Do not use antiemetics as a substitute for rehydration—hydrate first, then consider antiemetics if needed. 1
• Do not routinely use antiemetics in children <4 years—insufficient evidence for safety and efficacy. 1