What is the appropriate management for a 7-year-old female presenting with nausea and vomiting for 5 days?

Management of a 7-Year-Old Female with Nausea and Vomiting for 5 Days

Immediate Assessment and Hydration

The priority is to assess hydration status and initiate oral rehydration therapy, as fluid and electrolyte replacement is the cornerstone of management and takes precedence over antiemetic therapy. 1

Critical Red Flags to Assess Immediately

• Bilious or bloody vomiting (suggests surgical emergency like malrotation with volvulus or intussusception) 2
• Altered mental status or severe lethargy (may indicate metabolic derangement, intracranial pathology, or severe dehydration) 2
• Signs of severe dehydration: sunken eyes, decreased skin turgor, dry mucous membranes, decreased urine output, tachycardia, hypotension 1
• Abdominal distension or severe pain (consider appendicitis, obstruction) 2
• Fever with severe headache (meningitis, encephalitis) 2
• Recent head trauma (intracranial injury) 2

Hydration Assessment and Management

• If mild to moderate dehydration is present: Begin oral rehydration solution (ORS) with small, frequent volumes (5 mL every minute initially using a spoon or syringe), gradually increasing as tolerated 1
• Replace ongoing losses: Give 10 mL/kg of ORS for each episode of vomiting or diarrhea 1
• If severe dehydration or inability to tolerate oral fluids: Intravenous rehydration is required 1

Antiemetic Therapy

Ondansetron is the recommended antiemetic for children >4 years of age with acute gastroenteritis and persistent vomiting that prevents oral rehydration. 1

Ondansetron Dosing

• Oral dose: 0.2 mg/kg (maximum 4 mg) as a single dose 2
• Intravenous dose: 0.15 mg/kg (maximum 4 mg) if unable to tolerate oral medication 2
• Purpose: Facilitates tolerance of oral rehydration and reduces immediate need for hospitalization 1
• Important caveat: Ondansetron may increase stool volume/diarrhea as a side effect, but this does not outweigh its benefit in controlling vomiting 1

Critical Contraindications

• Never use loperamide or other antimotility agents in children <18 years of age (strong recommendation due to risk of ileus, lethargy, and reported deaths in young children) 1
• Avoid metoclopramide in this age group for gastroenteritis (not recommended by IDSA guidelines for pediatric acute gastroenteritis; reserved for other specific indications) 1

Nutritional Management

Early refeeding immediately upon adequate hydration improves outcomes and should not be delayed. 1

Feeding Strategy

• Resume normal diet as soon as the child is rehydrated (do not withhold solid foods for 24 hours) 1
• Offer age-appropriate foods: starches, cereals, yogurt, fruits, vegetables 1
• Avoid foods high in simple sugars and fats 1
• Continue breastfeeding on demand if applicable 1
• Lactose-containing foods can be continued unless clinical worsening occurs (presence of reducing substances in stool alone without clinical symptoms does not indicate lactose intolerance) 1

Diagnostic Considerations After 5 Days

At 5 days duration, consider causes beyond simple viral gastroenteritis:

• Infectious causes requiring specific treatment: Bacterial pathogens (Salmonella, Shigella, Campylobacter), parasites (Giardia) - consider stool culture and microscopy if diarrhea is also present, fever is present, or symptoms persist beyond 5 days 1
• Non-infectious causes to exclude:
  • Appendicitis (right lower quadrant pain, fever, anorexia) 2
  • Diabetic ketoacidosis (polyuria, polydipsia, weight loss, fruity breath) 2
  • Urinary tract infection/pyelonephritis (fever, dysuria, flank pain) 2
  • Intracranial pathology (headache, vision changes, morning vomiting) 2
  • Medication or toxin exposure (review all medications and potential ingestions) 2

Laboratory Testing Indications

• Order serum electrolytes, blood glucose, renal function, and urinalysis if:
  • Moderate to severe dehydration is present 2
  • Any red flag signs are present 2
  • Symptoms persist despite appropriate oral rehydration 2
  • Clinical concern for metabolic derangement or surgical cause 2

Follow-Up Instructions

Instruct caregivers to return immediately or call if:

• Child becomes increasingly lethargic or difficult to arouse 1
• Urine output decreases significantly (no urine for 8-12 hours) 1
• Vomiting becomes intractable or bilious 1
• Blood appears in vomit or stool 1
• Severe abdominal pain develops 1
• Symptoms worsen despite treatment 1

Common Pitfalls to Avoid

• Do not use antimotility agents (loperamide) in any child <18 years - this carries significant risk of serious adverse events including death 1
• Do not delay refeeding once hydration is adequate - early nutrition improves intestinal barrier function and reduces illness duration 1
• Do not use ondansetron as a substitute for adequate hydration - it is an adjunct to facilitate oral rehydration, not a replacement 1
• Do not assume viral gastroenteritis without considering serious causes - at 5 days duration, the differential broadens significantly 2
• Do not routinely restrict lactose without evidence of clinical intolerance - most children tolerate regular diet including dairy 1