What is the appropriate management for a 6-year-old female with 6 days of vomiting and lethargy?

Management of a 6-Year-Old with 6 Days of Vomiting and Lethargy

This child requires immediate medical evaluation to assess hydration status, rule out serious causes, and initiate appropriate rehydration therapy—6 days of vomiting with lethargy suggests significant dehydration or a potentially serious underlying condition that demands urgent attention. 1

Immediate Assessment Priorities

Critical Red Flags to Evaluate

• Assess for bilious (green) vomiting, which indicates intestinal obstruction and requires emergency surgical evaluation 1, 2
• Evaluate hydration status using physical examination findings: assess capillary refill, skin turgor, mucous membranes, mental status, and urine output 1, 3
• Check for signs of severe dehydration: lethargy (already present), decreased urine output, sunken eyes, absent tears, dry mucous membranes 1, 3
• Look for other red flags: altered mental status beyond simple lethargy, abdominal distension or tenderness, bloody vomitus, toxic appearance, or signs of increased intracranial pressure 2, 4

The 6-day duration with lethargy is concerning—most viral gastroenteritis resolves within 3-5 days, so this prolonged course warrants investigation for other causes including metabolic disorders, urinary tract infection, appendicitis, or other serious conditions 2, 4

Rehydration Strategy

For Mild to Moderate Dehydration (if no red flags present)

• Administer oral rehydration solution (ORS) in small, frequent volumes: start with 5 mL every 1-2 minutes using a spoon or syringe, gradually increasing as tolerated 5, 1
• Consider ondansetron to facilitate oral rehydration: at age 6 years, give 0.15-0.2 mg/kg orally (maximum 4 mg) to reduce vomiting and improve tolerance of oral fluids 5, 1, 2
• Replace ongoing losses: provide additional ORS for each vomiting episode 1

For Severe Dehydration or Failed Oral Rehydration

• Initiate intravenous fluid resuscitation: administer normal saline bolus 20 mL/kg rapidly, repeat as needed to correct hypotension and restore perfusion 5, 1
• Hospital admission is required for children with severe dehydration, persistent vomiting despite ondansetron, or inability to maintain oral intake 1, 3

Diagnostic Workup

Given the 6-day duration and lethargy, laboratory evaluation is warranted 2:

• Serum electrolytes and blood gases to assess for metabolic derangements from prolonged vomiting 2
• Renal function tests to evaluate for uremia or obstructive uropathy 2
• Blood glucose to rule out hypoglycemia or diabetic ketoacidosis 2
• Urinalysis to exclude urinary tract infection 2
• Abdominal imaging if there are signs of obstruction (distension, tenderness, bilious vomiting) 2, 4

Nutritional Management

Once vomiting is controlled and rehydration is underway:

• Resume age-appropriate diet immediately after rehydration is complete—do not withhold food for 24 hours 5, 1
• Offer usual foods: starches, cereals, yogurt, fruits, and vegetables 1
• Avoid high-sugar and high-fat foods 1
• Continue normal diet as tolerated; early feeding improves nutritional outcomes 5

Medications to Avoid

Do NOT give antimotility agents (loperamide) to this child—these are contraindicated in all children under 18 years with acute diarrhea and vomiting due to risk of serious adverse events including ileus, lethargy, and death 5, 1

Common Pitfalls

• Allowing ad libitum drinking: A frequent mistake is letting a thirsty child drink large volumes rapidly, which triggers more vomiting. Always use small, frequent volumes administered by spoon or syringe 5
• Delaying evaluation: Six days of vomiting is beyond typical viral gastroenteritis—don't assume this is simple gastroenteritis without proper evaluation 2, 4
• Using antiemetics as substitute for hydration: Ondansetron facilitates oral rehydration but is not a substitute for fluid replacement 5, 1
• Missing surgical emergencies: Always assess for bilious vomiting, abdominal distension, or peritoneal signs that require immediate surgical consultation 2, 4

Disposition

This child likely requires emergency department evaluation or hospital admission given the prolonged duration (6 days), presence of lethargy, and high risk of significant dehydration 1, 3. Outpatient management is only appropriate if the child has no red flags, can tolerate oral rehydration, and has reliable follow-up within 24 hours 1, 3.