What is the treatment for a child with vomiting, diarrhea, and oral thrush (white spots in the mouth)?

Treatment of Child with Vomiting, Diarrhea, and Oral Thrush

This child requires simultaneous treatment of two conditions: oral rehydration therapy for gastroenteritis-related dehydration and antifungal therapy with nystatin oral suspension for oral candidiasis (thrush). 1, 2

Immediate Management of Dehydration

Assessment of Hydration Status

First, determine the degree of dehydration based on clinical signs:

• Mild dehydration (3-5% fluid deficit): sunken eyes, dry mouth, thirst, normal to slightly decreased skin turgor 3
• Moderate dehydration (6-9% fluid deficit): previous signs plus tachycardia, irritability/lethargy, decreased skin turgor 3
• Severe dehydration (≥10% fluid deficit): previous signs plus shock or near shock, significantly altered mental status 3

Rehydration Protocol

For mild dehydration:

• Administer 50 mL/kg of oral rehydration solution (ORS) over 2-4 hours 4
• Replace ongoing losses: 10 mL/kg for each watery stool and 2 mL/kg for each vomiting episode 3

For moderate dehydration:

• Administer 100 mL/kg of ORS over 2-4 hours 4
• Replace ongoing losses as above 3

For severe dehydration:

• Immediate IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until vital signs normalize 1
• Once stabilized, transition to oral rehydration to complete fluid replacement 1

Managing Vomiting (Critical Technique)

The key to success is small-volume, frequent administration—this is where most caregivers fail. 1

• Administer 5-10 mL of ORS every 1-2 minutes using a spoon or syringe 4
• Never allow the child to drink large volumes at once from a cup or bottle—this is a common mistake that worsens vomiting 4
• Gradually increase volume as tolerated 4
• Over 90% of children with vomiting can be successfully rehydrated orally using this approach 5

For children >4 years with persistent vomiting:

• Consider ondansetron (0.2 mg/kg orally or 0.15 mg/kg parenterally, maximum 4 mg) to facilitate oral rehydration 1
• Only administer after attempting oral rehydration, not as first-line 1

Treatment of Oral Thrush

Nystatin oral suspension is the treatment for oral candidiasis. 2

Dosing by Age:

• Infants: 2 mL (200,000 units) four times daily 2

  • Use dropper to place one-half of dose in each side of mouth 2
  • Avoid feeding for 5-10 minutes after administration 2
  • For premature/low birth weight infants: 1 mL four times daily 2

• Children and adults: 4-6 mL (400,000-600,000 units) four times daily 2

  • Place one-half of dose in each side of mouth 2
  • Instruct child to retain in mouth as long as possible before swallowing 2

• Continue treatment for at least 48 hours after symptoms disappear 2

Nutritional Management

Do not withhold food—this is a common error that worsens outcomes. 1

• Continue breastfeeding throughout the illness if applicable 1, 4
• Resume age-appropriate diet during or immediately after rehydration 1
• For formula-fed infants: continue full-strength formula (diluted formula provides no benefit) 4
• For toddlers on solid foods: offer starches, cereals, yogurt, fruits, and vegetables 4
• Avoid foods high in simple sugars and fats 3

Critical Pitfalls to Avoid

• Do not allow ad libitum drinking of ORS—this triggers more vomiting 4
• Do not use antimotility drugs (loperamide) in children <18 years—strong contraindication 1
• Do not withhold food or practice "gut rest"—this reduces enterocyte renewal and increases intestinal permeability 4
• Do not use inappropriate fluids like apple juice, Gatorade, or soft drinks for rehydration 4

When to Seek Emergency Care

Return immediately if:

• Bilious (green) vomiting develops 5
• Signs of severe dehydration not responding to oral rehydration 5
• Decreased urine output, lethargy, or altered mental status 4
• Intractable vomiting despite small-volume technique 4
• Bloody diarrhea with high fever 3

Home Management Instructions

• Administer small, frequent volumes of ORS using a spoon or syringe 4
• Continue nystatin four times daily for oral thrush 2
• Monitor urine output (should have wet diapers every 6-8 hours) 4
• Replace each episode of vomiting or diarrhea with additional ORS 4
• Maintain age-appropriate nutrition as tolerated 1