What to do for a 5-year-old with vomiting, diarrhea, and fever for 3 days?

Management of a 5-Year-Old with Vomiting, Diarrhea, and Fever for 3 Days

The priority is to assess hydration status immediately and initiate oral rehydration solution (ORS) if the child has mild to moderate dehydration, while considering ondansetron to facilitate oral intake given the persistent vomiting. 1

Immediate Assessment of Hydration Status

Evaluate the child for clinical signs of dehydration to determine severity and guide treatment 1:

• Mild dehydration (3-5% fluid deficit): Look for slightly decreased urine output, thirst, normal mental status, moist mucous membranes 1
• Moderate dehydration (6-9% fluid deficit): Decreased skin turgor, dry mucous membranes, sunken eyes, decreased tears, capillary refill >2 seconds 1, 2
• Severe dehydration (≥10% fluid deficit): Altered mental status, prolonged skin tenting (>2 seconds), cool extremities, poor perfusion, rapid deep breathing, severe lethargy 1

The three most useful clinical predictors of 5% or more dehydration are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern. 3, 2 The presence of any two or more of these signs—capillary refill >2 seconds, absent tears, dry mucous membranes, and ill general appearance—indicates at least 5% dehydration 2.

Rehydration Strategy Based on Severity

For Mild to Moderate Dehydration (Most Likely Scenario)

Administer ORS at 50 mL/kg over 2-4 hours for mild dehydration or 100 mL/kg over 2-4 hours for moderate dehydration. 1

• Start with small volumes (one teaspoon) using a teaspoon, syringe, or medicine dropper, then gradually increase as tolerated 1
• Replace ongoing losses with 10 mL/kg of ORS for each watery stool and 2 mL/kg for each vomiting episode 1
• Reassess hydration status after 2-4 hours 1
• Continue ORS until clinical dehydration is corrected and ongoing losses cease 1, 4

For Severe Dehydration (Medical Emergency)

Initiate immediate intravenous rehydration with isotonic fluids (lactated Ringer's or normal saline) in 20 mL/kg boluses until pulse, perfusion, and mental status normalize. 1 Once the child's consciousness returns to normal, transition to ORS for the remaining deficit 1.

Antiemetic Therapy to Facilitate Oral Rehydration

Given this 5-year-old has persistent vomiting, ondansetron may be administered to facilitate tolerance of oral rehydration. 1

• Ondansetron reduces immediate need for hospitalization or intravenous rehydration and improves success of oral rehydration 1, 3
• This is appropriate for children >4 years of age with acute gastroenteritis and significant vomiting 1
• Note that ondansetron may increase stool volume as a side effect, but this does not outweigh its benefits in facilitating rehydration 1

Nutritional Management

Resume age-appropriate diet immediately after rehydration is completed or even during the rehydration process. 1, 4

• Early refeeding does not prolong diarrhea and may reduce duration by approximately half a day 1, 5
• Avoid restrictive diets like BRAT (bananas, rice, applesauce, toast) as supporting data are limited 1
• Do not instruct fasting for 24 hours, as this is not useful 1

Fever Management

If fever is causing discomfort, acetaminophen may be used for symptomatic relief. 6 However, seek medical attention if fever worsens or lasts more than 3 days, as this could indicate a more serious condition 6.

Critical Medications to AVOID

Do NOT give antimotility drugs (loperamide) to this child. 1, 4 Loperamide is contraindicated in children <18 years of age with acute diarrhea and should especially be avoided in cases with fever, as it may lead to serious complications including toxic megacolon 1.

When to Consider Further Evaluation

Stool cultures are generally not needed for typical acute watery diarrhea 1. However, consider stool culture if 1:

• Bloody diarrhea (dysentery) develops
• Symptoms persist beyond 5-7 days
• The child appears severely ill or has altered mental status

Laboratory studies (serum electrolytes) are rarely needed unless clinical signs suggest significant electrolyte abnormalities 1.

Infection Control Measures

Practice strict hand hygiene after toilet use, before food preparation, and after handling soiled items to prevent transmission to other household members. 1, 4 Keep the child separated from siblings until at least 2 days after symptom resolution 4.

Common Pitfalls to Avoid

• Do not delay rehydration while awaiting diagnostic testing—initiate ORS immediately based on clinical assessment 4
• Do not use sports drinks or apple juice as primary rehydration solutions, as these have inappropriate electrolyte composition and high sugar content that can worsen diarrhea 4
• Do not withhold food during or after rehydration 1, 4
• Do not give antimotility agents to any child with acute diarrhea, especially with fever present 1, 4