What is the treatment for vomiting in a pediatric patient?

Treatment for Vomiting in a 14-Year-Old

The primary treatment is oral rehydration therapy (ORT) using small, frequent volumes of oral rehydration solution (ORS), starting with 5 mL every 1-2 minutes and gradually increasing as tolerated, with ondansetron (0.15-0.2 mg/kg, maximum 4 mg) reserved for persistent vomiting that interferes with oral rehydration. 1

Initial Assessment

Before initiating treatment, determine the nature and severity of vomiting:

• Assess for bilious (green-colored) vomiting, which indicates intestinal obstruction or malrotation and requires immediate emergency surgical evaluation 1, 2
• Evaluate hydration status to guide treatment intensity 3, 2:
  • Mild dehydration (3-5% deficit): slightly dry mucous membranes, normal mental status 2
  • Moderate dehydration (6-9% deficit): sunken eyes, decreased skin turgor, reduced urine output 2
  • Severe dehydration (≥10% deficit): severe lethargy, prolonged skin tenting, cool extremities, signs of shock—requires immediate IV therapy 2

Oral Rehydration Strategy

The cornerstone of treatment is properly administered ORS, which succeeds in over 90% of vomiting children 3, 1:

• Start with very small volumes: 5 mL (one teaspoon) every 1-2 minutes using a spoon, syringe, or medicine dropper 3, 1
• Gradually increase volume as tolerated 3, 1
• For mild dehydration: administer 50 mL/kg ORS over 2-4 hours 3
• For moderate dehydration: administer 100 mL/kg ORS over 2-4 hours 3, 2
• Replace each vomiting episode with an additional 2 mL/kg of ORS 3, 2

Common pitfall: Allowing a thirsty adolescent to drink large volumes rapidly from a cup or bottle will trigger more vomiting. Small, frequent volumes are essential for success 3.

Antiemetic Medication

Ondansetron should be considered when persistent vomiting interferes with oral rehydration 1:

• Dosing: 0.15-0.2 mg/kg orally (maximum 4 mg) 1, 4
• Evidence: A single oral dose reduces vomiting, improves ORT success, decreases need for IV fluids, and shortens emergency department stays 5, 6, 7
• Timing: Only administer after adequate assessment and when vomiting is limiting oral intake 1, 8
• FDA approval: Ondansetron is approved for children ≥4 years for chemotherapy-induced nausea but is used off-label for gastroenteritis-related vomiting 4, 6

Medications to absolutely avoid:

• Never give antimotility drugs (loperamide) to children under 18 years with vomiting and diarrhea—they can cause serious complications 1, 2

Nutritional Management

Continue normal diet as tolerated 1:

• Do not restrict food intake—early feeding improves outcomes 1
• Recommended foods: starches, cereals, yogurt, fruits, vegetables 1
• Avoid: foods high in simple sugars and fats 1
• For younger adolescents still on formula: continue full-strength formula; consider lactose-free options only if intolerance is evident 3, 1

When to Escalate Care

Immediate emergency evaluation required for 1, 2:

• Bilious (green) vomiting 1, 2
• Projectile vomiting that persists 1
• Signs of severe dehydration not responding to oral rehydration 1
• Increasing lethargy or difficulty arousing 2
• Bloody vomitus 2
• Abdominal distension or tenderness 1

Home Management Instructions

Provide clear discharge instructions 1:

• Offer small, frequent sips of ORS rather than large volumes 1
• Continue appropriate nutrition as tolerated 1
• Monitor urine output (should urinate at least every 6-8 hours) 1
• Return immediately if vomiting becomes green, bloody, or if the child becomes increasingly lethargic 2

The key to success is patience with small-volume, frequent ORS administration—this simple approach avoids IV therapy in the vast majority of cases 3, 1.