What is the management for a pediatric patient with an acid-related disorder, moderate dehydration, and a 2-day history of fever, who has vomited twice with brownish watery stools and has a decreased appetite?

Management of Pediatric Acid-Related Disorder with Moderate Dehydration

For this pediatric patient with moderate dehydration (6-9% fluid deficit), administer 100 mL/kg of oral rehydration solution (ORS) containing 50-90 mEq/L sodium over 2-4 hours, followed by immediate resumption of age-appropriate feeding once rehydration is achieved. 1

Immediate Priority: Address the Dehydration

The brownish vomitus raises concern for possible hematemesis or coffee-ground emesis, which requires urgent evaluation, but the moderate dehydration takes precedence as the immediate life-threatening issue. 1

Rehydration Protocol for Moderate Dehydration

• Administer 100 mL/kg of ORS over 2-4 hours using small volumes initially (one teaspoon at a time) with a teaspoon, syringe, or medicine dropper, gradually increasing as tolerated. 1

• The ORS must contain 50-90 mEq/L of sodium to effectively replace both water and electrolyte losses. 1, 2

• Reassess hydration status after 2-4 hours by examining skin turgor, mucous membranes, mental status, and capillary refill time. 1, 2

• If still dehydrated after initial rehydration, reestimate the fluid deficit and restart the rehydration phase. 1

Managing Ongoing Losses

• Replace each episode of vomiting with 2 mL/kg of ORS and each watery/loose stool with 10 mL/kg of ORS continuously during both rehydration and maintenance phases. 3, 2

• For children with persistent vomiting, give small volumes (5-10 mL) of ORS every 1-2 minutes to facilitate tolerance—over 90% of vomiting patients can be successfully rehydrated orally using this technique. 3, 2

Nutritional Management

• Resume age-appropriate diet immediately upon achieving rehydration, including starches, cereals, yogurt, fruits, and vegetables. 3

• If breastfed, continue breastfeeding throughout the entire episode without interruption. 3, 2

• If bottle-fed, resume full-strength formula immediately upon rehydration. 3, 2

• Avoid foods high in simple sugars and fats during the acute phase. 3

Critical Red Flags Requiring IV Therapy

Escalate to intravenous rehydration if the patient develops:

• Signs of severe dehydration (≥10% fluid deficit): severe lethargy, altered consciousness, prolonged skin tenting >2 seconds, cool/poorly perfused extremities, decreased capillary refill, or rapid deep breathing indicating acidosis. 1

• Inability to tolerate oral intake despite small-volume frequent administration. 1

• If IV therapy becomes necessary, administer 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize, then transition to oral rehydration for the remaining deficit. 1, 3

Addressing the Acid-Related Disorder

• The "acid-related disorder" should NOT be treated with proton pump inhibitors or H2-blockers during acute gastroenteritis, as acid suppression is not indicated for acute diarrheal illness and may interfere with normal gastric defense mechanisms. 4

• The brownish vomitus requires clinical correlation—if this represents coffee-ground emesis suggesting upper GI bleeding, further evaluation is needed, but this does not change the immediate rehydration priority. 1

• Serum electrolytes should be measured if there are clinical signs suggesting abnormal sodium or potassium concentrations, particularly given the fever and vomiting. 1

Medications to Avoid

• Antimotility drugs (loperamide) are absolutely contraindicated in all children <18 years due to risks of respiratory depression and serious cardiac adverse reactions. 3

• Metoclopramide should be avoided in this acute setting, as it produces sedation and extrapyramidal reactions and is not indicated for gastroenteritis-related vomiting. 5

• Ondansetron may be considered only after adequate hydration is achieved and only if the child is >4 years of age, to facilitate oral rehydration when vomiting persists. 3

Common Pitfalls to Avoid

• Do not delay oral rehydration waiting for IV access—oral rehydration is as effective as IV therapy for moderate dehydration and should be the first-line approach. 6, 7

• Do not withhold feeding once rehydration is achieved—early refeeding improves outcomes and does not prolong diarrhea. 3, 2

• Do not use plain water or sugary drinks (juice, soda) for rehydration—these lack appropriate sodium content and can worsen electrolyte imbalances. 1, 2