Treatment of Vomiting in Children
Oral rehydration solution (ORS) administered in small, frequent volumes (5-10 mL every 1-2 minutes) is the cornerstone of treatment for children with vomiting, successfully rehydrating over 90% of cases without antiemetic medication. 1
Initial Assessment and Hydration Status
Evaluate dehydration severity through clinical examination focusing on:
- Skin turgor, mucous membrane moisture, capillary refill time, mental status, and vital signs 2, 1
- Weight loss as the primary clinical index of dehydration degree 3
- Categorize as mild (3-5%), moderate (6-9%), or severe (≥10%) dehydration 1, 4
Oral Rehydration Strategy
For Mild to Moderate Dehydration
Begin ORS administration immediately using small volumes (5-10 mL) every 1-2 minutes via spoon or syringe 1, 4. This technique is critical—allowing a thirsty child to drink large volumes ad libitum commonly triggers more vomiting and represents a major pitfall 4.
Dosing by dehydration severity:
- Mild dehydration (3-5%): 50 mL/kg ORS over 3-4 hours 4
- Moderate dehydration (6-9%): 100 mL/kg ORS over 3-4 hours 2, 4
- Replace ongoing losses: 10 mL/kg for each watery stool, 2 mL/kg for each vomiting episode 1, 4
Use commercially available low-osmolarity ORS formulations such as Pedialyte 2. While Pedialyte contains 45 mEq/L sodium (lower than the ideal 75-90 mEq/L for rehydration), it remains acceptable when the alternative is inappropriate fluids or IV therapy 2.
Common Pitfall to Avoid
Never use apple juice, sports drinks (Gatorade), or soft drinks as primary rehydration solutions—these contain inadequate sodium and excessive sugar, worsening diarrhea through osmotic effects 2, 1, 3.
Ondansetron Use
Ondansetron may be given to children >4 years of age to facilitate oral rehydration tolerance when vomiting is significant 2, 4. This increases ORT success rates and reduces need for IV therapy and hospitalization 4. However, ondansetron should only be used after adequate hydration is initiated, not as a substitute for fluid therapy 2.
Severe Dehydration Management
Immediate intravenous rehydration with isotonic fluids (lactated Ringer's or normal saline) is required for:
- Severe dehydration (≥10% fluid deficit) 2
- Shock or altered mental status 2
- Failure of oral rehydration therapy 2, 4
- Intractable vomiting preventing successful oral intake 4
Continue IV fluids until pulse, perfusion, and mental status normalize, then transition to ORS to complete rehydration 2, 4.
Nasogastric Alternative
Nasogastric ORS administration may be considered for children with moderate dehydration who cannot tolerate oral intake or refuse to drink adequately 2.
Nutritional Management
Continue breastfeeding throughout the entire illness without interruption 2, 4. This reduces severity and duration of diarrhea 3.
Resume age-appropriate diet during or immediately after rehydration is completed 2, 1. Early refeeding shortens illness duration 3. Recommended foods include starches, cereals, yogurt, fruits, and vegetables; avoid foods high in simple sugars and fats 4.
Medications to Avoid
Antimotility drugs (loperamide) are absolutely contraindicated in all children <18 years of age 2, 4. These do not prevent dehydration and can cause serious complications 3.
Antidiarrheal agents shift focus away from appropriate fluid and electrolyte therapy and should not be used 1.
Monitoring and Reassessment
Reassess hydration status after 2-4 hours of rehydration 1, 4. Monitor for:
- Decreased urine output, lethargy, or irritability requiring immediate medical attention 1, 4
- Bloody diarrhea (dysentery) requiring antimicrobial consideration 4
- High stool output (>10 mL/kg/hour) indicating need for higher sodium ORS or IV therapy 4
Home Management Preparation
Families should keep ORS at home at all times and begin administration when vomiting or diarrhea first occurs, before seeking medical care 1. Prescription and dispensing should include written instructions 3.