What should be done for a child who has been vomiting for four days?

Management of a Child with Four Days of Vomiting

For a child who has been vomiting for four days, the priority is immediate assessment for red flag signs (bilious vomiting, dehydration, altered mental status, abdominal distension) and prompt rehydration with oral rehydration solution (ORS), while most cases represent self-limited viral gastroenteritis requiring only supportive care. 1, 2, 3

Immediate Assessment Priorities

Red Flag Signs Requiring Urgent Evaluation

• Bilious (green) vomiting indicates obstruction distal to the ampulla of Vater and requires immediate surgical consultation and imaging 4, 2, 3
• Blood in vomit or stool suggests mucosal injury or serious pathology 1, 4
• Severe dehydration (≥10% fluid deficit) manifested by decreased urine output (fewer than 4 wet diapers in 24 hours), sunken eyes, dry mucous membranes, poor skin turgor, or altered mental status 1, 2
• Abdominal distension or severe pain suggests obstruction or surgical abdomen 2, 3
• Altered sensorium, toxic appearance, or inconsolable crying indicates serious systemic illness 2, 3

Hydration Status Assessment

• Evaluate for mild dehydration (3-5% deficit), moderate (6-9%), or severe (≥10%) based on clinical signs including capillary refill time, mucous membranes, skin turgor, and urine output 1
• After four days of vomiting, dehydration is highly likely and must be addressed immediately 1, 2

Management Algorithm

For Non-Bilious Vomiting Without Red Flags (Most Common Scenario)

Step 1: Oral Rehydration

• Administer ORS in small, frequent volumes (5 mL every minute initially) using a spoon or syringe with close supervision 1
• Replace each vomiting episode with 10 mL/kg of ORS 1
• Oral rehydration is successful in more than 90% of cases when given properly over 3-4 hours 5
• Continue breastfeeding on demand if breastfed; do not interrupt breast milk 1
• Resume full-strength formula or regular diet immediately after rehydration is achieved—do not use diluted formula 1, 5

Step 2: Antiemetic Consideration

• Ondansetron (0.2 mg/kg oral, maximum 4 mg) may be considered ONLY if persistent vomiting prevents oral intake entirely 1, 2
• Antiemetics are generally NOT indicated for routine viral gastroenteritis in young children 1
• Do NOT use antidiarrheal or antimotility agents—these can cause serious side effects and are ineffective 1

Step 3: Monitoring and Follow-Up

• Regular weight checks are essential—poor weight gain elevates concern from benign reflux to GERD disease requiring more aggressive intervention 1
• Instruct parents to return immediately if vomiting becomes projectile, bilious (green), or bloody, or if signs of dehydration worsen 1, 2

For Projectile Vomiting Pattern

• Projectile vomiting is a red flag requiring thorough evaluation to distinguish from simple regurgitation 1
• In infants 2-8 weeks old, consider hypertrophic pyloric stenosis (HPS)—palpate for "olive" mass in right upper quadrant and obtain ultrasound as first-line imaging 1
• Malrotation with volvulus can present at any age, not just newborns—maintain vigilance for any change to bilious emesis 1, 4

For Bilious Vomiting (Surgical Emergency)

• Bilious vomiting is a surgical emergency until proven otherwise 6, 4
• Immediately obtain abdominal X-ray to identify signs of intestinal obstruction (dilated loops, air-fluid levels) 4
• Withhold all oral feeds and place nasogastric tube for gastric decompression 2
• Obtain immediate pediatric surgical consultation—conditions like volvulus can cause intestinal necrosis within hours 4
• Upper GI series is the next appropriate study (sensitivity 96% for malrotation) to evaluate duodenojejunal junction position 6, 4

Common Pitfalls to Avoid

• Do not dismiss four days of vomiting as "just a virus" without assessing hydration status—dehydration develops more rapidly in children due to higher fluid turnover 2, 3
• Do not use IV fluids if the child can be rehydrated orally or via nasogastric tube—oral rehydration is equally effective and less invasive 5
• Do not routinely order laboratory tests or stool studies in uncomplicated gastroenteritis—they are usually unnecessary and do not change management 2, 5
• Do not confuse pyloric stenosis (non-bilious projectile vomiting, 2-8 weeks old) with malrotation (bilious vomiting, any age)—imaging approach differs completely 1, 4
• Do not provide only symptomatic antiemetic treatment without identifying the underlying cause—this may delay specific diagnosis and therapy for serious conditions 3

When to Refer or Admit

• Any bilious vomiting requires immediate surgical evaluation 4, 2
• Severe dehydration or inability to tolerate oral rehydration requires hospitalization for IV fluids 1, 2
• Persistent vomiting beyond 4-5 days without improvement or with poor weight gain warrants pediatric gastroenterology referral 6, 3
• Suspected pyloric stenosis on examination or ultrasound requires surgical consultation 1