What is the best course of treatment for a 2-year-old child with a 3-day history of vomiting?

Management of a 2-Year-Old with 3-Day History of Vomiting

Immediate Assessment Priorities

Begin oral rehydration therapy with small, frequent volumes of oral rehydration solution (ORS) as the cornerstone of treatment, while simultaneously assessing for red flag symptoms that would require urgent intervention. 1

Critical Red Flags to Evaluate Immediately

• Bilious (green) vomiting indicates intestinal obstruction and requires emergency surgical evaluation 1, 2
• Blood in vomit or stool suggests serious pathology requiring urgent assessment 3, 2
• Projectile vomiting that persists may indicate pyloric stenosis or other obstructive conditions, though less common at age 2 1
• Abdominal distension or tenderness suggests obstruction or surgical abdomen 1
• Altered mental status, lethargy, or inconsolable irritability indicates severe dehydration or neurological involvement 2
• Signs of severe dehydration (>10% fluid deficit, signs of shock) 1, 4

Hydration Assessment and Management

Assess Dehydration Severity

Evaluate hydration status through physical examination, which is the most reliable method 4:

• Mild dehydration (3-5% deficit): Slightly decreased urine output, normal vital signs 3
• Moderate dehydration (6-9% deficit): Decreased tears, dry mucous membranes, delayed capillary refill, decreased skin turgor 3, 5
• Severe dehydration (≥10% deficit): Lethargy, sunken eyes, very delayed capillary refill, minimal urine output 3, 4

Rehydration Protocol

For mild to moderate dehydration without red flags, initiate oral rehydration immediately:

• Start with 5 mL of ORS every 1-2 minutes using a spoon or syringe under close supervision 1, 5
• Gradually increase volume as tolerated once vomiting decreases 1
• Replace each vomiting episode with additional 10 mL/kg of ORS 3
• Continue small, frequent volumes rather than large boluses, which are more likely to trigger vomiting 1

This approach is effective even in vomiting children—oral rehydration has proven effective in over 90% of children with vomiting and is safer than intravenous therapy. 1

Nutritional Management

• Continue breastfeeding on demand if the child is breastfed 3, 1
• Resume normal diet as soon as tolerated, including starches, cereals, yogurt, fruits, and vegetables 1
• Avoid foods high in simple sugars and fats 1
• Do NOT withhold food once rehydration is established, as early feeding shortens illness duration 5

Medication Considerations

Ondansetron Use

Consider ondansetron (0.2 mg/kg orally, maximum 4 mg) ONLY if persistent vomiting prevents oral intake entirely and the child is over 4 years old. 3, 1

• Ondansetron should be given only after adequate hydration is established 1
• For a 2-year-old, ondansetron is generally NOT indicated for routine viral gastroenteritis 3
• The medication may facilitate oral rehydration when vomiting is truly intractable 1, 4

Medications to AVOID

• Do NOT use antimotility drugs (e.g., loperamide) in children under 18 years 1
• Do NOT use antibiotics unless there is evidence of bacterial infection (high fever, bloody diarrhea, symptoms >5 days) 1
• Avoid antidiarrheal agents as they shift focus from appropriate fluid therapy and can cause serious side effects 3

When to Escalate Care

Indications for Emergency Evaluation

• Bilious vomiting (requires immediate surgical consultation) 1
• Persistent projectile vomiting 1
• Signs of severe dehydration not responding to oral rehydration 1
• Abdominal distension or significant tenderness 1
• Decreased urine output (fewer than 4 wet diapers in 24 hours) 3

Indications for Hospitalization

• Failure to respond to oral rehydration therapy plus antiemetic trial 4
• Severe dehydration (signs of shock or >10% dehydration) 4
• Inability to tolerate any oral fluids after appropriate trial 4

Parent Instructions for Home Management

• Offer small, frequent sips of ORS rather than large volumes 1
• Monitor urine output (should have at least 4 wet diapers per 24 hours) 3
• Watch for worsening signs: increased lethargy, persistent vomiting, no improvement after 24 hours of ORS 1
• Return immediately if vomiting becomes green (bilious), child becomes unresponsive, or severe abdominal pain develops 3, 1

Common Pitfalls to Avoid

• Do not assume viral gastroenteritis without ruling out red flag symptoms—bilious vomiting, blood, or signs of obstruction require urgent evaluation 2, 6
• Do not use inappropriate beverages like cola drinks for rehydration, as they contain insufficient sodium and excessive sugar 5
• Do not routinely prescribe antiemetics to young children—focus on oral rehydration first 3, 1
• Do not delay rehydration while waiting for test results in a child without red flags 4