What is the line of management for a small child with recurrent vomiting (10 episodes in 4 hours)?

Management of Small Child with 10 Vomiting Episodes in 4 Hours

Immediately assess for dehydration severity and red flag signs, then begin oral rehydration therapy with small, frequent volumes of ORS (5-10 mL every 1-2 minutes), with ondansetron as an adjunct if vomiting prevents adequate oral intake. 1, 2, 3

Immediate Assessment Priorities

Assess for red flag signs requiring immediate intervention:

• Bilious or bloody vomiting (suggests surgical emergency) 4
• Altered mental status or toxic/septic appearance 4
• Signs of severe dehydration (≥10% fluid deficit): prolonged capillary refill >2 seconds, absent tears, sunken eyes, rapid deep breathing, decreased skin turgor 2, 4
• Shock or near-shock state 1
• Inconsolable cry, excessive irritability, or bent-over posture 4

If any red flag signs are present, immediately switch to IV isotonic fluids (lactated Ringer's or normal saline) and consider surgical consultation for bilious vomiting. 2, 3, 4

Rehydration Protocol for Non-Severe Cases

The key to managing persistent vomiting is administering ORS in very small, frequent volumes rather than allowing ad libitum drinking:

• Give 5-10 mL of ORS every 1-2 minutes using a teaspoon, syringe, or medicine dropper 1, 2
• Gradually increase volume as tolerated 2
• This approach succeeds in >90% of vomiting children 1

For moderate dehydration (6-9% deficit with dry mucous membranes, decreased urine output, rapid breathing):

• Administer 100 mL/kg of ORS over 2-4 hours 2, 5
• Replace each additional vomiting episode with 2 mL/kg of ORS 2
• For infants <10 kg, provide 60-120 mL ORS per vomiting episode 2

For mild dehydration (3-5% deficit):

• Administer 50 mL/kg of ORS over 2-4 hours 5
• Replace ongoing losses as above 5

Ondansetron as Adjunctive Therapy

Consider ondansetron if vomiting prevents adequate oral intake, as it improves ORS tolerance and reduces need for IV therapy: 3, 4, 6

Dosing (per FDA label and guidelines):

• Age 4-11 years: 4 mg oral dose 7
• Age 12-17 years: 8 mg oral dose 7
• Alternative dosing from research: 0.2 mg/kg oral (maximum 4 mg) 4

Ondansetron reduces vomiting episodes, facilitates ORT, and minimizes hospitalization without significant adverse events in gastroenteritis. 4, 6, 8

Critical Pitfalls to Avoid

• Never allow a thirsty, vomiting child to drink large volumes rapidly from a cup or bottle—this is the most common mistake and perpetuates vomiting 1
• Do not use antimotility agents (loperamide) in any child <18 years—they are contraindicated 5, 3
• Do not give empiric antibiotics for uncomplicated watery diarrhea with vomiting—this is viral gastroenteritis requiring only supportive care 5, 3
• Do not delay rehydration while awaiting diagnostic tests 3
• Do not restrict diet—resume age-appropriate feeding immediately after rehydration or during the rehydration process 2, 5, 3

Alternative Route if Oral Fails

If the child cannot tolerate even small volumes orally but is not in shock, use nasogastric tube administration at 15 mL/kg/hour as an alternative to IV therapy. 1, 2

Feeding During and After Rehydration

• Continue breastfeeding throughout the illness on demand 2, 3
• Resume full-strength formula or age-appropriate diet immediately after rehydration (within 4 hours) 2, 5, 3
• Early feeding improves nutritional outcomes and is as safe as delayed feeding 5
• No need for lactose-free formulas in most cases 2

Monitoring Response

Reassess hydration status after 2-4 hours by examining:

• Skin turgor and mucous membrane moisture 2, 5
• Mental status and activity level 2
• Urine output (should resume within 6-8 hours) 2
• Weight changes (most reliable indicator) 2

If still dehydrated after initial rehydration attempt, reestimate fluid deficit and restart the protocol. 2