What is the management for a 1-year-old child with severe vomiting (7 episodes) and signs of dehydration (sunken eyeballs)?

Management of a 1-Year-Old Child with Severe Vomiting and Dehydration

Begin immediate oral rehydration therapy with small, frequent volumes of ORS (5-10 mL every 1-2 minutes using a spoon or syringe), and consider ondansetron to facilitate oral intake if vomiting persists despite proper ORS administration. 1

Immediate Assessment

Assess dehydration severity: The presence of sunken eyeballs indicates at least moderate dehydration (6-9% fluid deficit). 1, 2 Additional signs to evaluate include:

• Skin turgor (prolonged tenting suggests severe dehydration) 2
• Mental status and activity level (severe lethargy indicates severe dehydration requiring IV fluids) 3, 2
• Capillary refill time (prolonged >2 seconds suggests significant deficit) 2
• Mucous membrane dryness 2
• Urine output (decreased or absent) 1

Rule out shock: Check pulse quality, perfusion, and mental status. If the child is lethargic, has poor perfusion, or shows signs of shock, immediately switch to IV isotonic fluids (lactated Ringer's or normal saline) at 20 mL/kg boluses. 3, 1

Rehydration Protocol for Moderate Dehydration

Administer 100 mL/kg of ORS over 2-4 hours (approximately 1000 mL for a 10 kg child). 1, 2 The critical technique is:

• Give 5-10 mL every 1-2 minutes using a teaspoon, syringe, or medicine dropper 1, 3
• Gradually increase volume as tolerated 1
• Replace each additional vomiting episode with 2 mL/kg of ORS 1
• Replace each diarrheal stool with 60-120 mL of ORS 3

Critical pitfall to avoid: Do NOT allow the thirsty child to drink large volumes rapidly from a cup or bottle—this perpetuates vomiting and leads to ORS failure. 3, 1 The caretaker must administer small amounts slowly via spoon or syringe. 3

Adjunctive Antiemetic Therapy

Consider ondansetron if vomiting prevents adequate oral intake. 1 Ondansetron improves ORS tolerance and reduces the need for IV therapy. 3, 1 However, it may increase stool volume as a side effect. 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. 1, 3 This is preferable to IV therapy when the child is not severely dehydrated. 3, 1

Feeding During Rehydration

Continue breastfeeding on demand throughout the illness. 1, 2 If bottle-fed, resume full-strength formula immediately after rehydration is complete (within 4 hours). 1, 2 Do not dilute formula or delay feeding—early feeding improves nutritional outcomes. 3, 1

For a 1-year-old, offer age-appropriate foods every 3-4 hours as soon as appetite returns. 3, 1 There is no justification for "resting the bowel" through fasting. 3

Reassessment After 2-4 Hours

Examine the following to determine if rehydration is adequate: 1

• Skin turgor and mucous membrane moisture 1
• Mental status and activity level 1
• Urine output 1
• Weight changes 1

If the child remains dehydrated, continue ORS in the supervised setting. 3 If dehydration worsens or the child develops altered mental status, switch to IV rehydration. 3, 1

Medications to AVOID

Do NOT give loperamide or any antimotility agents—these are contraindicated in all children <18 years of age. 3, 1 Deaths have been reported in children given loperamide. 3

Do NOT give empiric antibiotics for uncomplicated watery diarrhea with vomiting—this is viral gastroenteritis requiring only supportive care. 1, 3 Antimicrobial drugs are contraindicated for routine treatment of watery diarrhea. 3

When to Switch to IV Therapy

Switch to intravenous isotonic fluids if: 3, 1

• Severe dehydration with shock or altered mental status 3, 1
• Persistent vomiting despite proper ORS technique and ondansetron 1
• Intestinal ileus (absent bowel sounds) 3
• Stool output >10 mL/kg/hour (though most will still respond to ORS) 3