What is the best course of treatment for a 6-year-old (six-year-old) patient with persistent vomiting for days?

Management of a 6-Year-Old with Persistent Vomiting

Administer small volumes (5 mL) of oral rehydration solution (ORS) every 1-2 minutes using a spoon or syringe, gradually increasing as tolerated, and consider ondansetron 0.2 mg/kg orally (maximum 4 mg) if vomiting persists and impedes oral rehydration. 1, 2

Immediate Red Flag Assessment

Before initiating treatment, rapidly assess for life-threatening conditions that require emergency intervention:

• Bilious (green) vomiting indicates possible intestinal obstruction or malrotation with volvulus and requires immediate surgical consultation 1, 2, 3
• Projectile vomiting that persists may indicate pyloric stenosis or other obstructive pathology requiring urgent evaluation 1, 2
• Abdominal distension or tenderness necessitates emergency surgical evaluation 1, 2
• Altered mental status, lethargy, or toxic appearance suggests serious systemic illness including meningitis, sepsis, or metabolic derangement 3

Hydration Status Determination

Assess dehydration severity through physical examination findings:

• Mild dehydration: Slightly dry mucous membranes, normal mental status, normal urine output 2
• Moderate dehydration: Sunken eyes, decreased skin turgor, reduced urine output, increased thirst 2
• Severe dehydration: Severe lethargy, prolonged skin tenting, cool extremities, minimal urine output, signs of shock 2

Oral Rehydration Protocol (First-Line Treatment)

The critical mistake parents make is allowing the child to drink large volumes at once, which triggers more vomiting. 4, 2

For Mild to Moderate Dehydration:

• Administer 5-10 mL of ORS every 1-2 minutes using a spoon, syringe, or cup—never allow ad libitum drinking from a bottle 4, 1, 2
• Gradually increase volume as the child tolerates without vomiting 4, 1
• Target 50-100 mL/kg over 2-4 hours for moderate dehydration 2
• Replace each vomiting episode with an additional 2 mL/kg of ORS 2
• Over 90% of children with vomiting can be successfully rehydrated orally when this technique is properly executed 4, 1

Alternative Route if Oral Administration Fails:

• Continuous nasogastric infusion of ORS via feeding tube can be effective for children who continue vomiting with oral attempts 4
• Nasogastric rehydration is as safe and efficacious as intravenous rehydration and more cost-effective 5

Ondansetron Administration

Ondansetron should only be given after attempting oral rehydration, not as first-line therapy. 1, 2

• Dosing for 6-year-old: 0.2 mg/kg orally (maximum 4 mg) 1, 6, 3
• Indication: Persistent vomiting that impedes oral rehydration despite proper small-volume technique 1, 2, 3, 7
• Benefit: Improves tolerance of oral rehydration solutions and reduces need for hospitalization 7
• Timing: Administer 30 minutes before attempting oral rehydration 6

Nutritional Management During Illness

• Continue normal diet as tolerated—do not withhold food 1, 2
• Recommended foods: Starches, cereals, yogurt, fruits, vegetables 1, 2
• Avoid: Foods high in simple sugars and fats 1, 2
• Do not use apple juice, Gatorade, or soft drinks for rehydration—these have inappropriate osmolarity and electrolyte composition 2

Medications to Absolutely Avoid

• Never give antimotility drugs (loperamide) to children under 18 years—these can cause ileus, toxic megacolon, and serious complications 1, 2
• Do not routinely use antibiotics unless there is evidence of bacterial infection (high fever, bloody diarrhea, symptoms >5 days) 1

When Intravenous Therapy is Required

Escalate to IV rehydration if:

• Severe dehydration with signs of shock or near-shock 4, 2
• Failure of oral rehydration plus ondansetron after appropriate trial 2, 7
• Intractable vomiting despite nasogastric attempts 4
• Intestinal ileus (absent bowel sounds)—patient must remain NPO until bowel sounds return 4

IV Protocol:

• Administer 20 mL/kg boluses of Ringer's lactate or normal saline until vital signs normalize 2

Return Precautions for Parents

Instruct parents to return immediately if:

• Vomiting becomes bilious (green) or bloody 1, 2
• Child becomes increasingly lethargic or difficult to arouse 1, 2
• No urine output for >8 hours 1, 2
• Signs of severe dehydration develop despite home management 1, 2
• Persistent symptoms beyond 5 days, especially with high fever 1, 2

Common Pitfalls to Avoid

• Giving large volumes of ORS at once—this is the most common error and guarantees treatment failure 4, 2
• Using ondansetron before attempting proper oral rehydration technique—most children respond to small-volume ORS alone 1, 2
• Withholding food—continued nutrition improves outcomes 1, 2
• Ordering routine laboratory tests—these are unnecessary in uncomplicated gastroenteritis with mild-moderate dehydration 5