What is the diagnosis and management for a 1-year-old female with a history of ingesting an unknown amount of Bioderm soap, presenting with 6 episodes of vomiting, abdominal pain, and stable vital signs (VS)?

Diagnosis and Management of Soap Ingestion in a 1-Year-Old

Primary Diagnosis

This is most likely acute toxin-mediated gastroenteritis from soap ingestion, which typically presents with vomiting and abdominal pain within 1-4 hours of exposure. 1

The clinical presentation—repetitive vomiting (6 episodes) with abdominal pain following soap ingestion—is consistent with direct irritant effects from the alkaline pH (9-12) of most household soaps. 1

Critical Differential Diagnoses to Exclude

While soap ingestion is the presumed cause, you must actively rule out:

• Viral gastroenteritis - Most common cause of vomiting in this age group, but the temporal relationship to soap ingestion makes this less likely 2
• Food protein-induced enterocolitis syndrome (FPIES) - Would require vomiting 1-4 hours after a specific food trigger (not soap), absence of IgE symptoms, and typically needs ≥3 minor criteria for diagnosis 3
• Sepsis or meningitis - Can present with vomiting; check for fever, lethargy, altered mental status 3, 2
• Intestinal obstruction - Bilious vomiting would suggest this; nonbilious vomiting makes it less likely 3

Immediate Assessment Priorities

Evaluate for severe dehydration and systemic toxicity:

• Hydration status: Check for prolonged skin tenting >2 seconds, cool extremities, decreased capillary refill, rapid deep breathing indicating ≥10% fluid deficit 2
• Respiratory symptoms: Assess for stridor, increased work of breathing, or cough—soap inhalation can cause late-onset respiratory distress 4
• Oropharyngeal examination: Look for labial edema, oropharyngeal irritation, or salivation which occur in 28-38% of soap exposures 1
• Neurologic status: Assess for extreme lethargy or altered mental status 3

Management Algorithm

For Mild Presentation (Current Case - Stable Vital Signs)

Supportive care with oral rehydration is the primary treatment:

• Oral rehydration therapy: Attempt breast-feeding or clear fluids to replace losses 3, 2, 5
• Ondansetron consideration: If age ≥6 months and persistent vomiting prevents oral rehydration, give ondansetron 0.15 mg/kg intramuscular (maximum 16 mg) 3, 2
• Observation period: Monitor for 4-6 hours from onset of reaction for symptom resolution 3
• Resume normal diet: Once tolerating fluids, resume age-appropriate diet immediately 5

Escalation Criteria Requiring Emergency Department Transfer

Transfer immediately if any of the following develop:

• >3 episodes of vomiting with severe lethargy, hypotonia, or ashen appearance 3
• Signs of severe dehydration (≥10% fluid deficit) 2
• Respiratory distress (stridor, increased work of breathing, cough) 4
• Persistent vomiting preventing oral rehydration 3
• Development of hypotension or shock 3

Hospital Management for Severe Cases

If severe symptoms develop:

• IV access and fluid resuscitation: Normal saline bolus 20 mL/kg rapidly, repeat as needed 3
• IV ondansetron: 0.15 mg/kg (maximum 16 mg) if age ≥6 months 3
• Consider methylprednisolone: 1 mg/kg IV (maximum 60-80 mg) for severe presentations 3
• Monitor and correct: Acid-base abnormalities, electrolyte disturbances 3

What NOT to Do

• Do NOT give antimotility drugs (loperamide) in children under 18 years—risk of ileus and serious side effects 2, 5
• Do NOT give antibiotics—this is toxin-mediated, not an active infection requiring antimicrobials 6
• Do NOT induce vomiting or give activated charcoal—not indicated for soap ingestion 1
• Do NOT assume benign course—while most soap ingestions are mild, serious complications including aspiration pneumonia and fatal outcomes have occurred, particularly with larger ingestions 1

Expected Clinical Course

Symptoms typically resolve within 24-48 hours with supportive care alone. 5, 6

• Soap-mediated symptoms resolve faster than viral gastroenteritis (hours vs. days) 3, 6
• Most patients (79%) can be discharged after observation with <4% returning within 72 hours 7

Key Pitfalls to Avoid

• Missing respiratory involvement: Soap inhalation can cause late-onset stridor and respiratory distress—maintain high suspicion even if initial respiratory exam is normal 4
• Underestimating severity in young children: While adults rarely have serious outcomes, children can develop significant complications including oropharyngeal edema and aspiration 1
• Failing to observe adequately: Maintain 4-6 hour observation period even if symptoms improve quickly 3
• Not considering alternative diagnoses: If symptoms persist beyond 24-48 hours or worsen, reconsider viral gastroenteritis, FPIES, or other gastrointestinal pathology 2, 5

Disposition

Discharge criteria:

• Back to baseline mental status 3
• Tolerating oral fluids 3
• No respiratory symptoms 4
• Adequate hydration status 2
• 4-6 hours from symptom onset with resolution 3

Return precautions: Instruct parents to return immediately for persistent vomiting, respiratory distress, lethargy, or inability to maintain hydration 3, 2