What is the best approach to manage vomiting in a 2-year-old patient?

Management of a 2-Year-Old Admitted for Vomiting

Begin immediate oral rehydration with 5 mL of oral rehydration solution (ORS) every minute using a spoon or syringe, as this approach successfully resolves vomiting in over 90% of children and is safer than intravenous therapy. 1

Immediate Red Flag Assessment

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

• Check if vomiting is bilious (green-colored) – this indicates intestinal obstruction or malrotation with volvulus and requires immediate surgical consultation 1, 2, 3
• Assess for projectile vomiting – persistent forceful vomiting suggests pyloric stenosis or other obstructive pathology requiring urgent evaluation 1, 2
• Examine the abdomen for distension or tenderness – these findings necessitate emergency surgical evaluation 1, 3
• Evaluate mental status – lethargy or altered consciousness indicates severe dehydration or central nervous system pathology 3

Hydration Status Determination

Assess dehydration severity through physical examination:

• Mild dehydration (3-5% deficit): Slightly dry mucous membranes, normal mental status, normal urine output 3
• Moderate dehydration (6-9% deficit): Sunken eyes, decreased skin turgor, reduced urine output, increased thirst 3
• Severe dehydration (≥10% deficit): Severe lethargy, prolonged skin tenting, cool extremities, minimal urine output, signs of shock 3

Rehydration Protocol

For Mild to Moderate Dehydration (Most Common Scenario)

The cornerstone of management is small-volume, frequent oral rehydration:

• Start with 5 mL of ORS every 1-2 minutes using a teaspoon or syringe under close supervision 4, 1, 3
• Gradually increase volume as tolerated – the key is patience with small amounts rather than large volumes that trigger more vomiting 4, 3
• Target 50-100 mL/kg of ORS over 2-4 hours for moderate dehydration 2, 3
• Replace each vomiting episode with an additional 2 mL/kg of ORS 2, 3
• Reassess hydration status after 2-4 hours and adjust the plan accordingly 2

Critical pitfall to avoid: Do not give large volumes of ORS at once – this will trigger more vomiting and perpetuate the cycle. Small, frequent volumes are essential for success. 3

For Severe Dehydration

• Initiate immediate intravenous rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until vital signs normalize 3
• Transition to oral rehydration once the child is stabilized and able to tolerate oral intake 3

Antiemetic Considerations

Do not routinely use antiemetics as first-line therapy – most children respond to proper ORS administration alone. 3

However, ondansetron may be considered in specific circumstances:

• Ondansetron is indicated only for children ≥4 years with persistent vomiting that impedes oral rehydration 1, 3
• Since this patient is 2 years old, ondansetron is NOT recommended based on current guidelines 2
• Dose (if applicable for older children): 0.2 mg/kg orally or 0.15 mg/kg parenterally (maximum 4 mg) 1, 5
• Administer only after attempting oral rehydration, not as first-line therapy 3

Nutritional Management

Continue age-appropriate nutrition as soon as vomiting is controlled:

• Do not restrict diet unnecessarily – early refeeding improves outcomes 2
• Continue the child's usual diet with starches, cereals, yogurt, fruits, and vegetables 4, 1, 2, 3
• Avoid foods high in simple sugars and fats 4, 1, 2, 3
• If formula-fed, continue full-strength formula if tolerated 1, 3
• Consider lactose-free formula only if intolerance is suspected (indicated by worsening diarrhea upon lactose introduction) 1, 3

Medications to Avoid

Never administer antimotility drugs (loperamide) to children under 18 years with vomiting and diarrhea – these can cause serious complications including ileus and toxic megacolon. 3

Antibiotics are not indicated unless there is evidence of bacterial infection (high fever, bloody diarrhea, or symptoms lasting >5 days). 4, 1

Monitoring and Discharge Criteria

Discharge is appropriate when:

• Vomiting has resolved or significantly decreased 1
• The child tolerates oral fluids and maintains hydration 1
• Urine output is adequate 1
• Parents understand home management instructions 4

Parent Education for Home Management

Instruct parents to return immediately if:

• Vomiting becomes bilious (green) or bloody 3
• The child becomes increasingly lethargic or difficult to arouse 3
• Urine output decreases significantly (no urine for >8 hours) 4, 3
• Signs of severe dehydration develop despite oral rehydration attempts 3
• Symptoms persist beyond 5 days, especially with high fever 3

Provide parents with a 24-hour supply of ORS upon discharge to ensure they have appropriate rehydration solution at home. 4

Common Pitfalls to Avoid

• Do not use apple juice, Gatorade, or soft drinks for rehydration – these have inappropriate osmolarity and electrolyte composition 3
• Do not give large volumes at once – this is the most common error that leads to treatment failure 3
• Do not delay assessment for bilious vomiting – this requires immediate surgical consultation 1, 2, 3
• Do not routinely use antiemetics before attempting proper oral rehydration – over 90% of children respond to ORS alone when administered correctly 1, 3