Yellow Vomit in a Toddler: Urgent Evaluation Required
Yellow vomit in a toddler indicates bilious emesis, which represents intestinal obstruction until proven otherwise and requires immediate emergency evaluation with surgical consultation. 1, 2, 3
Immediate Action Required
Bilious (yellow-green) vomiting is a surgical emergency that mandates urgent imaging and surgical evaluation, as it may indicate life-threatening conditions including midgut volvulus, which can cause intestinal necrosis within hours. 1, 2, 3
Critical Time-Sensitive Conditions to Exclude:
- Midgut malrotation with volvulus: Can cause complete intestinal necrosis requiring massive bowel resection or death if not surgically corrected within hours 2
- Intussusception: Common cause of bilious vomiting in toddlers aged 1-3 years 2
- Intestinal obstruction from other causes: Including internal hernia or adhesions 2
Emergency Department Evaluation Protocol
Immediate Imaging Studies:
Obtain abdominal radiograph immediately to look for "double bubble" sign, dilated bowel loops, or abnormal gas patterns, though normal radiographs do NOT exclude malrotation or volvulus 2
Proceed directly to upper GI contrast series if clinical suspicion exists based on bilious vomiting alone, regardless of radiograph findings—this is the definitive diagnostic study with 96% sensitivity for malrotation 2
Do not delay imaging based on normal initial radiographs, as up to 7% false-negative rates occur 2
Immediate Management While Awaiting Imaging:
- Stop all oral intake immediately 4
- Place nasogastric tube for gastric decompression in patients with bilious vomiting 4
- Establish IV access for fluid resuscitation if any signs of dehydration are present 3
- Obtain immediate surgical consultation 1, 3
Assessment of Hydration Status
While awaiting emergency evaluation, assess dehydration severity:
Mild Dehydration (3-5% deficit):
- Slightly dry mucous membranes, normal mental status, normal urine output 3
- Management: IV fluids in emergency setting given the bilious vomiting 3
Moderate Dehydration (6-9% deficit):
- Sunken eyes, decreased skin turgor, reduced urine output, increased thirst 3
- Management: IV rehydration required 3
Severe Dehydration (≥10% deficit):
- Severe lethargy, prolonged skin tenting >2 seconds, cool extremities, minimal urine output, signs of shock 3
- Management: Aggressive IV resuscitation, treat as shock 5, 3
Critical Pitfalls to Avoid
Common mistake: Assuming yellow vomit is simply gastroenteritis and attempting oral rehydration at home. Bilious vomiting requires emergency evaluation regardless of the child's overall appearance. 1, 2, 3
Do NOT:
- Attempt oral rehydration therapy until surgical obstruction is excluded 1, 4
- Give antiemetics before surgical evaluation 3, 4
- Give antimotility drugs (loperamide)—these are contraindicated in children under 18 years 1, 3
- Delay imaging based on normal initial radiographs 2
If Non-Bilious Vomiting (After Surgical Causes Excluded)
Only if imaging definitively excludes obstruction and vomiting is determined to be non-bilious (clear, white, or food-colored):
Oral Rehydration Strategy:
- Administer 5 mL of oral rehydration solution (ORS) every 1-2 minutes using a spoon or syringe—never allow ad libitum drinking from a cup 5, 1
- Gradually increase volume as tolerated 5, 1
- Replace each vomiting episode with additional 2 mL/kg of ORS 3
Ondansetron Consideration:
- May give ondansetron 0.2 mg/kg orally (maximum 4 mg) only after adequate hydration is established and surgical causes excluded, to facilitate oral rehydration 1, 4
Nutritional Management:
- Continue breastfeeding on demand 1
- Continue full-strength formula if tolerated 1
- Continue usual diet with starches, cereals, yogurt, fruits, and vegetables; avoid high-sugar and high-fat foods 1
When to Return Immediately
Parents must return to emergency care if: