What is the management for a child over 1 year old with severe emesis and diarrhea?

Management of Severe Vomiting and Diarrhea in a Child Over 1 Year

The cornerstone of management is oral rehydration therapy (ORS) with small, frequent volumes (5 mL every minute via spoon or syringe) to correct dehydration, followed by immediate resumption of the child's usual diet—antibiotics and antidiarrheal agents are not indicated unless specific criteria are met. 1

Immediate Clinical Assessment

First, assess the degree of dehydration to guide therapy intensity, as this directly impacts morbidity and mortality 1:

• Mild dehydration (3-5% deficit): Increased thirst, slightly dry mucous membranes 1
• Moderate dehydration (6-9% deficit): Loss of skin turgor, skin tenting when pinched, dry mucous membranes 1
• Severe dehydration (≥10% deficit): Severe lethargy or altered consciousness, prolonged skin tenting (>2 seconds), cool/poorly perfused extremities, decreased capillary refill, rapid deep breathing (acidosis) 1

Critical point: Prolonged skin retraction time, decreased perfusion, and rapid deep breathing are more reliable predictors of dehydration than sunken fontanelle or absent tears 1

Rule out serious non-GI illnesses that can mimic gastroenteritis: meningitis, bacterial sepsis, pneumonia, otitis media, urinary tract infection, metabolic disorders, or toxic ingestions 1

Rehydration Phase

For Mild to Moderate Dehydration (Most Cases)

Administer ORS orally despite ongoing vomiting 1:

• Start with 5 mL every minute using a spoon or syringe under close supervision 1
• Mild dehydration: Give 50 mL/kg ORS over 2-4 hours 2
• Moderate dehydration: Give 100 mL/kg ORS over 2-4 hours 2
• Key principle: Small, frequent volumes prevent vomiting, and correcting dehydration itself reduces vomiting frequency 1

Replace ongoing losses continuously 2:

• 10 mL/kg ORS for each watery stool 2
• 2 mL/kg ORS for each vomiting episode 2

For Severe Dehydration

Immediately administer IV fluids: 20 mL/kg boluses of lactated Ringer's or normal saline until pulse, perfusion, and mental status normalize 2

Nutritional Management (Critical for Reducing Morbidity)

Resume the child's usual diet immediately after rehydration (within 3-4 hours) 1:

• Do NOT withhold food or use diluted formulas—this worsens nutritional outcomes and prolongs illness 1
• Recommended foods: Starches, cereals, yogurt, fruits, vegetables 1
• Avoid: Foods high in simple sugars and fats 1

For children on formula: Continue full-strength lactose-containing formula unless true lactose intolerance develops (diagnosed only by clinical worsening with more severe diarrhea upon reintroduction, NOT by stool pH or reducing substances) 1

Drug Therapy: What NOT to Use

Antidiarrheal agents are contraindicated and dangerous 1:

• Loperamide has caused severe abdominal distention, ileus, drowsiness, and at least 6 deaths in children 1
• These agents shift focus away from appropriate fluid/electrolyte therapy and can interfere with oral rehydration 1

Antibiotics are NOT indicated unless 1:

• Dysentery (bloody diarrhea) is present 1
• High fever is present 1
• Watery diarrhea persists >5 days 1
• Stool cultures identify a specific treatable pathogen 1

Laboratory Testing

Routine labs are NOT needed for typical acute watery diarrhea 1:

• Serum electrolytes only if clinical signs suggest abnormal sodium/potassium 1
• Stool cultures only indicated for dysentery (bloody diarrhea), not for routine watery diarrhea 1

Monitoring and Red Flags for Return

Reassess hydration status after 2-4 hours of ORS therapy 2

Instruct parents to return immediately if 1:

• Child becomes irritable or lethargic 1
• Decreased urine output develops 1
• Intractable vomiting occurs 1
• Diarrhea persists or worsens 1

Common Pitfalls to Avoid

• Do NOT use IV fluids when oral rehydration is feasible—oral therapy is equally effective and avoids hospitalization 3
• Do NOT delay feeding—early refeeding reduces duration of illness and prevents malnutrition 1
• Do NOT switch to lactose-free formula preemptively—most children tolerate lactose during acute diarrhea 1
• Do NOT prescribe antidiarrheal medications—they increase morbidity and mortality without benefit 1