What is the recommended initial assessment and management for a pediatric patient presenting with vomiting and diarrhea?

Management of Vomiting and Diarrhea in Pediatric Patients

Initial Assessment

The cornerstone of initial assessment is determining the degree of dehydration through clinical examination, which dictates all subsequent management decisions. 1

Dehydration Classification

Assess dehydration severity using these specific clinical parameters:

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

Capillary refill time is the most reliable predictor of dehydration in children. 2 Abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern are the three most useful predictors of 5% or more dehydration 3.

Obtain accurate body weight to establish baseline and calculate fluid deficit 2. Do not rely solely on sunken fontanelle or absent tears for dehydration assessment 2.

Red Flag Signs Requiring Immediate Attention

Identify these warning signs that indicate serious pathology or need for immediate intervention:

• Bilious or bloody vomiting 4
• Altered sensorium or severe lethargy 4
• Toxic/septic appearance 4
• Inconsolable cry or excessive irritability 4
• Severe dehydration with shock or near-shock 1
• Intractable vomiting preventing oral rehydration 1
• High stool output (>10 mL/kg/hour) 1

Rehydration Strategy

Severe Dehydration (≥10% Deficit)

Administer 20 mL/kg boluses of Ringer's lactate or normal saline IV immediately until pulse, perfusion, and mental status normalize. 2 This constitutes a medical emergency 2. Monitor continuously for improvement in vital signs and perfusion 2. Once circulation is restored, transition to oral rehydration solution (ORS) for the remaining deficit 2.

Moderate Dehydration (6-9% Deficit)

Administer 100 mL/kg of reduced osmolarity ORS (containing 75-90 mEq/L sodium) over 2-4 hours. 1, 2 If oral intake is not tolerated, consider nasogastric administration 5, 2.

Mild Dehydration (3-5% Deficit)

Administer 50 mL/kg of ORS over 2-4 hours. 1, 2

ORS Administration Technique for Vomiting Children

A critical pitfall is allowing a thirsty child to drink large volumes of ORS ad libitum, which worsens vomiting. 1 Instead, administer small volumes (5-10 mL) every 1-2 minutes using a spoon, syringe, cup, or feeding bottle, with gradual increase in the amount consumed 1. Do not allow ad libitum drinking in vomiting patients 6.

Ongoing Loss Replacement

After initial rehydration, replace ongoing losses with:

• 10 mL/kg of ORS for each watery stool 1, 2
• 2 mL/kg of ORS for each vomiting episode 1, 2

Continue maintenance fluids until diarrhea and vomiting resolve 5, 1.

Reassess hydration status after 2-4 hours of rehydration therapy 1, 2.

Nutritional Management

Continue breastfeeding on demand throughout the entire diarrheal episode without any interruption. 5, 1, 2 This is a strong recommendation from the American Academy of Pediatrics 1.

Resume age-appropriate usual diet during or immediately after rehydration is completed. 5, 1 There is no justification for "bowel rest" 2. Recommended foods include starches, cereals, yogurt, fruits, and vegetables; avoid foods high in simple sugars and fats 1, 2.

For bottle-fed infants, resume full-strength formula immediately upon rehydration 1. Consider lactose-free or lactose-reduced formula if severe diarrhea occurs upon reintroduction of lactose 2.

Pharmacological Management

Antiemetics

Ondansetron may be given to children >4 years of age to facilitate oral rehydration when vomiting is present, but only after adequate hydration is achieved. 1 Evidence shows increased ORS success rates and reduced need for IV therapy and hospitalization 1. The dose is 0.2 mg/kg oral or 0.15 mg/kg parenteral (maximum 4 mg) 4.

Antimotility Agents

Antimotility drugs (loperamide) are absolutely contraindicated in all children <18 years of age due to risks of respiratory depression and serious cardiac adverse reactions. 5, 1, 2 This is a strong recommendation that should never be violated 5.

Probiotics

Probiotic preparations may be offered to reduce symptom severity and duration in immunocompetent children with infectious diarrhea 5, 1.

Zinc Supplementation

Zinc supplementation reduces diarrhea duration in children 6 months to 5 years of age who reside in countries with high zinc deficiency prevalence or show signs of malnutrition. 5, 1

Antimicrobial Therapy

In most children with acute watery diarrhea, empiric antimicrobial therapy is not recommended. 5 An exception may be made in immunocompromised children or young infants who are ill-appearing 5.

Consider antibiotics only when:

• Dysentery (bloody diarrhea) is present 1, 2
• High fever occurs 2
• Watery diarrhea persists >5 days 1, 2
• Stool cultures indicate a specific pathogen requiring treatment 1, 2

Antimicrobial treatment should be modified or discontinued when a clinically plausible organism is identified 5.

Laboratory Testing

Laboratory tests are not routinely required for mild-moderate dehydration, as they do not affect management in most cases. 2 Investigations (serum electrolytes, blood gases, renal and liver functions, radiological studies) are required in any child with severe dehydration or red flag signs 4.

Admission Criteria

Hospitalize patients who have:

• Severe dehydration (≥10% deficit) or signs of shock 2
• Intractable vomiting preventing successful oral rehydration 1
• High stool output (>10 mL/kg/hour) 1
• Failure of oral rehydration therapy 1

Common Pitfalls to Avoid

• Do not use cola drinks or soft drinks for rehydration as they contain inadequate sodium and excessive osmolality that worsens diarrhea 2
• Do not mix ORS packets with inappropriate volumes of water; provide detailed written and oral instructions when packets are used 1
• Do not routinely order laboratory tests for mild-moderate dehydration without specific clinical indications 2
• Do not delay feeding as there is no justification for "bowel rest" 2