Management of Vomiting in a 2-Year-Old Child Weighing 30 lb
Immediately assess hydration status and rule out surgical emergencies—particularly bilious vomiting, which indicates intestinal obstruction and requires urgent surgical evaluation. 1, 2
Immediate Red Flag Assessment
First, determine if the vomiting is bilious (green-colored) versus non-bilious:
- Bilious vomiting constitutes a surgical emergency until proven otherwise, indicating obstruction distal to the ampulla of Vater 3, 1, 2
- Obtain an abdominal X-ray immediately if bilious vomiting is present, followed by urgent surgical consultation 2
- Look for associated symptoms: bloody vomit or "currant jelly" stools (suggests intussusception), abdominal distension, lethargy, or inconsolable crying with leg drawing 1, 2
If vomiting is projectile and non-bilious, consider pyloric stenosis (though this typically presents between 2-8 weeks of age, not at 2 years) 1, 4
Hydration Status Evaluation
Assess dehydration severity using these clinical signs 1:
Mild dehydration (3-5% deficit):
- Slightly decreased urine output
- Normal mental status 1
Moderate dehydration (6-9% deficit):
- Sunken fontanelle (if still open)
- Dry mucous membranes
- Decreased skin turgor
- Capillary refill >2 seconds 1
Severe dehydration (≥10% deficit):
- Severe lethargy or altered consciousness
- Cool extremities
- Poor perfusion
- Rapid deep breathing (acidosis) 1
Rehydration Protocol
For mild to moderate dehydration (most common scenario):
- Administer oral rehydration solution (ORS) as first-line therapy: 50-100 mL/kg over 3-4 hours 3, 1
- For a 30 lb (approximately 14 kg) child, this equals 700-1400 mL ORS over 3-4 hours 3
- Give in small, frequent volumes: 5 mL every minute initially using a spoon or syringe 1, 4
- Replace ongoing losses: 10 mL/kg (140 mL) for each vomiting episode 3, 1
Simultaneous correction of dehydration often reduces vomiting frequency, so aggressive oral rehydration may be therapeutic as well as diagnostic 1, 4
Feeding Management
- Continue full-strength formula or breast milk immediately—do not dilute or withhold feeds 1, 4
- Resume age-appropriate solid foods immediately, including starches, cereals, yogurt, fruits, and vegetables 1
- Avoid foods high in simple sugars and fats 1
Antiemetic Consideration
Ondansetron (0.2 mg/kg oral, maximum 4 mg) may be considered ONLY if persistent vomiting prevents oral intake entirely 1, 4
However, antiemetics are generally not indicated for routine viral gastroenteritis in young children, as they shift focus away from appropriate fluid therapy 4
When to Escalate to IV Rehydration
Immediate hospitalization and IV rehydration required for:
- Severe dehydration (≥10% deficit) with signs of shock 3, 1
- Bilious vomiting (with mandatory surgical consultation) 1, 2
- Failure of oral rehydration therapy 3
- Altered mental status 3
For severe dehydration, administer intravenous isotonic crystalloid boluses up to 20 mL/kg until pulse, perfusion, and mental status normalize 3
Critical Return Precautions
Instruct parents to return immediately or call if 1:
- Vomiting becomes projectile or bilious (green color)
- Decreased urine output (fewer than 4 wet diapers in 24 hours)
- Lethargy or altered mental status
- Bloody vomit or stool
- Inability to keep down any fluids
Common Pitfalls to Avoid
- Do not assume non-bilious vomiting is benign—malrotation with volvulus can present at any age, not just newborns, and can progress from non-bilious to bilious vomiting 4, 2
- Do not use popular beverages like apple juice, Gatorade, or commercial soft drinks for rehydration—these are inappropriate substitutes for ORS 3
- Do not withhold feeds or dilute formula, as this delays nutritional recovery 1, 4
- Do not rely solely on weight estimation formulas in emergencies—the child's stated weight of 30 lb should be verified if possible, as modern formulas like Weight(kg)=3(age)+7 are more accurate than older methods 5, 6