What is the appropriate management for a 3‑year‑old child presenting with acute vomiting, diarrhea, and fever?

Management of a 3-Year-Old with Vomiting, Diarrhea, and Fever

Immediate Assessment of Dehydration Severity

The first priority is to rapidly assess dehydration status through physical examination, as this determines all subsequent management decisions. 1

Classify dehydration using these specific clinical signs:

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

The most reliable clinical predictors are capillary refill time, abnormal skin turgor, and abnormal respiratory pattern—these are more accurate than sunken fontanelle or absent tears 1, 2. Obtain the child's weight immediately to calculate fluid deficit accurately 1.

Rehydration Protocol Based on Severity

For Mild Dehydration (Most Likely Scenario)

Administer 50 mL/kg of oral rehydration solution (ORS) over 2-4 hours. 1

• Start with very small volumes (5-10 mL every 1-2 minutes) using a spoon or syringe to prevent triggering more vomiting 3
• Gradually increase volume as tolerated 1
• This small-volume technique successfully rehydrates >90% of children with vomiting and diarrhea without antiemetics 3, 4

For Moderate Dehydration

Administer 100 mL/kg of ORS over 2-4 hours. 1

• Use the same small-volume technique described above 1
• Consider nasogastric administration if oral intake is not tolerated 1, 3

For Severe Dehydration (Medical Emergency)

Administer 20 mL/kg boluses of Ringer's lactate or normal saline IV immediately until pulse, perfusion, and mental status normalize. 1

• This requires immediate hospitalization 1
• Once circulation is restored, transition to ORS for remaining deficit 1

Ongoing Loss Replacement

After initial rehydration, replace continuing losses:

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

Nutritional Management

Resume age-appropriate diet immediately upon rehydration—there is no justification for "bowel rest." 1

• Continue breastfeeding throughout the entire episode without interruption 1, 3
• Offer starches, cereals, yogurt, fruits, and vegetables 1
• Avoid foods high in simple sugars (soft drinks, undiluted apple juice) and high-fat foods, as these worsen diarrhea through osmotic effects 1, 3
• Early refeeding reduces severity and duration of illness 3

Pharmacological Considerations

Antiemetics

Ondansetron may be considered if vomiting prevents adequate oral intake. 1, 2

• Reduces vomiting rate, improves ORS tolerance, and decreases need for IV rehydration 1, 2
• Appropriate for children >4 years 3
• Very few serious side effects reported 2

Absolutely Contraindicated Medications

Never administer loperamide or other antimotility agents to children <18 years—these are absolutely contraindicated due to risks of respiratory depression and serious cardiac adverse reactions. 1, 3

• Metoclopramide should also not be used, as it has no role in gastroenteritis management and may worsen symptoms 3
• Antimicrobial therapy is not indicated unless stool cultures identify a specific pathogen requiring treatment or diarrhea persists >5 days 1

Monitoring and Reassessment

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

• Monitor capillary refill, skin turgor, mental status, mucous membrane moisture 3
• If rehydrated, transition to maintenance phase with ongoing loss replacement 1
• If still dehydrated, reestimate deficit and restart rehydration 3

Red Flags Requiring Immediate Medical Attention

Instruct caregivers to return immediately if:

• Signs of severe dehydration develop (altered consciousness, prolonged skin tenting >2 seconds, cool extremities) 1
• Intractable vomiting despite small-volume ORS administration 1
• Bloody diarrhea develops 1
• High stool output (>10 mL/kg/hour) persists 1
• Condition worsens or fever increases 1

Special Considerations for This Age Group

At 3 years old, this child is at lower risk than infants <6 months but still requires careful monitoring 5. Most cases are viral (norovirus or rotavirus) and self-limited, lasting <7 days 5. Laboratory testing of blood or stool is usually unnecessary unless the child appears toxic, has bloody diarrhea, or fails to improve with appropriate rehydration 3, 4.

Infection Control

• Practice proper hand hygiene after using toilet, before eating, and after handling soiled items 3
• Clean and disinfect contaminated surfaces promptly 3
• Keep the child separated from well siblings until at least 2 days after symptom resolution 3