What is the appropriate management for a 14‑year‑old presenting with vomiting, diarrhea and a temperature of 102.3 °F?

Management of 14-Year-Old with Vomiting, Diarrhea, and Fever

This 14-year-old with acute gastroenteritis should be assessed for dehydration severity and managed primarily with oral rehydration solution (ORS), early refeeding with age-appropriate diet, and replacement of ongoing losses—antibiotics and antidiarrheal medications are not indicated unless specific criteria are met. 1, 2

Initial Assessment

Assess hydration status through specific clinical signs:

• Mild dehydration (3-5% deficit): Increased thirst, slightly dry mucous membranes, normal mental status, normal skin turgor 1, 2
• Moderate dehydration (6-9% deficit): Dry mucous membranes, decreased skin turgor, sunken eyes, decreased urine output 1, 2
• Severe dehydration (≥10% deficit): Severe lethargy or altered consciousness, prolonged skin tenting (>2 seconds), cool and poorly perfused extremities, rapid deep breathing indicating acidosis 1, 2

Obtain an accurate body weight and check for adequate bowel sounds before initiating oral therapy. 1

Laboratory studies are rarely needed—stool cultures are indicated only for bloody diarrhea (dysentery), not for typical watery diarrhea in immunocompetent patients. 1

Rehydration Protocol Based on Severity

For Mild Dehydration (Most Likely Scenario)

• Administer 50 mL/kg of ORS over 2-4 hours 1, 2
• Start with small volumes (5-10 mL every 1-2 minutes) using a spoon or syringe to prevent triggering more vomiting 2, 3
• Reassess hydration status after 2-4 hours and progress to maintenance therapy if rehydrated 1

For Moderate Dehydration

• Administer 100 mL/kg of ORS over 2-4 hours 1, 2
• Use the same gradual approach with small, frequent volumes 1

For Severe Dehydration (Medical Emergency)

• Initiate immediate IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 1
• Once consciousness returns, the patient can take remaining deficit by mouth 1

Replacement of Ongoing Losses

Replace each watery/loose stool with 10 mL/kg of ORS and each vomiting episode with 2 mL/kg of ORS throughout both rehydration and maintenance phases. 1, 2

Management of Vomiting

For persistent vomiting, administer small volumes (5 mL) of ORS every minute using a spoon or syringe—simultaneous correction of dehydration often lessens vomiting frequency. 1, 3

Consider ondansetron 0.2 mg/kg orally (maximum 4 mg) for children >4 years with persistent vomiting to facilitate oral rehydration tolerance, but only after hydration is established. 2, 3, 4

Nutritional Management

Resume age-appropriate diet immediately during or after rehydration—do not restrict diet or use prolonged fasting. 2, 3

Recommended foods for adolescents:

• Starches: rice, potatoes, noodles, crackers, bananas 1, 2
• Cereals: rice, wheat, oat cereals 1, 2
• Yogurt, vegetables, fresh fruits 1, 2

Avoid foods high in simple sugars (soft drinks, undiluted apple juice, Jell-O, presweetened cereals) as they exacerbate diarrhea through osmotic effects. 1, 2

Avoid foods high in fat as they delay gastric emptying. 1

Medication Considerations

Antibiotics

Antibiotics are NOT routinely indicated for acute viral gastroenteritis. 1

Consider antibiotics only when:

• Bloody diarrhea (dysentery) is present 1
• High fever persists with systemic symptoms 1, 3
• Watery diarrhea lasts >5 days 1
• Stool cultures identify a specific treatable pathogen 1

Antidiarrheal Agents

Do NOT use antimotility agents (loperamide) or other nonspecific antidiarrheal agents—they are ineffective at reducing diarrhea volume or duration and carry serious risks including ileus and death. 1, 2, 3

Fever Management

The fever of 102.3°F (39.1°C) is consistent with viral gastroenteritis and does not automatically require antibiotics. 1 Standard antipyretics (acetaminophen or ibuprofen) can be used for comfort if the patient is adequately hydrated. 5

Red Flags Requiring Emergency Evaluation

Seek immediate medical attention if:

• Bilious (green) vomiting occurs—suggests intestinal obstruction 3, 6
• Signs of severe dehydration develop 1, 2
• Altered mental status or severe lethargy 1, 2
• Bloody diarrhea with high fever 1
• Abdominal distension or severe tenderness 6

Common Pitfalls to Avoid

Do not rely on sports drinks, apple juice, or other high-sugar beverages as primary rehydration solutions—they worsen diarrhea. 2

Do not delay oral rehydration while waiting for laboratory results in non-severe cases. 1

Do not use the "BRAT diet" exclusively or for prolonged periods—it provides inadequate energy and protein. 1

Do not prescribe antimotility agents despite parental requests—the risks outweigh any theoretical benefits. 1, 2