What is the appropriate management for a 1-year-old child presenting with five episodes of vomiting over the past 12 hours, no fever or abdominal pain, normal activity, being fed breast milk and cereal, and constipation with hard stools?

Management of a 1-Year-Old with Vomiting and Constipation

This child's vomiting is likely related to constipation causing functional obstruction, so the primary management should focus on treating the constipation while ensuring adequate hydration and continued feeding.

Immediate Assessment

Assess hydration status first by examining:

• Skin turgor, mucous membranes, mental status, pulse, and capillary refill time 1
• Thirst (an early sign of dehydration) 2
• Delayed capillary filling, absence of tears, mucosal dryness 2
• Weigh the child to establish baseline and monitor treatment effectiveness 1

Since the child has good activity and no fever, this suggests no or minimal dehydration currently 3.

Hydration Management

For a child with no signs of dehydration but ongoing vomiting:

• Skip the rehydration phase and proceed directly to maintenance therapy 3
• Replace ongoing losses with 10 mL/kg of oral rehydration solution (ORS) after each vomiting episode 1
• If vomiting persists, give small, frequent volumes (5 mL every 1-2 minutes) using a teaspoon or syringe 1, 2
• This approach is feasible even with vomiting and prevents dehydration 2

Feeding Strategy

Continue all feeding without interruption:

• Continue breastfeeding on demand throughout the episode - this is strongly recommended and reduces symptom severity 3, 1
• Continue full-strength cereal (Cerelac) immediately - do not dilute or delay solid foods 3
• Early feeding improves nutritional outcomes and does not worsen vomiting or diarrhea 3

Constipation Management (Primary Issue)

Address the underlying constipation causing the vomiting:

• Increase fluid intake beyond normal amounts 3
• Increase dietary fiber through age-appropriate foods (fruits, vegetables, whole grains)
• Consider a glycerin suppository for immediate relief if impaction is suspected
• Avoid prolonged use of stimulant laxatives in this age group

Medications: Critical Contraindications

Do NOT give:

• Antimotility drugs (loperamide) - absolutely contraindicated in children <18 years 3
• Antiemetics (ondansetron) - only recommended for children >4 years of age 3
• Antidiarrheal medications - these do not prevent dehydration and carry risks 2

Red Flags Requiring Immediate Medical Attention

Return immediately if the child develops:

• Sunken eyes, very poor skin turgor, or altered mental status 1
• Irritability or lethargy 1
• Decreased urine output 1
• Intractable vomiting (unable to keep down even small sips) 1
• Fever develops 2
• Bilious (green) vomiting suggesting true obstruction

Common Pitfalls to Avoid

• Do not withhold food - this worsens nutritional outcomes and prolongs illness 3, 1
• Do not dilute breast milk or formula - full-strength feeding is safe and beneficial 3, 1
• Do not use cola drinks or inappropriate beverages for hydration - these are hyperosmolar and worsen symptoms 2
• Do not assume this is infectious gastroenteritis - the constipation history and lack of fever/diarrhea suggest mechanical vomiting from stool impaction

Follow-Up

• Monitor stool pattern closely over next 24-48 hours
• If constipation persists beyond 2-3 days despite conservative measures, consider pediatric evaluation for possible disimpaction
• Keep ORS sachets at home for future episodes 2