How should I manage a 1‑year‑old with 8 days of watery yellow diarrhea, vomiting, intermittent low‑grade fever, and inability to tolerate milk?

Management of 8-Day Diarrhea with Vomiting in a 1-Year-Old

This 1-year-old with 8 days of watery yellow diarrhea, vomiting, intermittent low-grade fever, and milk intolerance most likely has viral gastroenteritis and requires immediate assessment of hydration status, oral rehydration therapy with ORS, and transition to lactose-free formula. 1, 2

Immediate Clinical Assessment

Rapidly assess hydration status by examining:

• Skin turgor and tenting (prolonged tenting >2 seconds indicates severe dehydration) 1, 2
• Mucous membranes (dry indicates moderate dehydration) 1, 3
• Mental status (lethargy or altered consciousness indicates severe dehydration) 1, 3
• Capillary refill time (prolonged indicates severe dehydration) 1, 2
• Weight loss (most reliable indicator if pre-illness weight is known) 2, 4

Classify dehydration severity:

• Mild (3-5% deficit): slightly dry mucous membranes, increased thirst 1, 3
• Moderate (6-9% deficit): loss of skin turgor, dry mucous membranes, decreased urine output 1, 3
• Severe (≥10% deficit): severe lethargy, prolonged skin tenting, cool extremities, rapid deep breathing 1, 3

Rehydration Protocol

For mild dehydration: Give 50 mL/kg of oral rehydration solution (ORS) over 2-4 hours 2, 4

For moderate dehydration: Give 100 mL/kg of ORS over 2-4 hours 2, 4

For severe dehydration: Immediately start IV rehydration with 20 mL/kg boluses of Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize, then transition to ORS 2, 4

Managing the Vomiting

Give small, frequent volumes of ORS (5 mL every 1-2 minutes) using a spoon or syringe to prevent triggering more vomiting 1, 2, 3. Gradual administration with close supervision is critical 1. Simultaneous correction of dehydration often lessens vomiting frequency 1, 2.

Replacing Ongoing Losses

After initial rehydration, replace ongoing losses with:

• 10 mL/kg of ORS for each watery stool 2, 4
• 2 mL/kg of ORS for each vomiting episode 2, 4

Continue this replacement until diarrhea and vomiting resolve 2.

Nutritional Management: The Milk Intolerance Issue

This child's inability to tolerate milk after 8 days of diarrhea suggests secondary lactose intolerance, which is common after prolonged viral gastroenteritis 1, 2.

Switch to lactose-free or lactose-reduced formula immediately upon rehydration 2, 4. Resume full-strength formula without dilution 4. True lactose intolerance is confirmed by worsening diarrhea when lactose-containing formula is reintroduced 1, 2.

If the child is on solid foods, resume age-appropriate diet immediately, including:

• Starches, cereals, yogurt, fruits, and vegetables 1, 2, 4
• Avoid foods high in simple sugars and fats 1, 2

Zinc Supplementation

Administer oral zinc supplementation to reduce diarrhea duration, particularly beneficial for infants with signs of malnutrition 2, 4. This is recommended by the World Health Organization for children aged 6 months to 5 years 2, 4.

When to Consider Antibiotics

Do NOT use antibiotics routinely for this presentation 1, 2. Watery diarrhea and vomiting in a child less than 2 years of age most likely represents viral gastroenteritis and does not require antimicrobial therapy 1.

Consider antibiotics only if:

• Bloody diarrhea (dysentery) with high fever is present 1, 2
• Watery diarrhea persists beyond this point (already 8 days) 1, 2
• Stool cultures indicate a specific pathogen requiring treatment 2, 4

Given this child is already at 8 days, if diarrhea continues beyond 5 days with no improvement, stool cultures should be obtained 1, 2.

Medications to AVOID

Do NOT use antimotility agents (loperamide) in this 1-year-old child 1, 2, 4. These are absolutely contraindicated in children under 18 years due to risks of ileus, respiratory depression, and deaths 1, 2, 4. Reports from Pakistan documented 18 cases of severe abdominal distention with loperamide use, including at least six deaths 1.

Do NOT use antiemetics (ondansetron) in this 1-year-old 2, 4. Ondansetron is only recommended for children over 4 years of age 2, 4.

Do NOT use nonspecific antidiarrheal agents (kaolin-pectin, adsorbents, antisecretory drugs) as they do not reduce diarrhea volume or duration, can cause side effects, and shift focus away from appropriate fluid and nutritional therapy 1.

Reassessment and Red Flags

Reassess hydration status after 2-4 hours of rehydration 2, 4. If the child remains dehydrated, reassess the fluid deficit and restart the rehydration protocol 2, 4.

Instruct parents to return immediately if:

• Persistent watery stools continue 2
• Intractable vomiting develops 1, 2
• Decreased urine output occurs 1, 2
• Child becomes irritable, lethargic, or condition worsens 1, 2

Common Pitfalls to Avoid

Do not use "clear liquids" like cola, apple juice, or sports drinks for rehydration, as they contain inadequate sodium and excessive sugar, which can cause osmotic diarrhea and worsen electrolyte imbalance 2.

Do not dilute formula when reintroducing feeds 4. Use full-strength lactose-free formula immediately 2, 4.

Do not delay refeeding after rehydration is achieved, as early nutritional support reduces severity and duration of illness 1, 3.