How should I manage a 2½‑year‑old boy with seven days of watery diarrhea, intermittent vomiting, nighttime cough, no fever, normal respiratory rate, and a sibling who had a mild viral upper‑respiratory infection?

Management of Probable Viral Gastroenteritis in a Toddler

This 2½-year-old boy with seven days of watery diarrhea, intermittent vomiting, nighttime cough, no fever, and normal respiratory rate most likely has viral gastroenteritis and should be managed with oral rehydration solution (ORS) administered in small, frequent volumes (5 mL every 1–2 minutes), immediate resumption of his normal diet, and close monitoring for dehydration—no antibiotics or antimotility agents are indicated. 1

Clinical Assessment & Diagnosis

Determine hydration status immediately, as this drives all management decisions:

• Mild dehydration (3–5% fluid deficit): slightly dry mucous membranes, normal mental status, adequate urine output 2
• Moderate dehydration (6–9% fluid deficit): dry mucous membranes, skin tenting, reduced urine output, mild lethargy 2, 3
• Severe dehydration (≥10% fluid deficit): altered consciousness, skin tenting >2 seconds, cool extremities, poor capillary refill, rapid deep breathing—this is a medical emergency requiring immediate IV rehydration 2, 3

The clinical picture strongly suggests viral gastroenteritis because watery diarrhea and vomiting in a child under 3 years of age, without fever or bloody stools, is most consistent with viral etiology (rotavirus, adenovirus, or norovirus). 1, 4 The sibling's recent URI supports a viral household transmission pattern. 5

Oral Rehydration Protocol

Administer ORS using the small-volume, frequent technique—this is the single most important intervention and succeeds in >90% of cases when done correctly:

• Give 5 mL of ORS every 1–2 minutes using a spoon or syringe 2, 6, 3
• Never allow the child to drink large volumes rapidly from a cup, as this triggers vomiting and falsely suggests ORT failure 3, 7
• Gradually increase volume as tolerated without provoking vomiting 2, 6
• For moderate dehydration, deliver 100 mL/kg total over 2–4 hours 2, 3
• Replace ongoing losses: 10 mL/kg for each watery stool and 2 mL/kg for each vomiting episode 2, 3
• Reassess hydration status after 2–4 hours 2, 3

Nutritional Management

Resume his normal age-appropriate diet immediately—do not withhold food or enforce restrictive diets:

• Continue regular meals during or immediately after rehydration 1, 2
• Recommended foods: starches (rice, potatoes, noodles, crackers, bananas), cereals (rice, wheat, oats), yogurt, cooked vegetables, fresh fruits 1, 2
• Avoid: soft drinks, undiluted apple juice, gelatin, presweetened cereals (high simple sugars worsen diarrhea via osmotic effects), high-fat foods, caffeinated beverages 1, 2, 3
• The BRAT diet is acceptable short-term but should not be prolonged, as it provides inadequate energy and protein 1

Medications: What NOT to Give

Antimotility agents (loperamide) are absolutely contraindicated in all children under 18 years—they can cause severe abdominal distension, ileus, and death. 1, 2

Antibiotics are not indicated because viral agents predominate in this clinical scenario (watery diarrhea, no fever, no blood in stool). 1, 3 Consider antibiotics only if:

• Bloody diarrhea with high fever develops 1, 3
• Watery diarrhea persists beyond 5 days 1
• Stool culture identifies a treatable bacterial pathogen 1

Antiemetics (ondansetron) may be considered for children >4 years with persistent vomiting to facilitate oral rehydration, but only after adequate hydration is established. 2, 6, 8 Given this child is 2½ years old, ondansetron is generally not advised, though it can be considered in severe cases. 2

Adsorbents, antisecretory drugs, and toxin binders (kaolin-pectin, cholestyramine) are ineffective and should be avoided. 1, 3

Addressing the Nighttime Cough

The nighttime cough likely represents:

• Post-viral upper respiratory symptoms from the household URI exposure 4
• Possible post-tussive vomiting (cough triggering emesis)
• No specific treatment is needed if respiratory rate is normal and there are no signs of respiratory distress

Red Flags Requiring Immediate Medical Evaluation

Seek emergency care if any of the following develop:

• Bilious (green) vomiting—suggests intestinal obstruction 6, 3
• Bloody stools with fever—indicates possible bacterial infection requiring stool culture 1, 3
• Signs of severe dehydration: altered consciousness, severe lethargy, skin tenting >2 seconds, cool extremities, decreased capillary refill 2, 3
• Persistent vomiting despite proper small-volume ORS technique 2, 6
• Decreased urine output or no urine for >8 hours 2, 6
• Intractable vomiting that prevents any oral intake 2, 6

Monitoring & Follow-Up

• Reassess hydration status every 2–4 hours during the acute phase 2, 3
• Monitor for adequate urine output (wet diapers every 4–6 hours) 2, 6
• If diarrhea persists beyond 7–10 days or worsens, return for re-evaluation 1
• Most viral gastroenteritis resolves within 3–7 days 4, 8

Common Pitfalls to Avoid

• Do not delay ORS administration while waiting for medical evaluation—parents should keep ORS at home and start immediately when diarrhea begins 3
• Do not use sports drinks, soft drinks, or undiluted fruit juice as primary rehydration fluids—they lack appropriate electrolyte balance 2, 3
• Do not withhold food or enforce prolonged fasting—this impairs intestinal recovery and worsens nutritional status 1, 2
• Do not underestimate dehydration in young children, who are at higher risk due to higher body surface-to-weight ratio and higher metabolic rate 2, 3
• Do not give large volumes of ORS rapidly—this is the most common reason for ORT "failure" 3, 7