What is the appropriate management for a 2‑year‑old girl presenting with fever, persistent vomiting, and abdominal pain?

Management of a 2-Year-Old Girl with Fever, Vomiting, and Abdominal Pain

The priority is immediate assessment of hydration status and ruling out serious bacterial infections—particularly urinary tract infection, streptococcal pharyngitis, and surgical emergencies like appendicitis or intussusception—while simultaneously initiating oral rehydration therapy and providing pain relief without delay. 1, 2

Immediate Assessment and Red Flags

Hydration Status Evaluation

• Assess for dehydration using the three most reliable clinical signs: abnormal capillary refill (>2 seconds), prolonged skin turgor (>2 seconds), and abnormal respiratory pattern (rapid, deep breathing suggesting acidosis) 1, 3
• Mild dehydration (3-5% deficit) presents with increased thirst and slightly dry mucous membranes 1
• Moderate dehydration (6-9% deficit) shows loss of skin turgor, skin tenting, dry mucous membranes, and decreased perfusion 1
• Severe dehydration (≥10% deficit) manifests as severe lethargy, altered consciousness, cool extremities, and prolonged capillary refill 1

Critical Surgical Red Flags Requiring Immediate Escalation

• Bilious or persistent forceful vomiting (suggests malrotation, obstruction, or intussusception) 4, 5
• Bloody diarrhea or gastrointestinal bleeding (intussusception, bacterial colitis) 4, 5
• Localized right lower quadrant pain with fever (appendicitis) 4, 5
• Abdominal distension, rigidity, rebound tenderness, or absent bowel sounds (peritonitis, obstruction) 5
• Palpable abdominal mass (intussusception, though classic triad is rare) 6

Diagnostic Workup Based on Clinical Presentation

If Fever Without Clear Source

• Obtain urinalysis and urine culture via catheterization or suprapubic aspiration (not bag collection, which has 85% false-positive rate) 1
• Girls aged 1-2 years with fever without source have 8.1% prevalence of urinary tract infection 1
• Risk factors include: temperature ≥39°C, fever ≥2 days, age <1 year, and absence of another fever source 1

If Sore Throat Component Present

• Perform rapid antigen detection test (RADT) for Group A Streptococcus, backed by throat culture if negative 7
• Abdominal pain occurs in 27% of children with streptococcal pharyngitis and is a recognized presenting symptom 7
• The combination of sore throat, abdominal pain, fever, and vomiting strongly suggests GAS pharyngitis 7

If Persistent Vomiting with Severe Abdominal Pain

• Obtain abdominal ultrasound as first-line imaging to evaluate for intussusception, appendicitis, or other surgical emergencies 4, 6
• Ultrasound is safe, sensitive, and specific—avoiding radiation exposure in young children 4
• Plain abdominal radiography lacks sensitivity to reliably exclude intussusception 6

Immediate Management

Rehydration Protocol

• Start oral rehydration therapy (ORT) immediately with oral rehydration solution (ORS), not plain water or juice 2
• Administer 5-10 mL every 1-2 minutes initially, even if vomiting continues 2
• For mild dehydration: give 50 mL/kg ORS over 2-4 hours 2
• For moderate dehydration: give 100 mL/kg ORS over 2-4 hours 2
• Consider ondansetron (oral or IV) for children >4 years to facilitate oral rehydration when vomiting is significant—this decreases vomiting rate, improves oral intake success, and reduces need for IV hydration 2, 3

If Oral Rehydration Fails or Severe Dehydration

• Initiate intravenous fluids at 80% of basal levels after correcting hypovolemia 1
• Monitor serum electrolytes due to risk of inappropriate ADH secretion 1

Pain Management

• Provide pain relief immediately—do NOT withhold while awaiting diagnosis 7, 4
• Use oral NSAIDs (ibuprofen or acetaminophen) for mild-to-moderate pain without contraindications 4
• Pain control facilitates better examination and does not affect diagnostic accuracy 7

Nutritional Management

• Continue age-appropriate feeding immediately after rehydration—do not suspend nutrition 2
• For breastfed infants: continue breastfeeding on demand throughout illness 2
• For formula-fed infants: resume full-strength formula immediately after rehydration 2
• Early feeding reduces stool production and duration of diarrhea by approximately 50% 2

Antibiotic Considerations

If GAS Pharyngitis Confirmed

• First-line: Amoxicillin or Penicillin V for 10 days 7
• For penicillin allergy (non-Type I): cephalosporins (cefdinir, cefpodoxime, cefuroxime) 7
• For Type I hypersensitivity: azithromycin, clarithromycin, or erythromycin (note 20-25% bacterial failure rate) 7

If Urinary Tract Infection Confirmed

• Initiate appropriate antibiotic therapy based on local resistance patterns and culture results 1

If Viral Gastroenteritis Suspected

• Avoid routine broad-spectrum antibiotics when there is low suspicion of complicated bacterial infection 4, 2
• Watery diarrhea and vomiting in a child <2 years most likely represents viral gastroenteritis and does not require antimicrobial therapy 1

Medications to AVOID

• Do NOT use antimotility agents (loperamide) in children—risk of severe abdominal distention, ileus, drowsiness, and even death has been reported 1, 2
• Do NOT use adsorbents (kaolin-pectin) or antisecretory drugs—they do not reduce diarrhea volume or duration and may increase electrolyte losses 1
• Probiotics are not recommended for routine use in acute infectious gastroenteritis in North American children 2

Monitoring and Follow-Up

• Monitor heart rate, temperature, respiratory rate, oxygen saturation, and respiratory pattern based on illness severity 1
• Reassess hydration status frequently—at least every 2-4 hours initially 1
• If no improvement after 72 hours of appropriate treatment, consider alternative diagnoses or treatment failure 7
• For strep pharyngitis treatment failure: switch to high-dose amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) 7

Common Pitfalls to Avoid

• Never withhold pain medication while awaiting diagnosis—this is an outdated practice that causes unnecessary suffering and impairs examination quality 7, 4
• Do not rely on bag-collected urine specimens for culture—85% false-positive rate makes positive results unreliable 1
• Do not assume plain abdominal radiography rules out intussusception—ultrasound is required when clinically suspected 6
• Do not delay surgical consultation when red flags are present—bilious vomiting, bloody stools, or peritoneal signs require immediate evaluation 4, 5