How should I evaluate and manage a 14‑month‑old who has had five episodes of non‑projectile, non‑diarrheal vomiting today?

Management of Non-Projectile, Non-Diarrheal Vomiting in a 14-Month-Old

In a 14-month-old with five episodes of non-projectile, non-bilious vomiting without diarrhea, assess hydration status immediately and initiate oral rehydration therapy with small frequent volumes while ruling out red-flag conditions that require urgent intervention. 1, 2

Immediate Assessment Priorities

Hydration Status Evaluation

• Check capillary refill time, urine output (≥4 wet diapers per 24 hours), and mucous membrane moisture to determine degree of dehydration. 3
• Mild dehydration (3-5% fluid deficit) presents with slightly dry mucous membranes and normal mental status; moderate dehydration (6-9% deficit) shows sunken eyes, decreased skin turgor, and reduced urine output. 1
• Weigh the child if possible, as weight loss helps quantify fluid deficit. 1

Red-Flag Screening

• Confirm the vomitus remains non-bilious (not green); any bilious vomiting constitutes a surgical emergency requiring immediate evaluation for malrotation with volvulus. 3, 4, 2
• Examine for abdominal distension, which suggests intestinal obstruction or necrotizing enterocolitis. 3, 2
• Assess for blood in vomit or stool, which signals mucosal injury and raises concern for intussusception or other serious pathology. 3, 2
• Check for fever, lethargy, altered mental status, or poor perfusion—these indicate possible sepsis, meningitis, or metabolic disorder. 3, 5
• Palpate the epigastrium for an "olive" mass; although this child is older than typical pyloric stenosis presentation (2-8 weeks), forceful vomiting with epigastric fullness warrants consideration. 4

Initial Management Based on Hydration Status

For Mild Dehydration (Most Likely Scenario)

• Begin oral rehydration solution (ORS) containing 50-90 mEq/L sodium at 50 mL/kg over 2-4 hours. 1
• Administer small, frequent volumes initially (approximately 5 mL every minute using a teaspoon or syringe), then gradually increase as tolerated. 1, 2
• Replace each vomiting episode with 10 mL/kg of ORS. 2
• Continue full-strength formula or breast milk; do not dilute feeds. 3

For Moderate Dehydration

• Increase ORS volume to 100 mL/kg over 2-4 hours using the same gradual administration technique. 1
• Reassess hydration status after 2-4 hours; if still dehydrated, reestimate deficit and restart rehydration. 1

For Severe Dehydration (≥10% Deficit, Signs of Shock)

• This is a medical emergency requiring immediate IV fluid resuscitation with 20 mL/kg boluses of normal saline or Ringer's lactate until perfusion normalizes. 1

Differential Diagnosis Considerations at 14 Months

Most Likely: Viral Gastroenteritis

• Viral gastroenteritis is the leading cause of acute vomiting in children, though this case lacks diarrhea which is typically present. 5, 6
• The absence of diarrhea does not exclude gastroenteritis, as vomiting may precede diarrhea by 12-24 hours. 6

Consider: Gastroesophageal Reflux Disease (GERD)

• GERD is the most common cause of recurrent non-bilious vomiting in infants, with peak incidence at 4 months declining to 5-10% by 12 months. 1, 2
• However, GERD typically presents with non-forceful regurgitation and chronic symptoms rather than acute onset of five episodes in one day. 1
• Poor weight gain or weight loss distinguishes pathologic GERD from benign reflux. 3, 2

Less Likely but Important to Exclude

• Pyloric stenosis classically presents at 2-8 weeks with progressive projectile vomiting, making it unlikely at 14 months, but atypical late presentations can occur. 4
• Malrotation with intermittent volvulus can present at any age with intermittent non-bilious vomiting that may progress to bilious emesis. 3, 4
• Intracranial pathology or metabolic disorders should be considered if lethargy or altered mental status develops. 3, 5

When to Escalate Care

Immediate Referral/Emergency Department

• Any bilious (green) vomiting emerges. 3, 4, 2
• Signs of severe dehydration or shock develop. 1
• Abdominal distension, severe abdominal pain, or absent bowel sounds appear. 3
• Blood in vomit or stool is noted. 3, 2
• Lethargy, altered mental status, or inconsolable irritability develops. 3, 5

Urgent Outpatient Follow-Up (24-48 Hours)

• Vomiting persists beyond 24 hours despite oral rehydration. 1
• Decreased urine output continues despite adequate fluid intake. 1
• Poor weight gain or weight loss is documented. 3, 2

Conservative Management if No Red Flags

• If the child appears well-hydrated with no concerning features, a 2-4 week trial of smaller, more frequent feeds combined with upright positioning after feeds is appropriate. 3
• Instruct parents to monitor for decreased urine output, persistent vomiting, emergence of bilious vomiting, or development of lethargy. 1
• Antiemetics are generally not recommended in young children as they may mask clinical deterioration, though ondansetron (0.2 mg/kg oral, maximum 4 mg) may be considered for persistent vomiting preventing oral intake. 3, 5, 6

Common Pitfalls to Avoid

• Do not assume viral gastroenteritis without carefully excluding red-flag conditions, particularly bilious vomiting and abdominal obstruction. 5, 7
• Do not delay imaging if clinical suspicion for surgical pathology exists; the absence of projectile vomiting does not exclude pyloric stenosis or malrotation. 4
• Do not withhold oral rehydration in favor of IV fluids for mild-to-moderate dehydration; oral rehydration is equally effective and less invasive. 1, 6
• Do not dilute formula or restrict diet unnecessarily; continue age-appropriate nutrition once rehydration is achieved. 1, 3