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Vomiting
Very few things get parents, and children more upset than vomiting. The causes of vomiting vary with age, and fortunately most are short lived. Many children, however, are admitted to the hospital for dehydration for which vomiting played a major role. For an excellent discussion on vomiting in the first year of life click on this link for the AAP Parenting Corner. Then return back for a discussion about treatment.
In the older child vomiting is almost always due to gastrointestinal infection (GE), usually viral and not often severe or prolonged. GE is most commonly caused by Rotavirus, but due to the new Rotavirus vaccine the rate has decreased by 50% from last year. Other viruses have already lined up to take its place like Norovirus. This is the virus that has caused some of the GE on cruise ships. Bacterial GE occurs less commonly and diarrhea is a far more prominent symptom than vomiting. While bacterial GE can make you very sick and dehydrated, it's the viral GE that causes the majority of the illness and is responsible through the evil combination of diarrhea and vomiting for many pediatric hospitalizations. Food poisoning is mostly bacterial (and more common that thought previously) but usually lasts only a day or two.
Almost any illness can cause vomiting, especially in younger children, but there are a few illnesses to watch for:
Meningitis - This is a serious infection of the area around the brain and spinal cord. Due to vaccinations, the number of children who get bacterial meningitis each year have dropped dramatically. Viral meningitis is still a very common and significant illness. Headache, fever, stiff neck and vomiting are the prinary symptoms. Bacterial Meningitis attacks very rapidly and is often fatal, whereas the viral meningitis starts and progresses much like any viral illness.
Urinary Tract Infections (UTI) - This is truly an under-appreciated illness in pediatrics. Infections of the bladder and especially the kidney seem to frequently cause nausea . A young child with fever and vomiting will often prompt us to check a urine sample (not always easy in the smaller children) to be sure a UTI is not present.
Pneumonia - A very misunderstood diagnosis. Children that get pneumonia (not walking pneumonia or bronchitis) are often very sick. The have a fever, abdominal pain, vomiting and are lethargic - and they don't cough as much as you might think.
Appendicitis - Parents are usually tuned into this one. Steadily increasing abdominal pain, especially in the lower right part of the abdomen, associated with nausea, vomiting and a low grade fever are signs of a possible appendicitis. Nowadays, Ultrasounds and CT Scans have helped us confirm this diagnosis in questionable cases before the surgeons operate.
Treatment of Vomiting
For infants under 6 months:
Avoid giving plain water to a young infant unless we directly specify a particular amount. Offer your infant small but frequent amounts - about 2 to 3 teaspoons, or up to 1/2 ounce of an oral electrolyte solution, like pedialyte, every 15 to 20 minutes with a spoon or an oral syringe. Oral electrolyte solutions (available at most supermarkets or pharmacies and also called oral electrolyte maintenance solutions) are balanced with salts to replace what's lost with vomiting or diarrhea, and they also contain some sugar. It's especially important for young infants that any fluids given have the correct salt balance (unflavored electrolyte solutions are best for younger infants).
Gradually increase the amount of solution you're giving if your infant is able to keep it down for more than a couple of hours without vomiting. For instance, if your little one takes 4 ounces normally per feed, slowly work up to giving this amount of oral electrolyte solution over the course of the day.
Do not give more solution at a time than your infant would normally eat - this will overfill an already irritated tummy and will likely cause more vomiting.
After your infant goes for a period of time (more than about 8 hours) without vomiting, you can reintroduce formula slowly if your infant is formula-fed. Start with small (1/2 to 1 ounce), more frequent feeds and slowly work up to your infant's normal feeding routine. If your infant already eats baby cereal, it's OK to start solid feedings in small amounts again. If your infant is exclusively breastfeeding and vomits (not just spits up, but vomits what seems like the entire feed) more than once, then breastfeed for a total of 5 to 10 minutes every 2 hours. If your infant is still vomiting, then call us. After 8 hours without vomiting, you can resume breastfeeding normally.
If your infant is under 1 month old and vomiting all feeds (not just spitting up), call us immediately.
For infants 6 months to 1 year:
Avoid giving plain water to an infant under 1 year, unless an amount is directly specified by your provider. Give your infant small but frequent amounts - about 3 teaspoons, or 1/2 ounce of an oral electrolyte solution every 15 to 20 minutes. It's important that any fluids given to infants under 1 year of age who are vomiting have the correct salt balance. An infant over 6 months of age may not appreciate the taste of an unflavored oral electrolyte solution. Flavored solutions are also available, or you can add 1/2 teaspoon of juice to each feeding of unflavored oral electrolyte solutions. Frozen oral electrolyte solution pops are often appealing to infants in this age group; this approach also encourages the slow intake of fluids that's required.
Gradually increase the amount of solution you're giving if your infant is able to keep it down for more than a couple of hours without vomiting. For instance, if your infant takes 4 ounces normally per feed, work slowly up to giving this amount of oral electrolyte solution over the course of the day.
Do not give more solution at a time than your infant would normally eat - this will overfill an already irritated tummy and will likely cause more vomiting.
After your infant goes more than about 8 hours without vomiting, you can reintroduce formula slowly to your infant. Start with small (1 to 2 ounces), more frequent feeds and slowly work up to your infant's normal feeding routine. You can also begin small amounts of soft, bland foods that your infant is already familiar with such as bananas, cereals, crackers, or other mild baby foods. If your infant doesn't vomit for 24 hours, you can resume your normal feeding routine.
For children 1 year or older:
Give clear liquids (milk and milk products should be avoided) in small amounts (ranging from 2 teaspoons to 2 tablespoons, or up to 1 ounce) every 15 minutes. Clear liquids that are appropriate include:
Ice chips or sips of water.
Flavored oral electrolyte solutions, or add 1/2 teaspoon of nonacidic fruit juice to the oral electrolyte solution.
Frozen oral electrolyte solution pops. Regular ice pops are okay if that's all you have.
If your child vomits, then start over with a smaller amount of fluid (2 teaspoons) and continue as above. If there's no vomiting for approximately 8 hours, then introduce bland, mild foods gradually. But do not force any foods - your child will tell you when he or she is hungry. Saltine crackers, toast, broths, or mild soups (some noodles are OK), mashed potatoes, rice, and breads are all OK. If there's no vomiting for 24 hours, then you can slowly resume your child's regular diet. Wait 2 to 3 days before resuming milk products.
When Should You Call Your Provider?
As discussed above, the greatest risk of vomiting due to gastroenteritis is dehydration. Call your us if your child refuses fluids, if the vomiting continues after using the suggestions above, or if you see any of the signs of dehydration listed below:
Dry mouth
Few or no tears when crying
Fewer than four wet diapers per day in an infant
No urination for 4-6 hours in infants and 6-8 hours in children
Soft spot on an infant's head that looks flatter than usual or somewhat sunken
Inactivity or decreased alertness
Appears weak or limp
Sunken eyes
Excessive sleepiness or disorientation
Deep, rapid breathing
The following symptoms may indicate a condition more serious than gastroenteritis and indicate that you need to contact us:
Projectile or forceful vomiting in an infant, especially less than 3 months old
Vomiting in an infant after taking an oral electrolyte solution for close to 24 hours
Vomiting starts again as soon as you try to resume the child's normal diet
Vomiting after a head injury
Vomiting accompanied by fever
Vomiting of bright green or yellow-green fluid
Your child's belly feels hard, bloated, and painful between vomiting episodes
Vomiting is accompanied by severe stomach pain
Vomiting blood
Vomiting is always uncomfortable, both to experience and to watch. We hope that the tips and guidelines listed above help you through this very common symptom. Call us anytime. Our nurses and providers will always be happy to help.
Helpul links for this topic:
AAP Parenting Corner
Keep Kids Healthy