Management of Vomiting in Toddlers

Initial Assessment

The American Academy of Pediatrics suggests determining if vomiting is bilious or non-bilious, as bilious emesis suggests intestinal obstruction requiring urgent evaluation 3
Assess for forceful (projectile) vomiting which may indicate pyloric stenosis or other obstructive conditions 3

The Centers for Disease Control and Prevention recommends administering small volumes (5 mL) of ORS every minute using a spoon or syringe under close supervision for mild vomiting without significant dehydration 1, 2
Gradually increase the volume as tolerated for mild vomiting without significant dehydration 2
Continue with small, frequent volumes of ORS for moderate dehydration 1
Replace ongoing losses (each episode of vomiting) with additional ORS for moderate dehydration 1
Consider ondansetron (0.2 mg/kg orally or 0.15 mg/kg parenterally, maximum 4 mg) for children >4 years with persistent vomiting to improve tolerance of oral rehydration 4

The World Health Organization recommends that breastfed infants should continue nursing on demand 1, 3
For formula-fed infants, continue with full-strength formula if tolerated 1
If formula intolerance is suspected, consider lactose-free or lactose-reduced formulas 1, 3
For older toddlers on solid foods, continue their usual diet during episodes of vomiting 1
Recommended foods include starches, cereals, yogurt, fruits, and vegetables 1
Avoid foods high in simple sugars and fats 1

The Infectious Diseases Society of America recommends that antiemetics should only be considered after adequate hydration is established 4
Ondansetron may be given to children >4 years to facilitate oral rehydration when vomiting is persistent 4
Antimotility drugs (e.g., loperamide) should NOT be given to children <18 years with acute diarrhea and vomiting 4
Antibiotics are generally not indicated unless there is evidence of bacterial infection (high fever, bloody diarrhea, or symptoms lasting >5 days) 1

Parents should be instructed to offer small, frequent sips of ORS rather than large volumes 2
Continue appropriate nutrition as tolerated 1
Monitor for signs of worsening dehydration (decreased urine output, lethargy, persistent vomiting) 1
Return for medical care if the child becomes irritable or lethargic, has decreased urine output, develops intractable vomiting, or has persistent symptoms 1

Bilious vomiting (green color) requires emergency care 3
Projectile vomiting that persists requires emergency care 3
Signs of severe dehydration not responding to oral rehydration require emergency care 3
Abdominal distension or tenderness requires emergency care 3
ORT has been proven effective in over 90% of children with vomiting, even those with concurrent diarrhea, and is safer and more physiologic than intravenous therapy 5, 2