Treatment of Vomiting in Children

Initial Assessment and Hydration Status

The American Academy of Pediatrics recommends evaluating dehydration severity through clinical examination focusing on skin turgor, mucous membrane moisture, capillary refill time, mental status, and vital signs 2, 1
Dehydration can be categorized as mild (3-5%), moderate (6-9%), or severe (≥10%) 1, 3

The World Health Organization recommends beginning ORS administration immediately using small volumes (5-10 mL) every 1-2 minutes via spoon or syringe 1, 3
The Centers for Disease Control and Prevention suggests dosing by dehydration severity: mild dehydration (3-5%): 50 mL/kg ORS over 3-4 hours, moderate dehydration (6-9%): 100 mL/kg ORS over 3-4 hours 3, 2
Replace ongoing losses: 10 mL/kg for each watery stool, 2 mL/kg for each vomiting episode 1, 3
The American Academy of Pediatrics recommends using commercially available low-osmolarity ORS formulations such as Pedialyte 2, 4

The Infectious Diseases Society of America recommends ondansetron may be given to children >4 years of age to facilitate oral rehydration tolerance when vomiting is significant 6, 3

The American College of Emergency Physicians recommends immediate intravenous rehydration with isotonic fluids (lactated Ringer's or normal saline) for severe dehydration (≥10% fluid deficit), shock or altered mental status, failure of oral rehydration therapy, or intractable vomiting preventing successful oral intake 2, 6, 3
Continue IV fluids until pulse, perfusion, and mental status normalize, then transition to ORS to complete rehydration 2, 6, 3

The World Health Organization recommends continuing breastfeeding throughout the entire illness without interruption 2, 6, 3
Resume age-appropriate diet during or immediately after rehydration is completed, including starches, cereals, yogurt, fruits, and vegetables; avoid foods high in simple sugars and fats 2, 6, 1

The American Academy of Pediatrics recommends antimotility drugs (loperamide) are absolutely contraindicated in all children <18 years of age 6, 3
Antidiarrheal agents should not be used as they shift focus away from appropriate fluid and electrolyte therapy 1

The Centers for Disease Control and Prevention suggests reassessing hydration status after 2-4 hours of rehydration 1, 3
Monitor for decreased urine output, lethargy, or irritability requiring immediate medical attention, bloody diarrhea (dysentery) requiring antimicrobial consideration, and high stool output (>10 mL/kg/hour) indicating need for higher sodium ORS or IV therapy 1, 3