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Vomiting With Diarrhea

Vomiting With Diarrhea  
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  Does this describe your child's symptoms?
 
Definition
  • Vomiting is the forceful emptying (throwing up) of a large portion of the stomach's contents through the mouth
  • Nausea and abdominal discomfort usually precede each bout of vomiting
  • Diarrhea means 2 or more watery or very loose stools (Reason: 1 loose stool can be normal)
  • Vomiting and diarrhea together is covered by this topic (EXCEPTION: if vomiting is resolved, use the Diarrhea topic)

Causes

  • Main cause: stomach and intestinal infection (gastroenteritis) from a stomach virus (e.g., Rotavirus). The illness starts with vomiting but diarrhea usually follows within 12-24 hours.
  • Food poisoning from toxins produced by bacteria growing in poorly refrigerated foods (e.g. Staphylococcus toxin in egg salad or Bacillus cereus toxin in rice dishes).

Severity of Vomiting

The following is an arbitrary attempt to classify vomiting by risk for dehydration:

  • MILD: 1 - 2 times/day
  • MODERATE: 3 - 7 times/day
  • SEVERE: Vomits everything or nearly everything or 8 or more times/day
  • Severity relates even more to the length of time that the particular severity level has persisted. At the beginning of a vomiting illness (especially following food poisoning), it's common for a child to vomit everything for 3 or 4 hours and then become stable with mild or moderate vomiting.
  • Watery stools in combination with vomiting carry the greatest risk for causing dehydration.
  • The younger the child, the greater the risk for dehydration.

Dehydration: How to Recognize

  • Dehydration means that the body has lost excessive fluids, usually from vomiting and/or diarrhea. An associated weight loss of more than 3% is required. In general, mild diarrhea, mild vomiting or a mild decrease in fluid intake does not cause dehydration.
  • Dehydration is the most important complication of diarrhea.
  • The following are signs of dehydration:
  • Decreased urination (no urine in more than 8 hours) occurs early in the process of dehydration. So does a dark yellow, concentrated yellow. If the urine is light straw colored, your child is not dehydrated.
  • Dry tongue and inside of the mouth. Dry lips are not helpful.
  • Dry eyes with decreased or absent tears
  • In infants, a depressed or sunken soft spot
  • Delayed capillary refill longer than 2 seconds. This refers to the return of a pink color to the thumbnail after you press it and make it pale. Ask your doctor to teach you how to do this test.
  • Irritable, tired out or acting ill. If your child is alert, happy and playful, he or she is not dehydrated.
  • A child with severe dehydration becomes too weak to stand or very dizzy if tries to stand.

Return to School

  • Your child can return to child care or school after vomiting and fever are gone.
 If not, see these topics
  When to Call Your Doctor
  Call 911 Now (your child may need an ambulance) If
  • Unresponsive or difficult to awaken
  • Not moving or too weak to stand
  Call Your Doctor Now (night or day) If
  • Your child looks or acts very sick
  • Signs of dehydration (e.g., very dry mouth, no tears and no urine in more than 8 hours)
  • Blood in the stool
  • Blood in the vomit that's not from a nosebleed
  • Bile (bright yellow or green) in the vomit
  • Abdominal pain is also present (EXCEPTION: abdominal pain or crying just before and improved by vomiting is quite common)
  • Appendicitis suspected (pain low on right side, won't jump, prefers to lie still, etc)
  • Poisoning with a plant, medicine, or other chemical suspected
  • Age under 12 weeks with vomiting 2 or more times (EXCEPTION: spitting up)
  • Age under 12 months old who has vomited Pedialyte (or other brand of ORS) 3 or more times and also has watery diarrhea
  • Receiving Pedialyte (or clear fluids if age over 1 year old) and vomits everything over 8 hours
  • Weak immune system (sickle cell disease, HIV, chemotherapy, organ transplant, chronic steroids, etc)
  • Vomiting a prescription medicine
  • Fever over 104° F (40° C) and not improved 2 hours after fever medicine
  • Age under 12 weeks with fever above 100.4° F (38.0° C) rectally (Caution: Do NOT give your baby any fever medicine before being seen.)
  • You think your child needs to be seen urgently
  Call Your Doctor Within 24 Hours (between 9 am and 4 pm) If
  • You think your child needs to be seen, but not urgently
  • Has vomited over 24 hours
  • Fever present for more than 3 days
  Call Your Doctor During Weekday Office Hours If
  • You have other questions or concerns
  • Vomiting is a recurrent chronic problem
  Parent Care at Home If
  • Mild-moderate vomiting with diarrhea (probably viral gastroenteritis) and you don't think your child needs to be seen
  HOME CARE ADVICE FOR VOMITING WITH DIARRHEA
  1. Reassurance:
    • Most vomiting is caused by a viral infection of the stomach and intestines or by food poisoning.
    • Vomiting is the body's way of protecting the lower intestinal tract.
    • When vomiting and diarrhea occur together, treat the vomiting. Don't do anything special for the diarrhea.
  2. For Bottlefed Infants Offer Oral Rehydration Solution (ORS) for 8 Hours:
    • ORS (eg. Pedialyte or the store brand) is a special electrolyte solution that can prevent dehydration. It's readily available in supermarkets and drug stores.
    • For vomiting once, continue regular formula.
    • For vomiting more than once, offer ORS for 8 hours. If ORS not available, use formula.
    • Spoon or syringe feed small amounts: 1-2 teaspoons (5-10 ml) every 5 minutes.
    • After 4 hours without vomiting, double the amount.
    • After 8 hours without vomiting, return to regular formula.
    • For infants over 4 months old, also return to cereal, strained bananas, etc.
    • Return to normal diet in 24-48 hours.
  3. For Breastfed Infants, Reduce the Amount Per Feeding:
    • If vomits once, nurse 1 side every 1 to 2 hours.
    • If vomits more than once, nurse for 5 minutes every 30 to 60 minutes. After 4 hours without vomiting, return to regular breastfeeding.
    • If continues to vomit, switch to ORS (e.g., Pedialyte) for 4 hours.
    • Spoon or syringe feed small amounts of ORS: 1-2 teaspoons (5-10 ml) every 5 minutes.
    • After 4 hours without vomiting, return to regular breastfeeding. Start with small feedings of 5 minutes every 30 minutes and increase as tolerated.
  4. For Older Children (over 1 Year Old) Offer Small Amounts of Clear Fluids For 8 Hours:
    • ORS: Vomiting with watery diarrhea needs ORS (e.g, Pedialyte). If refuses ORS, use ½ strength Gatorade.
    • Give small amounts: 2-3 teaspoons (10-15 ml) every 5 minutes.
    • After 4 hours without vomiting, increase the amount.
    • After 8 hours without vomiting, return to regular fluids.
    • Solids: After 8 hours without vomiting, add solids:
      • Limit solids to bland foods. Starchy foods are easiest to digest.
      • Start with saltine crackers, white bread, cereals, rice, mashed potatoes, etc.
      • Return to normal diet in 24-48 hours.
  5. Avoid Medicines:
    • Discontinue all non-prescription medicines for 8 hours (reason: usually make vomiting worse).
    • Fever: Fevers usually don't need any medicine. For higher fevers, consider acetaminophen (Tylenol) suppositories. Never give oral ibuprofen; it is a stomach irritant.
    • Call your doctor if: vomiting a prescription medicine.
  6. Contagiousness: Your child can return to child care or school after vomiting and fever are gone.
  7. Expected Course: Moderate vomiting usually stops in 12 to 24 hours. Mild vomiting (1-2 times/day) with diarrhea can continue intermittently for up to a week.

  8. Call Your Doctor If:

    • Vomiting becomes severe (vomits everything) over 8 hours
    • Vomiting persists over 24 hours
    • Signs of dehydration
    • Diarrhea is severe
    • Your child becomes worse

And remember, contact your doctor if your child develops any of the "Call Your Doctor" symptoms.

Disclaimer: This information is not intended be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.

Author and Senior Reviewer: Barton D. Schmitt, M.D.

Last Reviewed: 11/15/2011

Last Revised: 11/15/2011

Content Set: Pediatric HouseCalls Symptom Checker

Copyright 1994-2012 Barton D. Schmitt, M.D.

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