Vomiting and Diarrhea

Vomiting or forceful emptying of the stomach usually happens when the stomach becomes irritated.  This is usually caused by a viral infection, although there are other causes.  When vomiting is due to a routine stomach virus, it is many times associated with diarrhea.  Although uncomfortable, vomiting in and of itself is not dangerous to the child.  If your child's vomiting is associated with a significant head injury, please refer to the section on "head injury" in this handbook.  Otherwise, continue reading in this section.

Diarrhea is characterized by frequent, loose, watery stools.  It is most commonly caused by a viral infection called gastroenteritis.  This causes the cells of the stomach and intestine to become sick and even stop their normal function (absorbing fluids and nutrients).  Gastroenteritis often begins with vomiting and fever.  Then, after several hours, the vomiting resolves and diarrhea follows.  Rarely, there are other more serious causes of diarrhea other than stomach viruses.  These include diarrhea due to bacteria (Salmonella, E. Coli, Campylobacter, Shigella and others), parasitic infections (such as Giardia) and milk allergy.  The vast majority of the cases of diarrhea are due to gastrointestinal viruses, which resolve without any specific treatment.  Our approach to treating vomiting and diarrhea is based on the assumption that the vomiting and diarrhea is due to a stomach virus which will eventually resolve on its own.  Please see the section below on when to worry that your child's vomiting and diarrhea is more serious.

The main concern with vomiting and diarrhea is that dehydration may result.  Our goal with therapy of vomiting and diarrhea is to prevent this until the intestine can recover and resume its normal function.  We do not recommend the routine use of medications to stop diarrhea unless specifically prescribed by our office.  Certain types of diarrhea can be dangerous to stop with an antidiarrheal medication.  These particular medications work by paralyzing the intestine and not by reversing the diarrhea process.  Serious types of diarrhea producing germs can sometimes enter into the blood stream in a small child if antidiarrheal medications are used.  The underlying cause of the diarrhea must be treated, not masked, and this is done by diet.

Dehydration results when there are excessive fluid losses from the infant or child, usually as a result of the vomiting or diarrhea.  Dehydration can also result from any condition in which the child does not take in adequate fluids such as with severe mouth ulcers and other viral infections, such as RSV bronchiolitis.   Dehydration is serious and should be evaluated in the office or emergency room.  Signs of dehydration include:

  1. Dry mouth.  Place your finger inside the child's cheek and then rub your thumb and forefinger together.  If it is wet, there is not need to worry about dehydration.  If, however, it feels sticky, tacky or definitely dry, then dehydration may be present.  A child that is drooling is not dehydrated.
  2. Poor urine output.  Infants and children usually urinate at least once every eight hours.  Decreased urine output in the presence of diarrhea may mean that dehydration is present.  No urine output in a 24 hour period is a serious sign of dehydration.
  3. Absence of Tears.  If your child is making tears when she cries, then there is little chance of dehydration.  If there are no tears when your child cries, this could possibly indicate dehydration when taken with other symptoms outlined above.
  4. Decreased skin turgor.  Pinching the skin on the back of the child's hand or abdomen should cause it to snap back into place readily and rapidly. If the skin is slow to return to its place, then dehydration may be present when taken with other symptoms outlined above.
  5. Lethargy.  If your child or infant is not alert or shows little interest in her surroundings and little interest in normal activities such as eating and playing and, this behavior is in association with diarrhea and or vomiting, this may be a sign of dehydration when taken into consideration with the above signs of dehydration.

Note:  The most reliable and important signs of dehydration are items #1 and 2.

Your Child Should be Evaluated If:

  1. Signs of dehydration are present.
  2. The diarrhea is associated with high fever over 104 degrees unresponsive to acetaminophen.
  3. If pus or blood is noted in the stool.
  4. If diarrhea persists for more than three days despite diet changes listed below.
  5. The vomiting persists more than 24 hours.
  6. Your child becomes confused or difficult to arouse.
  7. The vomiting is associated with a severe headache.
  8. The vomitus is green stained (bilious).
  9. Your child is less than three months old and is vomiting forcefully.
  10. Your child is less than three months old and is having a high volume of diarrhea after 24 hours.

Treatment of Vomiting and Diarrhea in Infants:

For the first 24 hours:

  1. Give nothing by mouth for two or three hours after your child's vomiting begins to rest the stomach.  Then, begin to give fluids gradually increasing the volume.  If your child is breast fed, continue to breast feed your baby encouraging a more frequent feeding schedule.  Breast milk is very easy on the stomach and has antibodies and other anti-infectious factors which can help your baby get over a stomach virus more rapidly.  If your baby is formula fed, discontinue giving the formula and give one of the oral rehydration solutions instead.  There are several of these that you can use.  We recommend Pedialyte or Infalyte.  These solutions have simple sugars and salts in them which are easily absorbed and help sustain your child until he or she recovers from the illness.  Give these solutions in small amounts, frequently and at room temperature.  Even if your infant's vomiting persists begin the fluids anyway, in between vomiting episodes.  As much as one-half of the fluid can be absorbed even though the vomiting continues.  If diarrhea alone is present, begin fluids as outlined below in large amounts.  The goal of fluid therapy in vomiting and diarrhea illnesses in children is to give more fluid to the child than is lost in the diarrhea and vomiting so that dehydration won't result.
  2. Watch closely for signs of dehydration.  (see above signs of dehydration)

After 24 hours:

  1. Continue breast-feeding.
  2. If your baby is formula fed and not allergic to soy, you should start a dilute soy formula, such as Prosobee, Isomil or Isomil DF.  If your baby is allergic to soy formulas please call us for advice on managing your child's vomiting or diarrhea illness.  Soy formulas are easier on the stomach during a stomach virus illness than are milk based formulas because milk based formulas have milk sugar, or lactose in them.  It is very common to become lactose intolerant during a stomach virus.  You should dilute the soy formula with an equal volume of water to make one-half strength formula.  Example:   to make a 6 ounce bottle, mix 3 ounces of formula with 3 ounces of water.  Give this for the next 24 hours and then go to full strength formula as described below.
  3. Watch closely for signs of dehydration.  (see above signs of dehydration)

After 48 hours:

  1. Continue breast-feeding.
  2. Give full strength soy formula for the next three to five days and then switch back to your baby's original formula as the illness resolves. 

Treatment of  Vomiting and Diarrhea for Older Children:

For the first 24 hours:

  1. Give nothing by mouth for three or four hours after your child's vomiting begins to rest the stomach.  Then, begin to give fluids, gradually increasing the volume.  Give these in small amounts, frequently and at room temperature.  Even if your child's vomiting persists begin the fluids anyway, in between vomiting episodes.  As much as one-half of the fluid can be absorbed even though the vomiting continues.  If diarrhea alone is present, begin fluids as outlined below in large amounts.  The goal of fluid therapy in vomiting and diarrhea illnesses in children is to give more fluid to the child than is lost in the diarrhea and vomiting so that dehydration won't result. 
  2. For the first 24 hours, give the following:
    1. no milk products
    2. clear fluids in small amounts at room temperature and offer frequently
    3. offer fluids such as:
      • Infalyte
      • Pedialyte
      • Kaolectrolyte
      • Kool-aide or Gatorade
      • Jello, Jello water
      • Sprite or 7-Up
      • Gingerale
      • Bouillon or chicken soup
      • Popsicles

Watch closely for signs of dehydration.  (see above signs of dehydration)

After 24 hours:

  • Offer bland foods if your child can tolerate these. These foods include:
  • Chicken and rice soup
  • Rice or cooked cereals
  • Ripe bananas
  • Applesauce
  • Crackers or dry toast
  • Plain macaroni, spaghetti, noodles (no cheese or grease)

Watch closely for signs of dehydration.  (see above signs of dehydration)

After 48 hours:

As your child's appetite increases, offer foods such as:

  1. Canned or cooked vegetables, apples, apricots, peaches and pears
  2. Angel Food cake or cookies
  3. Plain macaroni, spaghetti, noodles (no cheese or grease)
  4. Rice or mashed potatoes
  5. Baked or broiled chicken, fish or lamb

You should avoid milk or milk products, whole grain cereals or breads, raw fruits and vegetables, citrus juices, red meats, greasy foods, and fried and spicy foods for a few days after an episode of vomiting and or diarrhea. 

A common cause of vomiting and diarrhea are enteroviruses.  You read about these infections here.