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Always consult a pediatrician for persistent or concerning vomiting to ensure appropriate diagnosis and treatment.
01. Hydration
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Mild or no dehydration – maintenance intravenous fluids. (See "Maintenance intravenous fluid therapy in children".)
The goal of fluid therapy is to preserve the normal body water volume and its electrolyte composition:
●Maintenance fluid therapy replaces the ongoing daily losses of water and electrolytes occurring via physiologic processes (urine, sweat, respiration, and stool), which normally preserve homeostasis. Maintenance requirements vary depending on the patient's underlying clinical status and setting, especially in postoperative or hospitalized children, due to changes in their physiologic responses (eg, excess antidiuretic hormone [ADH] secretion).
●Repletion fluid therapy corrects water and acute electrolyte deficits that have accrued via illness or physiologic abnormality. Repletion returns the patient to a normal volume and electrolyte status.
Maintenance intravenous (IV) fluid therapy, including alterations in maintenance requirements, will be reviewed here. Assessment of hypovolemia and repletion therapy and management of fluid and electrolytes in neonates are discussed elsewhere. (See "Clinical assessment of hypovolemia (dehydration) in children" and "Treatment of hypovolemia (dehydration) in children in resource-abundant settings" and "Fluid and electrolyte therapy in newborns".)
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●Moderate or severe dehydration – Infants with moderate or severe dehydration require more intensive management by administering isotonic fluids (typically normal saline [0.9% NaCl]), given as an initial fluid bolus and/or higher rates of administration (1.5 to 2 times maintenance) until the calculated fluid deficit is repleted, followed by maintenance intravenous fluids. Renal function should be assessed before adding potassium to the intravenous fluids. (See "Treatment of hypovolemia (dehydration) in children in resource-abundant settings".)
We suggest the following targets for fluid and electrolyte therapy prior to undergoing surgery, as recommended by an expert panel [91]:
•pH ≤7.45 and/or base excess ≤3.5
•Bicarbonate <26 mEq/L
•Sodium ≥132 mEq/L
•Potassium ≥3.5 mEq/L
•Chloride ≥100 mEq/L
•Glucose ≥72 mg/dL (4.0 mmol/L)
Infants with significant alkalosis at the time of surgery are at increased risk of postoperative apnea [92,93]. Patients with severe hypokalemia (serum potassium <2.5 mEq/L) or hyponatremia (serum sodium <120 mEq/L) are at particularly high risk for perioperative complications and should be managed carefully, with expert consultation if needed. (See "Hypokalemia in children" and "Hyponatremia in children: Evaluation and management".)
For formula-fed babies:
- If vomiting once, give half the regular amount of formula every 1-2 hours[1].
- If vomiting multiple times, offer oral rehydration solution (ORS) like Pedialyte for 8 hours[1].
- Give small amounts frequently - 1-2 teaspoons every 5 minutes[1].
For breastfed babies:
- If vomiting once, nurse for half the usual time every 1-2 hours[1].
- If vomiting multiple times, nurse for 5 minutes every 30-60 minutes[1].
- If continued vomiting, switch to pumped breastmilk in small amounts[1].
## Feeding
- Stop all solid foods for 8 hours[1].
- Gradually reintroduce formula/breastmilk after 4-8 hours without vomiting[1].
- Slowly increase feeding amounts as tolerated[1].
## Other Measures
- Keep the baby lying on their stomach or side to prevent aspiration[2].
- Do not give over-the-counter medications unless prescribed by a doctor[1][2].
- Let the baby sleep, as this can help settle the stomach[1].
## When to Seek Medical Care
Call the doctor if the baby:
- Shows signs of dehydration
- Cannot keep down any fluids
- Has forceful projectile vomiting after every feed
- Has blood or bile in the vomit
- Seems unwell or has concerning symptoms[1][3]
The vomiting should improve within 12-24 hours in most cases. Focus on hydration and gradually returning to normal feeding as tolerated. Seek medical attention if symptoms persist or worsen.
Citations:
[1] https://www.seattlechildrens.org/conditions/a-z/vomiting-0-12-months/
[2] https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/treating-vomiting.aspx
[3] https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/children-and-vomiting
[4] https://kidshealth.org/en/parents/vomiting-sheet.html
[5] https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/vomiting-in-children-and-babies/
[6] https://www.merckmanuals.com/professional/pediatrics/symptoms-in-infants-and-children/nausea-and-vomiting-in-infants-and-children
[7] https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.vomiting-in-children-3-months-to-1-year-care-instructions.zx4670
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Dehydration
Intravenous Line
Normal Saline
Alkalosis
Hypovolemia
Hypovolemic Shock
Oxygenation?
Start Normal Saline
Assess for dehydration and electrolyte depletion.
●Electrolytes – Interpretation is as follows:
•Normal – Patients with recent onset of symptomatic IHPS usually have normal laboratory results.
•Hypochloremic alkalosis – Low serum chloride and potassium and elevated bicarbonate are common in infants with prolonged symptoms due to IHPS. Either hypernatremia or hyponatremia may be present. One study showed that serum pH >7.45, chloride <98, and base excess >+3 gave a positive predictive value of 88 percent in diagnosing IHPS in infants presenting with vomiting [76].
By contrast, elevated serum potassium with low bicarbonate is not consistent with IHPS; infants with this finding should be urgently evaluated for other causes, including adrenal crisis (eg, CAH). (See 'Differential diagnosis' below.)
●CBC – The CBC is usually normal in infants with uncomplicated IHPS. Abnormal results do not exclude IHPS but should raise suspicion of another cause of vomiting (eg, infection).
●Bilirubin – Infants with jaundice should be evaluated for total and conjugated bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase or gamma-glutamyl transpeptidase (GGTP).
•Elevated unconjugated bilirubin without other abnormalities is consistent with IHPS (see 'Clinical associations' above)
•Elevations in conjugated bilirubin, ALT, or AST are not consistent with IHPS and warrant further evaluation for underlying liver disease (see 'Differential diagnosis' below)
Infants who are severely dehydrated or ill-appearing may warrant further evaluation to rule out other causes including sepsis, intestinal obstruction, or a primary metabolic disorder. (See "Clinical features, evaluation, and diagnosis of sepsis in term and late preterm neonates".)
Treat dehydration and alkalosis.