Vomiting with Diarrhea

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
• 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 (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: 1–4 times/day
• MODERATE: 5–10 times/day
• SEVERE: Vomits everything or nearly everything or 10 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 if an infant; or more than 12 hous if an older child) 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.

See more appropriate topic (instead of this one) if

• Vomiting without diarrhea 
• Diarrhea is main symptom (vomiting is resolved)

When to Call Your Doctor for Vomiting

Call your doctor now (night or day) if

• Your child looks or acts very sick
• Newborn looking or acting ill in any way
• Difficult to waken or confused when awake
• Stiff neck or a bulging fontanelle if infant
• Signs of dehydration (e.g., very dry mouth, no tears and no urine in more than 8 hours if an infant or 12 hours if an older child)
• Blood in the stool
• Blood in the vomit that's not from a nosebleed
• Bile (green) in the vomit and with constant abdominal pain not relieved by vomiting or very swollen abdomen
• Bile in vomit of any infant less than 6 months of age.
• Severe abdominal pain is also present for more than one hour when not vomiting
• Appendicitis suspected (pain low on right side, won't jump, prefers to lie still, etc.)
• Continuous abdominal pain or crying and persists more than 2 hours
• Intussusception suspected with brief attacks of severe abdominal pain/crying suddenly switching to 2-10 minute perios of quiet, usually less than 3 years of age
• Diabetes suspected (excessive thirst, frequent urination, weight loss, rapid breathing, etc.)
• Severe headache for more than 2 hours with no history of migranes
• Poisoning with a plant, medicine, or other chemical suspected
• Age under 12 weeks with vomiting 3 or more times in last 24 hours (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; or if age 6 or older vomiting over 12 hours.
• Weak immune system or high risk child (sickle cell disease, HIV, chemotherapy, organ transplant, chronic steroids, diabetes mellitus, brain tumor, V-P shunt, previous abdominal surgery, inguinal hernia, etc.)
• Vomiting an essential medicine
• Abdominal injury in last 3 days
• Fever over 105° F (40.6° C) by any route
• 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.)

Call your doctor within 24 hours (between 9 a.m. and 4 p.m.) if

• You think your child needs to be seen
• Has vomited over 24 hours if less than 2 years old or vomiting more than 48 hours if more than 2 years old
• Fever present for more than 3 days
• Mild vomiting with diarrhea persist more than a week

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

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.

For bottle-fed infants offer oral rehydration solution (ORS) for 8 hours

• ORS (e.g., Pedialyte or the store brand) is a special electrolyte solution that can prevent dehydration. It's readily available in supermarkets and drug stores.
• Rest the stomach for 10 minutes after vomiting and before offering fluids.
• For vomiting once or twice, offer half strength formula for 2 feedings, then regular formula.
• For vomiting more than 2 times within last 2 hours, offer ORS for 8 hours. 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.

For breast-fed infants, reduce the amount per feeding

• If vomits once or twice, nurse 1 side every 1 to 2 hours.
• If vomits more than twice in last 2 hours, nurse for 4-5 minutes every 30 to 60 minutes. After 4 hours without vomiting, return to regular breastfeeding.
• If continues to vomit, switch to ORS 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.

For older children (over 1 year old) offer small amounts of clear fluids for 8 hours

• ORS: Vomiting with watery diarrhea needs ORS. If refuses ORS, use half-strength Gatorade.
  • Give small amounts: 2-3 teaspoons (10-15 ml) every 5 minutes.
  • After 4 hours without vomiting, double the amount.
• 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.

Avoid medicines

• Discontinue all nonessential 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 an essential medicine.

Contagiousness

Your child can return to child care or school after vomiting and fever are gone.

Expected course

Moderate vomiting usually stops in 12 to 24 hours. Mild vomiting with diarrhea can continue intermittently for up to a week.

Call your doctor if

• Vomiting becomes severe (vomits everything) over 8 hours (more than 12 hours if older than 6 years)
• Vomiting persists over 24 hours (over 48 hours if over 2 years )
• Mild vomiting associated with diarrhea persists more than one week
• 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. Clinical content review provided by Senior Reviewer and Healthpoint Medical Network.

Last Review Date: 9/24/2010
Last Revised: 10/20/2010 8:55:34 AM

Content Set: Pediatric HouseCalls Symptom Checker
Version Year: 2011

Copyright 1994-2011 Barton D. Schmitt, M.D.