Vomiting with diarrhea


* 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


* Main Cause: Stomach and intestinal infection (gastroenteritis) from a stomach virus (eg, rotavirus). The illness starts with vomiting but diarrhea usually follows within 12 to 24 hours.

* Food poisoning from toxins produced by bacteria growing in poorly refrigerated foods (eg, Staphylococcus toxin in egg salad, Bacillus cereus toxin in rice dishes).

Severity of Vomiting:

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

* Mild: 1 to 2 times a day

* Moderate: 3 to 7 times a day

* Severe: Vomits everything or nearly everything, or 8 or more times a 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

How to Recognize Dehydration:

* Dehydration means that the body has lost excessive fluids, usually from vomiting 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 child’s doctor to teach you how to do this test.

– Irritable, tired out, or acting ill. If your child is alert, happy, and playful, he is not dehydrated.

– A child with severe dehydration becomes too weak to stand or very dizzy if he tries to stand.

Return to School: Your child can return to child care or school after vomiting and fever are gone

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 (in Alberta, Canada call 780-408-LINK) If:

* Your child looks or acts very sick

* Signs of dehydration (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 (eg, pain low on right side, won’t jump, prefers to lie still)

* Poisoning with a plant, medicine, or other chemical suspected

* Child is younger than 12 weeks with vomiting 2 or more times (EXCEPTION: spitting up)

* Child younger than 12 months who has vomited Pedialyte (or other brand of oral rehydration solution) 3 or more times and also has watery diarrhea

* Receiving Pedialyte (or clear fluids if older than 1 year) and vomits everything longer than 8 hours

* Weak immune system (eg, sickle cell disease, HIV, chemotherapy, organ transplant, chronic steroids)

* Vomiting an essential medicine

* Fever above 104°F (40°C) and not improved 2 hours after fever medicine

* Child is younger than 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 9:00 am and 4:00 pm) If:

* You think your child needs to be seen

* Has vomited longer than 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 to 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 Bottle-fed Infants, Offer Oral Rehydration Solution (ORS) for 8 Hours:

* ORS (eg, Pedialyte, store brand) is a special electrolyte solution that can prevent dehydration. It’s readily available in supermarkets and drugstores.

* For vomiting once, continue regular formula

* For vomiting more than once, offer ORS for 8 hours. If ORS is not available, use formula.

* Spoon or syringe feed small amounts of ORS —1 to 2 teaspoons (5 to 10 mL) every 5 minutes.

* After 4 hours without vomiting, double the amount

* After 8 hours without vomiting, return to regular formula

* For infants older than 4 months, also return to cereal and strained bananas

* Return to normal diet in 24 to 48 hours

3. For Breastfed Infants, Reduce the Amount Per Feeding:

* If infant vomits once, nurse 1 side every 1 to 2 hours

* If infant vomits more than once, nurse for 5 minutes every 30 to 60 minutes. After 4 hours without vomiting, return to regular breastfeeding.

* If infant continues to vomit, switch to ORS (eg, Pedialyte) for 4 hours

* Spoon or syringe feed small amounts of ORS —1 to 2 teaspoons (5 to 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 (Older Than 1 Year), Offer Small Amounts of Clear Fluids for 8 Hours:

* ORS: Vomiting with watery diarrhea needs ORS (eg, Pedialyte). If child refuses ORS, use half-strength Gatorade.

* Give small amounts—2 to 3 teaspoons (10 to 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, and mashed potatoes

– Return to normal diet in 24 to 48 hours.

5. 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 (eg, Tylenol) suppositories. Never give oral ibuprofen (eg, Advil); it is a stomach irritant

* Call your doctor if your child is vomiting an essential 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 to 2 times a day) with diarrhea can continue intermittently for up to a week.

8. Call Your Doctor If:

* Vomiting becomes severe (vomits everything) longer than  8 hours

* Vomiting persists longer than 24 hours

* Signs of dehydration

* Diarrhea becomes severe

* Your child becomes worse

Based on recommendations/advice in “My Child is Sick; Expert Advice for Managing Common Illnesses and Injuries”, 14th Edition, by Barton D. Schmitt

One thought on “Vomiting with diarrhea

  1. Aileen Giesbrecht

    Thank you for this informative article. My infant will be 4 months when we travel to the Dominican Republic. Because of the article I will bring ORD with me just in case.


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