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Vomiting without Diarrhea

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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

Causes:

* Main Cause: Stomach infection (gastritis) 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)

* Serious Causes: If vomiting persists as an isolated symptom (without diarrhea) for more than 24 hours, more serious causes must be considered. Examples are appendicitis, kidney infection, meningitis, and head injury.

* Vomiting can also be triggered by hard coughing. This is common, especially in children with reflux.

Severity of Vomiting:

Te 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.

* The younger the child, the greater the risk for dehydration

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

* Your child looks or acts very sick

* Confused (delirious)

* Stiff neck or bulging soft spot

* Headache

* Signs of dehydration (very dry mouth, no tears, and no urine in more than 8 hours)

* 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)

* Diabetes suspected (excessive drinking, frequent urination, weight loss)

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

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

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

* High-risk child (eg, diabetes mellitus, abdominal injury, head injury)

* 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

* Fever returns after gone for longer than 24 hours

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 (probably viral gastritis) and you don’t think your child needs to be seen

Home Care Advice for Vomiting:

1. Reassurance:

* Most vomiting is caused by a viral infection of the stomach or mild food poisoning

* Vomiting is the body’s way of protecting the lower intestinal tract

* Fortunately, vomiting illnesses are usually brief

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 Children Older Than 1 Year, Offer Small Amounts of Clear Fluids for 8 Hours:

* Water or ice chips are best for vomiting in older children (Reason: water is directly absorbed across the stomach wall)

* ORS: If child vomits water, offer 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

* Other Options: Half-strength flat lemon-lime soda, popsicles, or ORS frozen pops

* After 4 hours without vomiting, increase the amount

* After 8 hours without vomiting, return to regular fluids

* CAUTION: If vomiting continues for more than 12 hours, switch to ORS or half-strength Gatorade

* 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. Sleep: Help your child go to sleep for a few hours (Reason: sleep often empties the stomach and relieves the need to vomit). Your child doesn’t have to drink anything if she feels very nauseated.

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

8. Expected Course: Vomiting from viral gastritis usually stops in 12 to 24 hours. Mild vomiting with nausea may last up to 3 days

9. Call Your Doctor If:

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

* Vomiting persists longer than 24 hours

* Signs of dehydration

* 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

Headache

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Definition:

* Pain or discomfort of the scalp or forehead areas

* The face and ears are excluded

Causes:

* Viral Illnesses: Most headaches are part of a viral illness, especially with colds. These usually last a few days.

* Muscle Tension Headaches: The most common type of recurrent headaches. Muscle tension headaches give a feeling of tightness around the head. The neck muscles also become sore and tight. Tension headaches can be caused by staying in one position for a long time, such as when reading or using a computer. Other children get tension headaches as a reaction to stress, such as pressure for better grades or family disagreements.

* Migraine Headaches: Recurrent severe, incapacitating headaches

* Other Common Causes: Hunger, exertion, sunlight, coughing

* Frontal Sinusitis: Can cause a frontal headache just above the eyebrow. Rare before 10 years of age because frontal sinus is not developed. Other sinuses cause face pain, not headache.

* Serious Causes: Meningitis or encephalitis. Symptoms include a headache, stiff neck, vomiting, fever, and confusion.

Call 911 Now (Your Child May Need an Ambulance) If:

* Difficult to awaken or passed out

* Confused thinking or talking, or slurred speech

* Blurred or double vision

* Weakness of arm or leg, or unsteady walking

Call Your Doctor Now (or in Alberta, Canada call 780-408-LINK) If:

* Your child looks or acts very sick

* Stiff neck (can’t touch chin to chest)

* Severe headache

* Vomiting

Call Your Doctor Within 24 Hours (Between 9:00 am and 4:00 pm) If:

* You think your child needs to be seen

* Fever

* Sinus pain (not just congestion) of forehead

Call Your Doctor During Weekday Office Hours If:

* You have other questions or concerns

* Headache without other symptoms present longer than 24 hours

* Sore throat present longer than 48 hours

* Any headache present more than 3 days

* Headaches are a recurrent chronic problem

Parent Care at Home If:

Mild headache and you don’t think your child needs to be seen

Home Care Advice for Headaches:

Treatment for Mild Headache

1. Pain Medicine: Give acetaminophen (eg, Tylenol) or ibuprofen (eg, Advil) as needed for pain relief. Headaches caused by fever are also helped by fever reduction.

2. Food: Give fruit juice or food if your child is hungry or hasn’t eaten in more than 4 hours (Reason: skipping a meal can cause a headache in many children).

3. Rest: Lie down in a quiet place and relax until feeling better

4. Local Cold: Apply a cold, wet washcloth or cold pack to the forehead for 20 minutes

5. Stretching: Stretch and massage any tight neck muscles

6. Call Your Doctor If:

* Headache becomes severe

* Vomiting occurs

* Isolated headache lasts longer than 24 hours

* Headache lasts more than 3 days

* Your child becomes worse

7. Muscle Tension Headaches: Extra Advice:

* If something is bothering your child, help him talk about it and get it off his mind

* Teach your child to take breaks from activities that require sustained concentration. Encourage your child to do relaxation exercises during the breaks.

* Teach your child the importance of getting adequate sleep

* If overachievement causes headaches, help your child find more balance

* CAUTION: Your child should have a complete medical checkup before you conclude that recurrent headaches are caused by worrying too much or stress

Treatment for Migraine Headache

8. Reassurance: This headache is similar to previous migraine headaches that your child has experienced.

9. Migraine Medication:

* If your child’s doctor has prescribed a specific medication for migraine, give it as directed as soon as the migraine starts. If not, ibuprofen (eg, Advil) is the best over-the-counter drug for migraine. Give ibuprofen now and repeat in 6 hours if needed.

10. Sleep: Have your child lie down in a dark, quiet place and try to fall asleep. People with migraine often awaken from sleep with their migraine gone.

11. Call Your Doctor If:

* Headache becomes much worse than usual

* Headache lasts longer than usual

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

Emergency symptoms not to miss

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Sick newborn Your baby is younger than 1 month and looks sick (eg, vomiting, cough, poor color) or acts abnormal (eg, poor feeding, excessive sleeping) in any way. At this age, these symptoms are serious until proven otherwise. During the first month of life, infections can progress quickly.

Severe lethargy Your child stares into space, won’t smile, won’t play at all, or hardly responds to you. Your child is too weak to cry, floppy, or hard to awaken. These are serious symptoms. Note: sleeping more when sick is normal, but when awake your child should be alert.

Confusion The sudden onset of confusion (delirium). Your child is awake but says strange things, sees things, and doesn’t recognize you. Note: transient delirium can be seen for 5 minutes or so with higher fevers. However, if not brief, confusion can have some serious causes.

Severe pain Severe pain is incapacitating. It interferes with all normal activities. The child just wants to be left alone. If your child cries when you  try to hold or move him, this can be a symptom of meningitis or appendicitis. Children also are unable to sleep or can only fall asleep briefly.

Inconsolable crying Inconsolable, constant crying is caused by severe pain until proven otherwise. Suspect this in children who are unable to sleep or will only fall asleep briefly, and when awake will not engage in any  normal activities. CAUTION: Instead of constant crying, severe pain may cause your child to groan, moan, or whimper.

Can’t walk If your child has learned to walk and then loses the ability to stand or walk, she may have a serious injury to the legs or a problem with balance. If your child walks bent over, holding her belly, she may have a serious problem such as appendicitis.

Tender abdomen Press on your child’s belly while he is sitting on your lap and looking at a book. You should be able to press an inch or so in with your  fingers in all parts of the belly without a problem. If your child winces or screams, it suggests a serious cause. If the belly is bloated and hard along with the pain, the problem is even more worrisome. Note: if your child just pushes your hand away, it probably means you  haven’t distracted him enough.

Tender testicle or scrotum Sudden pain in the groin area can be from twisting (torsion) of the testicle. This requires surgery within 8 hours to save the testicle.

Hard time breathing Breathing is essential for life. Most childhood deaths are due to severe breathing problems. If your child has trouble breathing,  tight croup (harsh sound when breathing in called stridor), or obvious wheezing or grunting with each breath, she needs to be seen immediately. Other signs of respiratory distress are fast  breathing, bluish lips, or retractions (skin pulling in between the ribs). Children with severe respiratory distress can’t drink, talk, or cry. Note: nasal congestion causes vibrations and some noisy breathing but usually without any trouble breathing. Check breathing after you clean out the nose with nasal washes and suction.

Bluish lips Bluish lips, tongue, or gums (cyanosis) can mean a reduced amount of oxygen in the bloodstream. Note: blueness only present around the mouth (but not the lips) can be caused by being cold.

Drooling The sudden onset of drooling or spitting when your child is ill means your child is having trouble swallowing. The cause can be  a serious infection of the tonsils, throat, or epiglottis (top part of  the windpipe). A serious allergic reaction can also cause trouble swallowing. Swelling in the throat could close off the airway.

Dehydration Dehydration means that your child’s body fluids are low. Dehydration usually follows severe vomiting or diarrhea. Suspect dehydration if your child has not urinated in 8 hours (more than 12 hours if your child is older than 1 year), crying produces no tears, the inside of the mouth is dry rather than moist, or the soft spot in the skull is sunken. Dehydrated children are also tired and weak. If your child is alert and active but not making much urine, she is not yet dehydrated. Children with severe dehydration become dizzy when they stand. Dehydration requires immediate fluid replacement by mouth or vein.

Bulging soft spot The soft spot in your baby’s head is tense and bulging. This means the brain is under pressure.

Stiff neck To test for a stiff neck, lay your child down, then lift his head until his chin touches the middle of his chest. If he is resistant, place a toy or other object of interest on the belly so he will have to look down to see it. Older children can simply be asked to look at their belly button. A stiff neck can be an early sign of meningitis.

Injured neck Talk to your child’s doctor about any neck injury, regardless of the symptoms. Neck injuries carry a risk of damage to the spinal cord.

Purple or blood-red spots or dots Unexplained purple or blood-red spots or dots on the skin could be  a sign of a serious bloodstream infection, especially if your child also has a fever. Note: bumps and bruises on the shins from active play are different.

Any fever (above 100.4°F or 38°C) in the first 3 months of life Bacterial infections in young infants can cause serious complications. All children younger than 3 months with a fever need to be examined as soon as possible to determine if the cause is viral or bacterial.

Fever above 105°F (40.6°C) All the preceding symptoms are stronger indicators of serious illness  than the level of fever. All of them can occur with low-grade fevers as well as high ones. Fevers alone are considered a risk factor for serious infections only when the child’s temperature rises above 105°F (40.6°C). Therefore if your child has a fever above 104°F (40°C) that doesn’t come down below 104°F after taking a fever medicine, call your child’s doctor.

Chronic diseases Most active chronic diseases can have some complications. If your child has a chronic disease, be sure to find out what those complications are and how to recognize them. Chronic diseases at highest risk for serious infections are those that weaken the immune system (eg, sickle cell disease, HIV, chemotherapy, organ transplant, chronic steroids). If you are talking with a doctor or  nurse who doesn’t normally see your child, always tell the doctor or nurse about your child’s chronic disease (eg, asthma). Never assume the doctor or nurse already knows this.

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