Child: 2.5 Years, 10 kg — 3–4 Episodes of Vomiting

Immediate Assessment Priorities

Common Causes at This Age

1. Acute Gastroenteritis (AGE) — most common; viral (rotavirus, norovirus)
2. Upper respiratory tract infection — post-nasal drip causing vomiting
3. Urinary tract infection (UTI) — often presents atypically
4. Otitis media — common in toddlers
5. Dietary indiscretion / food intolerance
6. Intussusception (peak 6m–3y) — intermittent colicky pain, "red currant jelly" stool
7. Raised intracranial pressure — early morning, projectile, non-nausea-associated

Assess Dehydration Status

Management

1. Oral Rehydration Therapy (ORT) — First Line

• ORS (Oral Rehydration Solution): Give small, frequent sips
• Dose: 5–10 mL every 5 minutes (increase gradually)
• For 10 kg child with mild–moderate dehydration:
  • Deficit replacement: 50–100 mL/kg over 3–4 hours = 500–1000 mL
  • Maintenance: ~100 mL/kg/day = ~1000 mL/day
• Avoid plain water, fruit juices, or carbonated drinks

2. Antiemetic — Ondansetron (if vomiting prevents ORT)

• Drug of choice in children with acute gastroenteritis-associated vomiting
• Dose: 0.15 mg/kg/dose → for 10 kg = 1.5 mg
• Available as 2 mg/5 mL syrup → give ~3.75 mL
• Or 2 mg ODT (orally disintegrating tablet)
• Single dose is usually sufficient; can repeat in 8 hours if needed
• Note: Guidelines suggest ondansetron primarily studied for >4 years; however, clinical practice widely supports use in younger children under physician supervision (Diagnosis and Management of Infectious Diarrhea, p. 9)

3. Diet

• Do NOT starve the child — resume age-appropriate diet early
• Breastfeeding should continue uninterrupted
• Avoid fatty, high-sugar foods acutely
• BRAT diet (banana, rice, applesauce, toast) has limited evidence but is well-tolerated

4. Avoid

• Metoclopramide — risk of extrapyramidal side effects in children
• Domperidone — cardiac risk concerns
• Loperamide — contraindicated in children <18 years for diarrhea

When to Refer / Admit

• Signs of moderate–severe dehydration → IV fluids (Normal Saline or Ringer's Lactate: 20 mL/kg bolus if in shock)
• Bile-stained or bloody vomiting
• Persistent vomiting despite antiemetic
• Suspected surgical cause (intussusception, obstruction)
• Altered sensorium or meningeal signs
• Inability to maintain oral intake after trial of ORT

Parent Counseling

• Give ORS in small sips frequently rather than large amounts at once
• Monitor urine output — wet diaper every 6–8 hours minimum
• Return immediately if: child becomes drowsy, vomiting worsens, blood appears, or no urine for >8 hours
• Fever management with paracetamol 15 mg/kg/dose (= 150 mg) if febrile

Clinical note: Always correlate with full history (onset, associated symptoms, travel, sick contacts, feeding history) and physical examination before initiating treatment.