Vomiting
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Vomiting: What goes down must come up.
Like fever, there is considerable confusion over vomiting and I will attempt to resolve the myths up front. First, let me remind you that the human race has survived for tens of thousands of years. Part of the credit for this amazing accomplishment is certainly due to the body's ability to rid itself of those things that are harmful. Vomiting is one of the ways the body accomplishes this and in almost all cases it is GOOD. In otherwise healthy children, there is little reason to believe that vomiting is dangerous.
On the other hand, take your kid into the ER and you may expose them to real hazards. In the ER they will have to deal with other sick kids and unnecessary, painful, and potentially dangerous procedures. My advice, avoid the ER if at all possible.
On this page you will find my treatment guidelines as well as a references section so that you can decide for yourself. Lastly there is information on Home & Natural Remedies where you can share your advice or learn from the experience of others.
On the other hand, take your kid into the ER and you may expose them to real hazards. In the ER they will have to deal with other sick kids and unnecessary, painful, and potentially dangerous procedures. My advice, avoid the ER if at all possible.
On this page you will find my treatment guidelines as well as a references section so that you can decide for yourself. Lastly there is information on Home & Natural Remedies where you can share your advice or learn from the experience of others.
Myth or Fact?
The body's great emetic.
Myth #1: Vomiting causes dehydration.
This statement is FALSE. The stomach has a limited capacity to hold fluids and it secretes virtually no fluid. Thus a child who is vomiting will lose whatever is in their stomach when the vomiting begins, but little to no actual body fluid. The only substantial risk they have to dehydration is if they are unable to take in any fluids for more than 24 hours or if they also have concurrent and profuse diarrhea.
Myth #2: If my child is vomiting they need an IV.
This is only true if you enjoy subjecting your child to torturous medical intervention. Vomiting alone rarely leads to dehydration and rarely requires an IV or IV fluids. This is not common practice though. If you go into the ER complaining that your child has been vomiting there is a good chance that your child will get an IV, not because they are dehydrated but because most ER doctors feel compelled to DO something. Your child will then be held down while a nurse attempts to place an IV which may take several attempts. All the while your child is crying and being stuck with needles, instead of resting at home and letting the body heal itself. The truth is that even in kids who have mild to moderate dehydration, rehydration can generally be accomplished orally and at home.
Myth #3: If my child is vomiting they need a medicine to stop the vomiting.
WRONG again. The body is protecting itself by vomiting. If your child ate some food and got food poisoning why would you want to keep that food in your child's system? The body doesn't and it is trying to get it all out. Remember, the body generally knows best and if left alone will generally heal itself much faster than if we start interfering.
You also must consider that many of the most commonly prescribed medicines for nausea and vomiting have very common and serious side-effects. I would avoid these medications in almost all situations. They are generally a waste of money, probably prolong the overall illness, and may cause significant side-effects.
Myth #4: Vomiting means my child has a serious illness.
FALSE. Vomiting is generally caused by a stomach virus or food poisoning. Neither of these is dangerous in any way. Both generally last less than 24 hours and can easily be managed at home. The exceptions include vomiting blood or bile (dark green fluid) and vomiting associated with severe abdominal pain, high fevers, lethargy, and profuse water or bloody diarrhea.
Fact #1: Oral rehydration is best.
True. True. True. This is less costly, involves no pain, and can easily be accomplished at home. Pedialyte is the fluid of choice but the actual choice of fluid is less important than the concept of providing some fluids orally (through the mouth).
Even though your child WILL continue to vomit most of what you give for the first 6 hours, some of the fluid that you give will get absorbed. The trick is to give small amounts of fluid frequently - like one ounce (or less) every 15 to 30 minutes. As the vomiting starts to slow down you can increase the amount of fluid that you give.
Fact #2: Vomiting generally lasts 12 to 24 hours.
This is almost always the case and this is what you should expect. DO NOT call your doctor or run to the ER just because your child has thrown up 2 or 3 times. They will get sicker in the ER and probably be subjected to painful and unnecessary procedures. If the vomiting persists for more than 24 hours, this is not typical, and a call to your pediatrician is warranted.
Fact #3: Vomiting is rarely caused by something dangerous.
True again. Most people worry about appendicitis and head problems. If your child has appendicitis they will also likely have fever and severe abdominal pain with the vomiting. If your child has a brain tumor the vomiting will not come on suddenly and is generally associated with headache or other neurological symptoms. Bleeding in the brain is almost always preceded by some sort of trauma - thus if your child has not just suffered some sort of trauma, they are very unlikely to have any bleeding in the brain.
The danger is that in some ERs the doctors are quick to order unnecessary and dangerous tests. CT scans, depending on age, can increase the life-time risk of cancer to a much as 1:1000. So use some caution - if you insist on a CT scan of the head because your child vomited a few times, you are unlikely to find a brain tumor on the scan, but there will now be a 1:1000 chance that there will be one some time during their lifetime.
Fact #4: Vomiting is GOOD.
This should be self-evident by now. Let the body do what it does best and rid itself of things that may cause it harm. Stay out of the way of this process, try to get in small amounts of fluids, and go see your doctor only if there is some sign that there is something more serious going on or the vomiting does not resolve in 24 hours.
This statement is FALSE. The stomach has a limited capacity to hold fluids and it secretes virtually no fluid. Thus a child who is vomiting will lose whatever is in their stomach when the vomiting begins, but little to no actual body fluid. The only substantial risk they have to dehydration is if they are unable to take in any fluids for more than 24 hours or if they also have concurrent and profuse diarrhea.
Myth #2: If my child is vomiting they need an IV.
This is only true if you enjoy subjecting your child to torturous medical intervention. Vomiting alone rarely leads to dehydration and rarely requires an IV or IV fluids. This is not common practice though. If you go into the ER complaining that your child has been vomiting there is a good chance that your child will get an IV, not because they are dehydrated but because most ER doctors feel compelled to DO something. Your child will then be held down while a nurse attempts to place an IV which may take several attempts. All the while your child is crying and being stuck with needles, instead of resting at home and letting the body heal itself. The truth is that even in kids who have mild to moderate dehydration, rehydration can generally be accomplished orally and at home.
Myth #3: If my child is vomiting they need a medicine to stop the vomiting.
WRONG again. The body is protecting itself by vomiting. If your child ate some food and got food poisoning why would you want to keep that food in your child's system? The body doesn't and it is trying to get it all out. Remember, the body generally knows best and if left alone will generally heal itself much faster than if we start interfering.
You also must consider that many of the most commonly prescribed medicines for nausea and vomiting have very common and serious side-effects. I would avoid these medications in almost all situations. They are generally a waste of money, probably prolong the overall illness, and may cause significant side-effects.
Myth #4: Vomiting means my child has a serious illness.
FALSE. Vomiting is generally caused by a stomach virus or food poisoning. Neither of these is dangerous in any way. Both generally last less than 24 hours and can easily be managed at home. The exceptions include vomiting blood or bile (dark green fluid) and vomiting associated with severe abdominal pain, high fevers, lethargy, and profuse water or bloody diarrhea.
Fact #1: Oral rehydration is best.
True. True. True. This is less costly, involves no pain, and can easily be accomplished at home. Pedialyte is the fluid of choice but the actual choice of fluid is less important than the concept of providing some fluids orally (through the mouth).
Even though your child WILL continue to vomit most of what you give for the first 6 hours, some of the fluid that you give will get absorbed. The trick is to give small amounts of fluid frequently - like one ounce (or less) every 15 to 30 minutes. As the vomiting starts to slow down you can increase the amount of fluid that you give.
Fact #2: Vomiting generally lasts 12 to 24 hours.
This is almost always the case and this is what you should expect. DO NOT call your doctor or run to the ER just because your child has thrown up 2 or 3 times. They will get sicker in the ER and probably be subjected to painful and unnecessary procedures. If the vomiting persists for more than 24 hours, this is not typical, and a call to your pediatrician is warranted.
Fact #3: Vomiting is rarely caused by something dangerous.
True again. Most people worry about appendicitis and head problems. If your child has appendicitis they will also likely have fever and severe abdominal pain with the vomiting. If your child has a brain tumor the vomiting will not come on suddenly and is generally associated with headache or other neurological symptoms. Bleeding in the brain is almost always preceded by some sort of trauma - thus if your child has not just suffered some sort of trauma, they are very unlikely to have any bleeding in the brain.
The danger is that in some ERs the doctors are quick to order unnecessary and dangerous tests. CT scans, depending on age, can increase the life-time risk of cancer to a much as 1:1000. So use some caution - if you insist on a CT scan of the head because your child vomited a few times, you are unlikely to find a brain tumor on the scan, but there will now be a 1:1000 chance that there will be one some time during their lifetime.
Fact #4: Vomiting is GOOD.
This should be self-evident by now. Let the body do what it does best and rid itself of things that may cause it harm. Stay out of the way of this process, try to get in small amounts of fluids, and go see your doctor only if there is some sign that there is something more serious going on or the vomiting does not resolve in 24 hours.
Decide for yourself.
To Treat or Not to Treat
I have included several of the most recent studies regarding the use of anti-nausea medication. I suggest avoiding anti-nausea medication. However, if you disagree with me, Ondansetron (Zofran) is really the only rational option. It is superior in all respects to Phenergan and does not have the same dangerous side-effects.
References:
Cochrane Review: 2006
Notice the conclusion in this article, "The small number of included trials provided some, albeit weak and unreliable, evidence which appeared to favor the use of ondansetron and metoclopramide over placebo to reduce the number of episodes of vomiting due to gastroenteritis in children. The increased incidence of diarrhea noted with both ondansetron and metoclopramide was considered to be as a result of retention of fluids and toxins that would otherwise have been eliminated through the process of vomiting."
Pharmacology & Therapeutics: 2007
This article also does not recommend routine use of anti-nausea medication. However, Ondansetron (Zofran) might be an option if you want to try and keep the IVs out of your child.
Annals of Emergency Medicine: 2002
Another article praising ondansetron (Zofran). This is a poor study though because there is no group that received NO treatment (because treatment is what you get in the ER). I suspect that if you gave no treatment to some patients, Zofran to some, and IV fluid to some, they would all be the same at 24 hours. Except that the latter two groups would have a larger hospital bill and more painful procedures - but that is just my opinion, I have no evidence to support it.
References:
Cochrane Review: 2006
Notice the conclusion in this article, "The small number of included trials provided some, albeit weak and unreliable, evidence which appeared to favor the use of ondansetron and metoclopramide over placebo to reduce the number of episodes of vomiting due to gastroenteritis in children. The increased incidence of diarrhea noted with both ondansetron and metoclopramide was considered to be as a result of retention of fluids and toxins that would otherwise have been eliminated through the process of vomiting."
Pharmacology & Therapeutics: 2007
This article also does not recommend routine use of anti-nausea medication. However, Ondansetron (Zofran) might be an option if you want to try and keep the IVs out of your child.
Annals of Emergency Medicine: 2002
Another article praising ondansetron (Zofran). This is a poor study though because there is no group that received NO treatment (because treatment is what you get in the ER). I suspect that if you gave no treatment to some patients, Zofran to some, and IV fluid to some, they would all be the same at 24 hours. Except that the latter two groups would have a larger hospital bill and more painful procedures - but that is just my opinion, I have no evidence to support it.
Dr. Reynolds Treatment Guidelines
Vomiting in children: When to treat and when to see your doctor.
When your child is vomiting...
1. Start with fluids, I suggest Pedialyte. Give 1/2 ounce every 15 minutes while your child is awake.
2. Your child will probably continue to vomit frequently for the first several hours. However, the pedialyte starts getting absorbed as soon as it is swallowed. Even if it only stays down for 5 or 10 minutes it is useful to prevent dehydration.
3. If your child vomits immediately after taking the fluids, give nothing for 2 hours (rest the stomach), then restart the oral rehydration (#1).
4. Children will likely continue to have vomiting for 12 to 24 hours. This is normal. Continue observing your child during this time. If they are vomiting blood or dark green fluid, or they develop severe abdominal pain, lethargy, or profuse/bloody diarrhea, call your pediatrician. You should also call your pediatrician if the vomiting lasts more than 24 hours.
5. The purpose of seeing your doctor is to rule out more severe illness (like appendicitis) and evaluate for dehydration. If more serious illnesses have been ruled out and your child is not dehydrated, no intervention is required.
6. If your child is getting dehydrated and oral rehydration has failed, a trial of Ondansetron(Zofran) should be attempted before IV fluids are considered.
7. Phenergan and older anti-nausea medications should never be taken.
8. By using this treatment protocol most children can successfully be treated at home and you will save you and your child the trauma of visiting the ER.
1. Start with fluids, I suggest Pedialyte. Give 1/2 ounce every 15 minutes while your child is awake.
2. Your child will probably continue to vomit frequently for the first several hours. However, the pedialyte starts getting absorbed as soon as it is swallowed. Even if it only stays down for 5 or 10 minutes it is useful to prevent dehydration.
3. If your child vomits immediately after taking the fluids, give nothing for 2 hours (rest the stomach), then restart the oral rehydration (#1).
4. Children will likely continue to have vomiting for 12 to 24 hours. This is normal. Continue observing your child during this time. If they are vomiting blood or dark green fluid, or they develop severe abdominal pain, lethargy, or profuse/bloody diarrhea, call your pediatrician. You should also call your pediatrician if the vomiting lasts more than 24 hours.
5. The purpose of seeing your doctor is to rule out more severe illness (like appendicitis) and evaluate for dehydration. If more serious illnesses have been ruled out and your child is not dehydrated, no intervention is required.
6. If your child is getting dehydrated and oral rehydration has failed, a trial of Ondansetron(Zofran) should be attempted before IV fluids are considered.
7. Phenergan and older anti-nausea medications should never be taken.
8. By using this treatment protocol most children can successfully be treated at home and you will save you and your child the trauma of visiting the ER.
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3spares1pair
Dec 20, 2010 @ 11:01 pm | delete
- Are you a nurse or a doctor or what?
I found your article painful to read. It was particularly harsh to read that the popular opinion is that I, and other moms like me, enjoy subjecting the children we love to torturous medical intervention.
"This is only true if you enjoy subjecting your child to torturous medical intervention."
You make ONE mention of lethargy in your entire blurb. My daughter nearly died because of advice like yours. That advice came from a nurse practitioner at our pediatrician's office years ago. Later, I sat outside in the parking lot of the hospital emergency room with a stop watch and syringe measuring out 5 cc's at a time every twenty minutes only to watch it (and more) pour out of her mouth several minutes later. I was a wreck by the time I got into the er. I was crying and confused after being warned that the only reason to take her to the hospital would be for my comfort, not hers.
Eight days later we left the hospital.
We have had many, many hospitalizations since that terrible night. Fortunately, none have been that long again.
My daughter had metabolic acidosis. For some unknown reason she is prone to it. It is a terrible condition. The most remarkable symptom? Vomiting.
We no longer have to go to the hospital for mild acidosis. My daughter has a port now and I can start her iv at home when she needs it. Now that we have symptom control, I started reading tonight to find out why some kids do not respond favorably to ort. And this is the first answer I get? Because their parents don't love them and enjoy torturing them.
What you're saying simply is not true. It may be true in many cases. I'm sure it's true in most cases. In fact, I have four other children for whom it is true. But the one kid out there whose parent is fretting over "do I call the doctor?" doesn't deserve to die or suffer permanent organ damage just because they don't fit the norm.
My daughter's kidneys will never function at full capacity again. That one episode with delayed treatment was enough. Oh yes, and our arrival at the er was less than 24 hours after the vomiting started, 12 hours after leaving the pedi's office. I knew something was wrong because she couldn't walk or talk very well. The lethargy preceded the vomiting. There were no other obvious signs. (except an odd smell, but try explaining that to the nurse on the phone!).
Your lens makes me wonder--do you think kids who are an exception to the rule should die? Some kind of natural selection to weed out the weak?
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It is important for everyone to understand that the purpose of this website is educational - to provide information. It is not a replacement for your doctor and I am not entering into a doctor-patient relationship with any of the readers of these pages or their children. It is my goal that by providing you with easy to understand information based on the latest research you will be empowered to work with your doctor to raise...healthy kids!
by DrReynolds
DrReynolds
Dr. Reynolds is a Board Certified Pediatrician and currently practices Pediatric Emergency Medicine. He currently manages several educational websites... more »
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