October 2, 2013

Vomiting and/or Diarrhea

Vomiting and diarrhea viruses are not fun for anyone. Doctors refer to the most common cause of these symptoms as "viral gastroenteritis". Some kids just vomit, some kids just have diarrhea, and the most unlucky have both. 

Most of these illnesses do not need to be treated with medications (antibiotics can make it worse, since they also kill the good bacteria in your tummy), and anti-diarrheal medicines (like Imodium) can be harmful to children. The most important thing is to keep your child HYDRATED (more on that below). If you suspect your child has vomiting or diarrhea from food poisoning or any other type of foreign ingestion, please call poison control 1-800-222-1222, who are free and staffed with physicians 24-7!

How can you tell if your child is starting to get dehydrated?
- their mouth/lips seem dry
- they are urinating (peeing) a little less than usual
- they are thirsty

Now what?
You need to keep your child hydrated!
- A baby can continue to breast feed or take infant formula, if they are just a little dehydrated. If they vomit after every feeding, or are refusing the breast/bottle, then try to hydrate them with an Oral Rehydration Solution, like Pedialyte. Warning: the plain ones taste like salt water, so I suggest getting a few flavored ones and trying them out, to see which ones they will take. If they refuse the bottle completely, you can try feeding them via a syringe or spoon, giving small amounts every 15 minutes.
- A child who is getting electrolytes from food (such as chicken soup, or crackers, even if it's just a little bit) can hydrate with water. If they are not taking in any food, or if they are throwing up the food, please hydrate them with an ELECTROLYTE solution (aka Oral Rehydration Solution, aka ORS). You can buy them at most USA markets (under brand name Pedialyte, or generic versions), you can make your own by mixing 1 liter (5 cups) clean water with 6 level teaspoons (=2 tablespoons) sugar and 1/2 teaspoon salt. You can add a little bit of orange juice or a banana for potassium. Common substitutions are rice water, congee, green coconut water, or mixing gatorade with water (although I do not recommend doing this, since it is hard to get the right balance of electrolytes this way). If your child does not want to drink, try giving them sips every 15-30 minutes, or giving them the ORS/Pedialyte in frozen popsicle form.
- For every age, and everybody in the house, WASH YOUR HANDS A LOT to prevent spread/transmission of the stuff that gets you sick. Teach everyone to wash their hands in warm water, scrubbing for at least 20 seconds (2 rounds of the Happy Birthday song). Try and use real soap and water, instead of no-rinse hand sanitizers, since they do a better job at killing the tummy microbes.

But what if they keep vomiting?
- Let their tummy rest.
- Call your pediatrician, or go to the hospital, if they have signs of dehydration (see more below).
- Ask your pediatrician if your child is old enough and healthy enough for a medication against nausea/vomiting.
- Start with no food, but still give an electrolyte fluid (aka ORS above), for the first 12 hours.
- When they are ready/want to eat, give bland foods (e.g. the popular rice, toast, soup) and avoid foods that are fried, acidic, oily, or contain lactose.

But what if they have icky diarrhea?
- Change the diaper or bring them to the toilet frequently. Use a LOT of diaper cream to keep the area from getting chapped/sore. Put on a zinc cream (like the purple desitin) as if you are icing a cake - this acts as a barrier layer, to prevent acidic poop from sitting on the skin.
- Feed them binding foods, like rice.
- Sometimes the microbes that cause diarrhea, also cause a temporary lactose (the sugar in cow's milk) intolerance, so avoid lactose-containing stuff, like cow's milk and cheese. You usually have to do this for 2-4 weeks after the onset of the illness, until their GI system is back to normal.
- Try a children's probiotic with lactobacillus once per day, such as children's culturelle.

When my patients get sick this way, I often refer them to the great patient resources at UpToDate, such as this one on nausea and vomiting in children:
or this one on diarrhea in children:

How can you tell if your child is dehydrated enough to warrant intervention (like an urgent care or ER), or at least a call to your pediatrician?
- they are not urinating (peeing)  often enough (every 4-6 hours for a baby, every 6-8 hours for a toddler/child, every 8-12 hours for an older child/adolescent)
- they are crying, but can not make tears
- they are an infant whose fontanel (soft spot on top of the head) is more sunken than usual
- eyes look very sunken

What are some other signs that I should call my pediatrician about, or head over to the local urgent care/ER?
- persistent high fever (above 102.5 F)
- any fever in an baby younger than 3 months old
- severe abdominal (tummy) pain
- abdominal pain that moves to the lower right side
- lethargy or decreased responsiveness
- bloody (red or black) or bright green (like pea soup) vomit or diarrhea
- diarrhea not improving after 1 week

Soon your baby will be back to enjoying (throwing) his food (c) 2013
The good news is that the gastroenteritis season is almost over, so hang in there. However, we are getting into cough and cold season, so see my August 2012 post for tips on that: