Vomiting with Diarrhea

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
• Diarrhea means 2 or more watery or very loose stools (Reason: 1 loose stool can be normal)
• Vomiting and diarrhea together is covered by this topic (EXCEPTION: if vomiting is resolved, use the Diarrhea topic)

Causes

• Main cause: stomach and intestinal infection (gastroenteritis) from a stomach virus (e.g., Rotavirus). The illness starts with vomiting but diarrhea usually follows within 12-24 hours.
• Food poisoning from toxins produced by bacteria growing in poorly refrigerated foods (e.g. Staphylococcus toxin in egg salad or Bacillus cereus toxin in rice dishes).

Severity of Vomiting

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

• MILD: 1 - 2 times/day
• MODERATE: 3 - 7 times/day
• SEVERE: Vomits everything or nearly everything or 8 or more times/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.

Dehydration: How to Recognize

• Dehydration means that the body has lost excessive fluids, usually from vomiting and/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 doctor to teach you how to do this test.
• Irritable, tired out or acting ill. If your child is alert, happy and playful, he or she is not dehydrated.
• A child with severe dehydration becomes too weak to stand or very dizzy if tries to stand.

Return to School

• Your child can return to child care or school after vomiting and fever are gone.

See More Appropriate Topic (instead of this one) If

• VOMITING WITHOUT DIARRHEA
• DIARRHEA is main symptom (vomiting is resolved)

WHEN TO CALL YOUR DOCTOR

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 Bottlefed Infants Offer Oral Rehydration Solution (ORS) for 8 Hours:
   • ORS (eg. Pedialyte or the store brand) is a special electrolyte solution that can prevent dehydration. It's readily available in supermarkets and drug stores.
   • For vomiting once, continue regular formula.
   • For vomiting more than once, offer ORS for 8 hours. If ORS not available, use formula.
   • Spoon or syringe feed small amounts: 1-2 teaspoons (5-10 ml) every 5 minutes.
   • After 4 hours without vomiting, double the amount.
   • After 8 hours without vomiting, return to regular formula.
   • For infants over 4 months old, also return to cereal, strained bananas, etc.
   • Return to normal diet in 24-48 hours.
3. For Breastfed Infants, Reduce the Amount Per Feeding:
   • If vomits once, nurse 1 side every 1 to 2 hours.
   • If vomits more than once, nurse for 5 minutes every 30 to 60 minutes. After 4 hours without vomiting, return to regular breastfeeding.
   • If continues to vomit, switch to ORS (e.g., Pedialyte) for 4 hours.
   • Spoon or syringe feed small amounts of ORS: 1-2 teaspoons (5-10 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 (over 1 Year Old) Offer Small Amounts of Clear Fluids For 8 Hours:
   • ORS: Vomiting with watery diarrhea needs ORS (e.g, Pedialyte). If refuses ORS, use ½ strength Gatorade.
   • Give small amounts: 2-3 teaspoons (10-15 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, mashed potatoes, etc.
     • Return to normal diet in 24-48 hours.
5. Avoid Medicines:
   • Discontinue all non-prescription medicines for 8 hours (reason: usually make vomiting worse).
   • Fever: Fevers usually don't need any medicine. For higher fevers, consider acetaminophen (Tylenol) suppositories. Never give oral ibuprofen; it is a stomach irritant.
   • Call your doctor if: vomiting a prescription 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 (1-2 times/day) with diarrhea can continue intermittently for up to a week.

8. Call Your Doctor If:

   • Vomiting becomes severe (vomits everything) over 8 hours
   • Vomiting persists over 24 hours
   • Signs of dehydration
   • Diarrhea is severe
   • Your child becomes worse

And remember, contact your doctor if your child develops any of the "Call Your Doctor" symptoms.

Disclaimer: This information is not intended be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.

Author and Senior Reviewer: Barton D. Schmitt, M.D.
Last Reviewed: 11/15/2011
Last Revised: 11/15/2011
Content Set: Pediatric HouseCalls Symptom Checker
Copyright 1994-2012 Barton D. Schmitt, M.D.