Vomiting in children: home care and when to worry

Most vomiting in children comes from a stomach bug and settles in a day or two. The real danger is dehydration (losing more water than the body takes in), not the vomiting itself. So your main job is to keep small amounts of fluid going in. Below are the questions parents ask Dr Dutta most, with short answers, and the warning signs that mean you should not wait at home.

Why is my child suddenly vomiting?

The most common cause is gastroenteritis, often called stomach flu. It is an infection of the gut, usually by a virus, and it often brings loose stools a few hours later.

Doctors think of gastroenteritis when vomiting or watery stools start suddenly. Contact with someone who has the same illness, or food or water that may be unsafe, makes it more likely.¹ Of all the gut germs, rotavirus tends to cause the most severe illness, and it often leads to dehydration.²

Vomiting can also come from other illnesses: a urine infection, an ear or throat infection, pneumonia, meningitis, a blocked bowel or appendicitis. That is why the warning signs later in this page matter more than the vomiting itself.

How long does vomiting last with a stomach bug?

Vomiting from gastroenteritis usually lasts 1 to 2 days and in most children stops within 3 days. The loose stools last longer, usually 5 to 7 days, and settle within 2 weeks in most children.¹

So a child who stops vomiting on day two but still has watery stools on day five is following the normal pattern. If vomiting goes on beyond 3 days, or the child is getting weaker instead of better, see a doctor.

How can I stop my child vomiting at home?

There is no home remedy that switches vomiting off. What works is giving the stomach small amounts often, so some fluid stays down even if some comes back up.

• Let the stomach settle for a short while after a vomit, then start again with tiny sips.
• Use a spoon, a cup or a syringe, one small sip at a time. Big gulps from a bottle tend to come straight back.
• Keep your child sitting up or lying on the side, never flat on the back, so vomit does not go into the lungs.
• Do not force food. Hunger will return as the vomiting settles.

Avoid medicines from the chemist "to stop vomiting" unless a doctor has examined your child. Medicines that stop diarrhoea should not be used in young children with gastroenteritis.¹

How do I give ORS to a child who keeps vomiting?

Give ORS (oral rehydration solution) in very small amounts, very often. A teaspoon every few minutes adds up to a lot over an hour, and most of it stays down.

Guidelines advise the low-osmolarity ORS (the newer, less salty WHO formula sold in India in sachets) and advise giving it frequently in small amounts.¹ Mix the sachet exactly as written, in boiled and cooled water. Too much powder makes it too salty, and too little makes it weak.

For a child with signs of dehydration, doctors aim for about 50 ml for every kilogram of body weight over 4 hours, plus the child's normal needs.¹ For a 10 kg toddler, that is roughly 500 ml of ORS in 4 hours. If your child cannot keep even small sips down, or refuses all fluid, that is a reason to see a doctor the same day.

Fluids by mouth work better than a drip for most children, and hospital is usually only needed when a child cannot be rehydrated by mouth.²

Can I give juice, coconut water or glucose water instead of ORS?

For a child who is only mildly unwell and not dehydrated, ordinary fluids the child likes are usually fine. For a child who is dehydrated or at higher risk, ORS is the right drink.

In a Canadian trial of children aged 6 months to 5 years with mild gastroenteritis, half-strength apple juice followed by the child's preferred drinks did better than an electrolyte drink. Fewer children in the juice group needed a drip.³ These children were only minimally dehydrated, so this does not apply to a child who is already dry.

NICE advises against fruit juices and fizzy drinks in children at higher risk of dehydration, and recommends ORS for them.¹ In practice, Dr Dutta suggests ORS first. If your child refuses it, diluted fluids they will actually drink are better than nothing. Avoid cola, packaged juices and glucose powder mixed strong, because very sugary drinks can make loose stools worse.

Should I keep breastfeeding and feeding my child?

Yes. Keep breastfeeding all through the illness. Go back to your child's usual food as soon as they want it, or, if they are dehydrated, as soon as the ORS has done its work.

European guidelines say breastfeeding should not be stopped, and that regular food, including milk, should continue without special diets.² NICE is slightly more cautious for a child who is already dehydrated: no solid food during the few hours of rehydration, then full-strength milk and the normal diet straight after.¹

In many homes, grandmothers advise stopping milk or giving only plain water and sago. There is no need. Soft dal-rice, khichdi, curd rice, banana or suji are all fine once the child is hungry. A child who eats recovers faster than a child kept on fluids alone.

What are the signs of dehydration in a child?

Signs of dehydration include passing less urine, a dry mouth, sunken eyes, fast breathing, a fast heartbeat, and a child who is unusually cranky or sleepy.¹ Cold, pale or blotchy hands and feet, with a very drowsy child, are signs of shock (the circulation failing), which is an emergency.¹

A review of studies found that doctors' best single clues are a slow capillary refill, skin that stays tented when pinched, and an abnormal breathing pattern. Several signs together are far more reliable than any one alone.⁴ Capillary refill means pressing on a fingernail until it goes pale and seeing how fast the pink returns.

At home, count wet nappies or trips to the toilet. A big drop in urine is a reason to see a doctor.

Which children get dehydrated faster?

Babies under 1 year, and especially those under 6 months, dry out much faster than older children. So do babies born small.¹

NICE also lists these as higher risk:¹

• more than 5 watery stools in the last 24 hours
• more than 2 vomits in the last 24 hours
• a child who has not been given, or could not keep down, extra fluids
• a baby who stopped breastfeeding during the illness
• a child who is undernourished

If your child is in one of these groups, start ORS early and keep a lower threshold for seeing a doctor. In a Kolkata summer, children also lose water through sweat, so dehydration can come on faster than you expect.

Is ondansetron safe for children?

A single dose of ondansetron, given after a doctor has seen your child, is well studied and helps many children keep ORS down. It is not a medicine to give repeatedly at home without advice.

In a trial of 215 children with gastroenteritis and dehydration, one oral dose cut vomiting during rehydration from 35% to 14%. Fewer children needed a drip.⁵ A Cochrane review of seven trials also found that oral ondansetron helped vomiting stop and reduced drips and immediate hospital admission. Loose stools were reported as a side effect in most of the ondansetron studies.⁶

Ondansetron has a warning about rare effects on heart rhythm, so experts advise care before routine use.² Dr Dutta uses it in selected children, as a single dose, and asks about heart problems and other medicines first. She does not recommend older anti-vomiting medicines for small children.

Do probiotics, zinc or antibiotics help vomiting and diarrhoea?

Antibiotics are rarely needed because most stomach bugs are viral. Zinc is advised for diarrhoea, but it can make vomiting worse. Probiotics give mixed results.

• Antibiotics: European guidelines reserve them for exceptional cases.² Your doctor will decide if, for example, there is blood in the stool.
• Zinc: WHO and UNICEF advise zinc for every child with diarrhoea, 10 mg a day under 6 months and 20 mg a day from 6 months, for 10 to 14 days.⁷ In children over 6 months it may shorten diarrhoea by about half a day.⁸ But zinc itself raised the risk of vomiting by about half in trials.⁸ Dr Dutta suggests giving it after a feed, and starting once the vomiting has settled.
• Probiotics: a large Canadian trial of 886 children found that a two-strain probiotic did not reduce how sick children became, or how long the diarrhoea or vomiting lasted.⁹ Some other strains may shorten diarrhoea a little.²

Money is better spent on ORS than on a bag of medicines.

What does green vomit mean in a baby or child?

Green vomit (bright or dark green, like bile) is a warning sign and needs a doctor urgently, especially in a baby. It can mean the bowel is blocked or twisted.

NICE lists green vomit among the signs that point to an illness other than simple gastroenteritis.¹ A blocked bowel needs a surgeon, sometimes within hours.

Do not confuse green with yellow. Yellow or curdled vomit after milk is common. Green vomit, with a swollen tummy or a baby who will not feed, is an emergency.

Is blood in my child's vomit serious?

A few red streaks after hard, repeated vomiting are often from a small tear at the lower end of the food pipe and usually settle. Large amounts of blood, or vomit that looks like coffee grounds, need a doctor straight away.

Other harmless causes are swallowed blood from a nosebleed or, in a breastfed baby, from a cracked nipple. Beetroot, red syrups and coloured drinks can also look like blood.

Go to hospital without waiting if the bleeding is more than a streak, if it keeps happening, or if your child is pale, sleepy or has black, tarry stools.

How do I know if vomiting is appendicitis?

With appendicitis, belly pain is the main problem and it gets steadily worse, while vomiting is a side feature. Pain that starts around the navel and moves to the lower right side is a strong clue.

A review of studies in children found that fever made appendicitis more likely. Pain that moves from the middle of the tummy to the lower right was more telling than right-sided pain alone. Pain when the doctor presses and then lets go also raised the chance.¹⁰

See a doctor the same day if your child has belly pain that lasts more than a few hours, walks bent over, does not want to jump or move, or has pain that is getting worse rather than better. Severe or one-sided pain is a reason to think beyond gastroenteritis.¹

Vomiting with headache: should I worry?

A child with a stomach bug can have a mild headache from fever and dehydration. But vomiting with a severe headache, a stiff neck, unusual drowsiness or a rash that does not fade when pressed needs emergency care.

NICE lists a stiff neck, a change in alertness, a bulging soft spot in babies and a rash that does not fade under a glass as signs of something other than gastroenteritis.¹ These can point to meningitis.

A different pattern also needs a doctor: headaches that wake a child or are worst in the morning, with vomiting, returning over days or weeks. This is uncommon, but it needs proper checking.

My child vomited after a fall or head injury. What should I do?

Any vomiting after a head injury is a reason to have your child checked by a doctor. Repeated vomiting is a stronger warning sign.

The NICE head injury guideline lists vomiting since the injury among the reasons to be assessed in an emergency department, though doctors use judgement in children aged 12 or under.¹¹ In children, 3 or more separate vomits after the injury is one of the risk factors doctors weigh when deciding on a CT scan.¹¹

Go straight to hospital if your child also becomes drowsy, confused, has a fit, has a worsening headache, or has clear fluid or blood from the nose or ears.

When can my child go back to school after a stomach bug?

Keep your child at home until 48 hours have passed since the last vomit or loose stool.¹

Stomach bugs spread very easily within families and classrooms. Washing hands with soap and water, and drying them well, is the most important way to stop the spread.¹ Wash hands after toilet trips and nappy changes, and before cooking or eating. Do not share towels.

Can vaccines prevent stomach flu in children?

Yes, partly. The rotavirus vaccine, given free in India under the national programme, protects against the most severe kind of stomach flu in babies.

In an Indian trial of the 116E rotavirus vaccine, given at 6, 10 and 14 weeks, it cut severe rotavirus gastroenteritis by about 54% overall and 56% in the first year of life.¹² It does not prevent every stomach bug, but it prevents many of the ones that land babies in hospital. Clean drinking water and handwashing do the rest.

When should I take my vomiting child to a doctor or hospital?

Go to a doctor or hospital urgently if you see any of these:¹

• green vomit
• very little or no urine, sunken eyes, or a dry mouth
• a child who is very sleepy, floppy, confused or hard to wake
• cold, pale or blotchy hands and feet, or fast breathing
• a stiff neck, a bulging soft spot, or a rash that does not fade when pressed
• severe or one-sided tummy pain, or a swollen tummy
• blood or mucus in the stools
• a baby under 3 months with a temperature of 38 degrees C or more, or an older child with 39 degrees C or more
• vomiting for more than 3 days, or a child who cannot keep any fluid down

Also go urgently for vomit with a lot of blood or coffee-ground material, and for any vomiting after a head injury.¹¹

Trust your instinct. If your child looks very unwell to you, that alone is a good reason to be seen.