Tuesday, March 30, 2010

Medical Mom Monday: Vomiting in Children

(I decided against posting a picture - they weren't pretty!)

** NOTE:  This article speaks to the common vomiting afflictions of kids.  Call your doctor or go to the Emergency Room if:

There is severe belly pain, esp with a fever
If there is blood in the vomit
If the vomiting is relentless and violent
If it was preceded by a head injury or fall
If there are other medical conditions present - such as diabetes! (management of a vomiting Type 1 diabetic is intensive)
If there is confusion, drowsiness, or lethargy
If a new or severe headache is present, or your child complains of neck pain/stiffness

Vomiting - barfing, tossing your cookies, urping, upchucking....whatever your family calls it......is unpleasant at best.  Let's just say it, it's just plain nasty.  For us parents, it's also worrisome, especially in small kids.  Vomiting seems to be a common concern for parents of young (and not so young) ones.  Kids that are vomiting do not feel good.  They're fussy and clingy (at least mine are).  They may or may not have a fever.

So, let's talk about it!

Vomiting is actually a reflex, meaning it is involuntary.  Yes, you can stick your finger down your throat and trigger your gag reflex, leading to vomiting, but the act itself is involuntary.  Did you know we have a "vomiting center" in our brain?  It doesn't have it's own office space, so to speak, it is more like a meeting room for the nerve pathways that bring the vomit message to the table.  These pathways include:  The Chemoreceptor Trigger Zone (sensitive to chemical abnormalities in the body),  The Vestibular System (motion sickness), The Vagus Nerve (gag reflex),  The Enteric Nervous System (part of the nervous system that controls the GI tract)- this comes into play with infectious causes, chemotherapy, anything that irritates the GI system.

The body has a plan of action for vomiting.  It's interesting how each step has a function.  (Not sure i want to know who was fascinated enough with vomiting to figure this all out......
1.  You start to salivate.  This protects the teeth from acidic stomach contents.
2.  You take a deep breath (so you don't inhale the icky stuff)
3.  Retroperistalsis starts in the middle of the small intestine - waves of movement going back up, rather than "on down"
4.  The pressure in your chest decreases while the pressure in your belly increases, causing the upchuck event.  Interestingly, the stomach itself does not contract.
5.  Because it's hard work, your heart rate increases and you sweat.

Was that more than  you wanted to know?  maybe, but it's important to know what causes all the symptoms because that is what people react to.....it's good to know what is a normal part of the process so you can distinguish when it isn't normal.

So, now we know how and why it happens......what do we do about it?

For Infants and Children:

HERE is a great flowchart from familydoctor.org that sums it all up!

Of note, Pyloric Stenosis is an emergent concern.  An infant less than 10 weeks with forceful projectile vomiting needs to be seen right away.  Intussusception is a intestinal blockage and is a medical emergency.  Go to your Emergency Room right away.

Vomiting is a fairly common occurrence in kids and generally is not an immediate cause to worry.  Most viral GI illnesses stop within 6-24 hours.  You are usually safe to ride it out at home for several hours for kids that are otherwise healthy.  Always watch for signs of dehydration, and if your child vomits continuously for more than 6 hours, you should call your doctor.  Vomiting once or twice all day can be managed at home (You'd be amazed at how many people come to the ER at 10pm and say their child has vomited 3 times in the last 8 hours). 

OK....I won't panic....but how do I take care of the pukey kid?

For breastfeeding infants - continue to breastfeed for 5-10 min every 2 hours or so.
For formula-fed infants - avoid formula for about 8 hours.  Instead, give 2-3 tsp of an oral replacement solution (see below) every 15 min with a spoon or oral syringe.  Don't underestimate the power of a parent armed with a dropper giving tiny amounts of liquids every few minutes.  Gradually increase the amount if the baby is able to keep it down for a couple hours.

Keep track of the number of wet diapers to help you know if your baby is becoming dehydrated.  They should have a minimum of 1 every 6 hours.

First, don't worry that your child is not eating.  I have so many parents say "but he/she hasn't eaten....."  Short periods of time without food is OK, the focus should be on fluid intake. 

Firstly, let the kid's stomach rest for the first hour after vomiting.  Then start with sips of clear liquids (can you see through it?, even if it has color) - like flat 7up, broth, sports drinks, liquid jello, etc - every 10 to 15 minutes.   Avoid milk products.   After a couple hours of no vomiting, you can graduate to popsicles and increased amounts of fluid.  After 24 hours without vomiting, you can resume their regular diet.  Many recommend avoiding dairy products for 2-3 days, though I never have with my own kids.

If your child doesn't make the 2 hours without vomiting, start over with smaller amounts of liquid or use a medicine dropper.  Can you tell i'm a fan of the dropper?  remember that liquid can be absorbed through the mucosa in your mouth...1-2 mls every few minutes can do wonders......

 If your child wants food (after a few successful hours), start with plain salted soda crackers.  Then try bananas, dry toast, rice, applesauce, or other blandish foods.  Avoid fruit with peels, raw vegetables, spicy food.

If you think your child is becoming dehydrated, use an "oral replacement fluid" like pedialyte or Resol.  My own kids would never tolerate pedialyte, but would take Gatorade.  You can try mixing pedialyte with apple juice, sometimes that is more palatable.  Avoid water - it doesn't have any electrolytes in it, and they are what you want to replace.

The World Health Organization has a field recipe for oral replacement fluid, when you don't have access to the commercial varieties.  Here's the recipe:
2 Tablespoons sugar or honey
1/4 tsp of salt
1/4 tsp of baking soda (can replace this with salt)
Mix in 1 liter of water

I haven't tried this, but it seems more appealing, esp with honey and warm water...maybe some mint leaves?

Be aware that if your child also has diarrhea, dehydration can happen more quickly.  Because diarrhea loses a lot of electrolytes, concentrate on using an oral replacement fluid or sports drinks.

Please remember - i'm just a mom that happens to be a Registered Nurse.  This article is for informational and educational purposes only, it is not meant, nor should, replace advice from your family health care provider.  You know your child best - trust your instincts!

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