Treatment of Vomiting in Older Children

• Help your child go to sleep (reason: sleep often empties the stomach and relieves the need to vomit). Your child doesn't have to drink anything if he feels nauseated.
• If vomits once or twice, rest stomach and offer sips of a liquid child request
• If vomits over three times offer Pedialyte or PediaPops.
• If  your child refused Pedialyte there are several options
  • Flavored Pedialyte--there is a bubble gum flavor
  • Mix nutrasweet Kool-Aid in Pedialyte for flavoring
  • Mix one fourth part of something the child will drink (example: Gatorade) with three fourths part of  Pedialyte.
  • Gatorade is not really adequate but if all else fails and vomiting less than 10 times use it.
• If unable or unwilling to tolerate Pedialyte and vomiting persists, give one tablespoon of Pedialyte as if it were a medicine ever 5 to 10 minutes)
• When vomiting slows  offer it out of a straw  or larger volumes
• When no vomiting for 6 hours offer solids.  Begin with bland starchy foods.
• Avoid foods high in fat for 24 hours.
• Return to school or day care when no vomiting for 24 hours and no fever.

Treatment of Diarrhea

• The suggestions above also apply and work for diarrhea.
• If less than 5 stools continue regular diet. Eat more starchy foods like crackers, rice, bread, noodles, potatoes, cooked carrots, sugarless applesauce, etc. Drink more fluids. Do avoid all fruit juices, soda and Kool Aid because they make diarrhea worse because of the high sugar content. 
• If your child really like milk and there are less than 5 stools milk may be continued unless it causes cramping or there is vomiting.
• For formula fed infants with 5-10 stools a day:
  • Start Pedialyte for frequent watery diarrhea stools.
  • Offered small amounts frequently. Offering small amounts more frequently can sometimes decrease cramping and certainly helps to keep them hydrated.
  • Avoid Jello water, sports drinks, fruit juices, milk or soda since they contain high amounts of sugar and can make diarrhea worse.
  • Continue with small frequent amounts of Pedialyte even if the child is vomiting.
  • Returning to formula may be a gradual process. Usually you can return to formula in about 24 hours hrs of the onset of diarrhea and you really should within 48. You may need to alternate formula feedings with Pedialyte feedings in the beginning or you may need to use the formula Isomil DF (which is specially made for infants with diarrhea) for a few days before returning to a milk based formula.
• For breast fed infants with  5-10 stools a day:
  • Continue breastfeeding at more frequent intervals.
  • Add solids as listed above.
  • Offer Pedialyte feedings if urine production is decreased or dark.
• For children over one year with > 5 stools a day:
  • The choice of solids is the key factor. Starchy foods are absorbed the best. Give low sugar cereals (especially  rice cereal), oatmeal, bread, crackers, noodles, mashed potatoes, cooked carrots, sugar free applesauce, strained bananas, etc. Pretzels or salty crackers can help meet sodium needs.
  • Replacing lost fluids is important in moderate diarrhea.
  • Children under the age of 2 should be offered Pedialyte or other sugarless fluids in small frequent amount to prevent dehydration.
  • Children over the age of 2 can be offered Gatorade for this.
  • Avoid all fruit juices, soda, and high sugar drinks  which will make diarrhea worse.

Dehydration (See also regular illness  handout)

Dehydration does not happen all at one.  In the early phases the urine output is decreased.  Then the child becomes progressively listless and eyes appear sick or sunken.  Eventually the mouth appears dry and the child is weak and very sleepy.

Signs of Hydration:

• A happy alert child
• Drooling normally
• Normal urine output

Signs of Dehydration:

• No urine output or wet diapers in 8-12 hours
• Sick sunken eyes
• Dry mouth
• Weak appearing.

Appendicitis 

Appendicitis can present in many ways and be very difficult to diagnose, particularly in younger children.

A typical presentation is:

• Loss of appetite--almost always seen.
• Low grade fever.
• Mild belly pain that begins around the belly button and gradually increases and migrates to the right mid or right lower side.
• Tenderness when pressing in the right lower side or pain with jostling movements such as jumping.
• Vomiting can be present but is often a late sign.

See also Dr. Rudloff's AAP Home Page  for the paper "Detecting appendicitis in your child."

Constipation

St. Louis Children's Hospital website (www.slch.org) defines constipation as  the following:

• Pain or crying during the passage of a bowel movement (BM) OR  
• Unable to pass a BM after straining or pushing longer than 10 minutes OR
• No BM after more than 7 days and older than 1 month; OR not in 4 days and less than 1 month
• The following symptoms are NOT constipation: normal grunting, brief straining or pushing for less than 10 minutes, large BMs, or BMs passed every 2 or 3 days. Hard or dry BMs are also normal if passed easily.
• Main cause:  lack of fiber in diet, holding BMs, too little fluid.

Treatment of constipation varies by age:

• Infants under two months-
  • Many infants go through a transition phase where they may experience difficulty passing their stool. They may grunt, strain and even cry because their abdominal muscles  are not developed enough to easily push out stool.   It is constipation if it is small and firm like rabbit pellet food and difficult to pass.
  • See your doctor if the baby is under one month and has frequent problems with constipation or  has a distended belly,
  • In a breast fed infant under one month, infrequent stools  may be a sign of not getting enough breast milk (In an older infant infrequent stools may be normal).
  • Iron in formula does not cause constipation, however, some infants with constipation may benefit from a change in formula.
• Infants older than 2 months of age
  • In years passed parents used one teaspoon of dark Karo syrup in one to several bottles a day.  There was a time when there was concern about botulism in Karo syrup,  however, the author of that paper later told Dr. Rudloff that he didn't think  it was a concern.
  • For immediate relief a sliver of a glycerin can placed in the child's rectum but this cannot be done every day.
  • For persisting problems, begin with one ounce of apple or apple prune juice in one ounce of water.  If necessary use 2 ounces of straight juice and titrate upward as needed to a maximum of 4 ounces.
• Infants older than 4 months of age
  • May offer juice as mentioned above.
  • Oatmeal or barley cereal may help.
  • Add baby foods with high fiber content twice a day (peas, beans, apricots, prunes, peaches, pears, plums, spinach). 
  • Using ground up or smashed up table food is more effective than purchased baby foods
• Toddlers one to two years of age
  • Whole cow's milk can be constipating.  Reduce the amount give or eliminate milk for a few days and see if the constipation resolves.
  • Increase fruit juice (apple, pear, cherry, grape, prune) (note: citrus fruit juices are not helpful), not to exceed 8 oz. juice daily.
  • Add fruits and vegetables high in fiber content (peas, beans, broccoli, bananas, apricots, peaches, pears, figs, prunes, dates).
  • Miller's unprocessed bran powder in the dose of one tablespoon can be mixed into cereal, added into scrambled eggs,  French toast, etc.
• Older toddlers and children
  • If this occurs with toilet training and results from a child refusing to use the toilet, stop toilet training efforts until no constipation for several weeks and a more accepting child.
  • Add fruits and vegetables high in fiber content (peas, beans, broccoli, bananas, apricots, peaches, pears, figs, prunes, dates).
  • Increase whole grain foods (bran flakes, bran muffins, graham crackers, oatmeal, brown rice, and whole wheat bread.
  •  Popcorn can be used if older than 4 years old.)
  • Increase fluids (water or juices).
  • Quaker Oat Bran cereal is an adult cereal that many kids like and is effective for constipation.
  • Fiber Choice is a big sweet tart like fiber supplement that can be given as one or two tablets a day.
  • Citrucel  is an orange flavored fiber supplement with a taste that is acceptable to some kids.
  • Avoid constipating foods like large volumes of milk or cheese.