Vomiting With Diarrhea

• Vomiting and diarrhea occur together
• Vomiting is the forceful emptying (throwing up) of what is in the stomach
• It's normal for nausea (upset stomach) to come before each bout of vomiting
• Diarrhea means 3 or more watery or very loose stools. Reason: 1 or 2 loose stools can be normal with changes in diet.
• If vomiting is done, use the Diarrhea care guide.

Causes of Vomiting with Diarrhea

• Viral Gastroenteritis. GI infection from a virus is the most common cause. A common agent is the Rotavirus. The illness starts with vomiting. Watery loose stools follow within 12-24 hours. On cruise ship outbreaks, the most common viral cause is Norovirus.
• Food Poisoning. This causes rapid vomiting and diarrhea within hours after eating the bad food. Caused by toxins from germs growing in foods left out too long. An example is Staph toxin in egg salad.
• Traveler's Diarrhea. Caused by germs in food or drink. Suspect this if it follows recent foreign travel.
• Bacterial GI Infection. Diarrhea can also be caused by some bacteria. Most bacterial diarrhea goes away on its own. A few can cause a severe large bowel infection (such as Shigella colitis).
• Serious Complication: Dehydration. This is the health problem where the body has lost too much fluid. (See below for more on this).

Vomiting Scale

• Mild: 1 - 2 times/day
• Moderate: 3 - 7 times/day
• Severe: Vomits everything, nearly everything or 8 or more times per day
• Severity relates even more to how long the vomiting goes on for. At the start of the illness, it's common to vomit everything. This can last for 3 or 4 hours. Children then often become stable and change to mild vomiting.
• The main risk of vomiting is dehydration. Dehydration means the body has lost too much fluid.
• Watery stools with vomiting carry the greatest risk for causing dehydration.
• The younger the child, the greater the risk for dehydration.

Diarrhea Scale

• Mild: 3-5 watery stools per day
• Moderate: 6-10 watery stools per day
• Severe: Over 10 watery stools per day
• The main risk of diarrhea is dehydration.
• Frequent, watery stools can cause dehydration.
• Loose or runny stools do not cause dehydration.

Dehydration: How to Know

• Dehydration means that the body has lost too much fluid. This can happen with vomiting and/or diarrhea. A weight loss of more than 3% is needed. Mild diarrhea or mild vomiting does not cause this. Neither does a small decrease in fluid intake.
• Vomiting with watery diarrhea is the most common cause of dehydration.
• Dehydration is a reason to see a doctor right away.
• These are signs of dehydration:
• Decreased urine (no urine in more than 8 hours) happens early in dehydration. So does a dark yellow color. 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 babies, a sunken soft spot
• Slow blood refill test: Longer than 2 seconds. First, press on the thumbnail and make it pale. Then let go. Count the seconds it takes for the nail to turn pink again. Ask your doctor to teach you how to do this test.
• Fussy, 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. They can also be very dizzy when trying to stand.

Call 911 Now

• Can't wake up
• Not moving or too weak to stand
• You think your child has a life-threatening emergency

Go to ER Now

• Hard to wake up
• Acts or talks confused
• Not alert when awake ("out of it")
• Blood in the vomit that's not from a nosebleed
• Bile (green color) in the vomit. Exception: stomach juice which is yellow.
• Appendicitis suspected (pain low on right side, won't jump, wants to lie still)
• Poisoning suspected

Call Doctor or Seek Care Now

• Dehydration suspected. No urine in more than 8 hours, dark urine, very dry mouth and no tears.
• Blood in the stool
• Stomach pain when not vomiting. Exception: stomach pain or crying just before vomiting is quite common.
• Age less than 12 weeks old with vomiting 2 or more times. Exception: normal spitting up.
• Age less than 12 months old and vomited Pedialyte 3 or more times
• Severe vomiting (vomits everything) for more than 8 hours while getting clear fluids
• Weak immune system. Examples are: sickle cell disease, HIV, cancer, organ transplant, taking oral steroids.
• Vomiting a prescription medicine
• Fever over 104° F (40° C)
• Fever in baby less than 12 weeks old. Caution: do NOT give your baby any fever medicine before being seen.
• Your child looks or acts very sick
• You think your child needs to be seen, and the problem is urgent

Contact Doctor Within 24 Hours

• Age less than 1 year with vomiting
• Has vomited for more than 24 hours
• Fever lasts more than 3 days
• You think your child needs to be seen, but the problem is not urgent

Contact Doctor During Office Hours

• Vomiting is a frequent problem
• You have other questions or concerns

Self Care at Home

• Mild or moderate vomiting with diarrhea

Care Advice for Vomiting with Diarrhea

1. What You Should Know About Vomiting With Diarrhea:
   • Most vomiting is caused by a viral infection of the stomach. Sometimes, mild food poisoning is the cause.
   • Throwing up is the body's way of protecting the lower intestines.
   • Diarrhea is the body's way of getting rid of the germs.
   • When vomiting and diarrhea occur together, treat the vomiting. Don't do anything special for the diarrhea.
   • The main risk of vomiting is dehydration. Dehydration means the body has lost too much fluid.
   • Here is some care advice that should help.
2. Formula Fed Babies - Give Oral Rehydration Solution (ORS) for 8 Hours:
   • If your child vomits more than once, offer ORS for 8 hours. If you don't have ORS, use formula until you can get some.
   • ORS is a special fluid that can help your child stay hydrated. You can use Pedialyte or the store brand of ORS. It can be bought in food stores or drug stores.
   • Spoon or syringe feed small amounts. Give 1-2 teaspoons (5-10 mL) every 5 minutes.
   • After 4 hours without throwing up, double the amount.
   • Return to Formula. After 8 hours without throwing up, go back to regular formula.
3. Breastfed Babies - Reduce the Amount Per Feeding:
   • If vomits more than once, nurse for 5 minutes every 30 to 60 minutes. After 4 hours without throwing up, return to regular nursing.
   • If continues to vomit, switch to pumped breastmilk. ORS is rarely needed in breastfed babies. It can be used if vomiting becomes worse.
   • Spoon or syringe feed small amounts of pumped milk. Give 1-2 teaspoons (5-10 mL) every 5 minutes.
   • After 4 hours without throwing up, return to regular feeding at the breast. Start with small feedings of 5 minutes every 30 minutes. As your baby keeps down the smaller amounts, slowly give more.
4. Older Children (over 1 Year Old), Offer Small Amounts of ORS For 8 Hours:
   • ORS. Vomiting with watery diarrhea needs ORS (such as Pedialyte). If refuses ORS, use half-strength Gatorade. Make it by mixing equal amounts of Gatorade and water.
   • The key to success is giving small amounts of fluid. Offer 2-3 teaspoons (10-15 mL) every 5 minutes. Older kids can just slowly sip ORS.
   • After 4 hours without throwing up, increase the amount.
   • After 8 hours without throwing up, go back to regular fluids.
   • Avoid fruit juices and soft drinks. They make diarrhea worse.
5. Stop All Solid Foods:
   • Avoid all solid foods and baby foods in kids who are vomiting.
   • After 8 hours without throwing up, gradually add them back.
   • Start with starchy foods that are easy to digest. Examples are cereals, crackers and bread.
6. Do Not Give Medicines:
   • Stop using any drug that is over-the-counter for 8 hours. Reason: Some of these can make vomiting worse.
   • Fever: Mild fevers don't need to be treated with any drugs. For higher fevers, you can use an acetaminophen suppository (such as FeverAll). This is a form of the drug you put in the rectum (bottom). Ask a pharmacist for help finding this product. Do not use ibuprofen. It can upset the stomach.
   • Call your doctor if: Your child vomits a drug ordered by your doctor.
7. Return to School:
   • Your child can return to school after the vomiting and fever are gone.
8. What to Expect:
   • For the first 3 or 4 hours, your child may vomit everything. Then the stomach settles down.
   • Moderate vomiting usually stops in 12 to 24 hours.
   • Mild vomiting (1-2 times per day) with diarrhea may last a little longer. It can continue off and on for up to a week.
9. Call Your Doctor If:
   • Vomits all clear fluids for more than 8 hours
   • Vomiting lasts more than 24 hours
   • Blood or bile (green color) in the vomit
   • Stomach pain present even when not vomiting
   • Dehydration suspected (no urine in over 8 hours, dark urine, very dry mouth, and no tears)
   • Diarrhea becomes severe
   • You think your child needs to be seen
   • Your child becomes worse