Patient education: Nausea and vomiting in infants and children (Beyond the Basics)

INTRODUCTION — Nausea and vomiting are common in children. These symptoms are usually related to a mild, brief illness, often a viral infection. Although most children recover from nausea and vomiting without any treatment, it is important to know when to seek help if the child does not get better.

Nausea usually, but not always, occurs before vomiting. Younger children may not be able to recognize nausea, although they may complain of a stomachache or generally feeling unwell.

Vomiting versus spitting up — Spitting up is different from vomiting, although people often use the terms interchangeably. Spitting up is common in babies and is normal. The medical term for this is "regurgitation" or "reflux." Vomiting is usually more forceful and is larger in amount, and the baby or child usually seems sick. But, in some cases, it can be hard to tell the difference, especially in babies who spit up forcefully or in large amounts. Sometimes, older children or adults have regurgitation or reflux, but the food usually does not come out of the mouth and is re-swallowed.

Spitting up and acid reflux are discussed separately. (See "Patient education: Acid reflux (gastroesophageal reflux) in babies (Beyond the Basics)" and "Patient education: Gastroesophageal reflux disease in children and adolescents (Beyond the Basics)".)

Why does vomiting occur? — Nausea and/or vomiting occur when nerves in the body or brain sense a trigger, such as certain infections or medicines, food allergies, food poisoning, or motion. In some cases, vomiting has a benefit since it provides a way for the body to get rid of potentially harmful substances or to get rid of food if the intestine is blocked. In other cases, vomiting is a reflex (reaction) to an illness that has no particular benefit.

Medicines and methods to intentionally induce vomiting (eg, syrup of ipecac, placing a finger in the throat) are no longer recommended, even if an infant or child has ingested a harmful substance. If someone ingests something that could be harmful, it is best to immediately call for emergency medical help (in the United States and Canada, call 9-1-1).

CAUSES OF VOMITING — Vomiting can be caused by a number of different problems, depending on a child's age. Your child's health care provider can help determine the cause and whether treatment is needed.

Newborns and young babies — In newborns and young babies (up to three months old), the first step is to distinguish between spitting up (which is normal) and vomiting. If the vomiting is not forceful and your baby is otherwise healthy, it's most likely just spitting up. If you are unsure, talk to your baby's health care provider. (See 'Vomiting versus spitting up' above.)

Forceful vomiting or vomiting that comes with fever (temperature 100.4°F [38°C] or higher) can be signs of a more serious problem. If your baby has these signs, they should see a health care provider right away. Possible causes include:

●Pyloric stenosis – Pyloric stenosis is a blockage or narrowing of the stomach. The vomiting is very forceful (sometimes called "projectile"), usually starts between 2 and 10 weeks of age, and gradually worsens. The baby usually feeds well despite the vomiting.

●Food allergy – A food allergy may cause vomiting, which usually occurs shortly after eating or drinking the food. In young babies, a common trigger is cow's milk protein, which can be from a cow's milk-based formula or even breast milk. Often, there are other symptoms such as diarrhea, eczema, or wheezing. (See "Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)".)

●Intestinal obstruction – Obstruction means that there is a blockage somewhere in the bowel. This also causes forceful vomiting. The vomit might look green or yellow. In some cases, babies are born with this condition and the vomiting starts right after birth. In other cases, it starts suddenly in a baby who was healthy at birth.

●Infection – Infections are the most common cause of vomiting in all age groups. The infection might be in the intestine (called gastroenteritis) or somewhere else in the body. If your baby is young (newborn to three months) and has a temperature of 100.4°F (38°C) or higher, with or without vomiting, they should be evaluated by a health care provider. This temperature is a sign of a possible infection, which can be risky in very young babies. (See "Patient education: Fever in children (Beyond the Basics)".)

You should also see a health care provider if your baby is not feeding normally. They can help figure out if there is a reason for not feeding well and whether your baby is getting enough nutrition.

Older babies and children

●Gastroenteritis – The most common cause of vomiting in all age groups is infectious gastroenteritis (an infection of the stomach or intestines), usually caused by a virus. Vomiting caused by gastroenteritis usually begins suddenly and resolves quickly, often within 24 to 48 hours. Other signs of gastroenteritis can include nausea, diarrhea, fever, or abdominal pain. (See "Patient education: Acute diarrhea in children (Beyond the Basics)".)

Gastroenteritis spreads between people through contaminated food or touching surfaces. The viruses that commonly cause gastroenteritis are spread easily. Careful hygiene (especially handwashing) can prevent these infections from spreading.

Less commonly, vomiting occurs after consuming improperly stored or prepared foods that contain bacteria or toxins; this is called food poisoning. (See "Patient education: Foodborne illness (food poisoning) (Beyond the Basics)".)

●Other infections – Some children vomit when they have an infection in another part of the body, such as an ear or urinary tract infection. This is more common in young children.

Other children have vomiting that starts with a viral infection but continues for weeks or months. This happens when the stomach does not empty well even after the infection has resolved and is called "postviral gastroparesis." The vomiting is intermittent, usually occurs hours after eating, and gradually improves over time.

●Intestinal obstruction – Less commonly, vomiting can be caused by intestinal obstruction or blockage. In most cases, the vomiting starts suddenly and the child also has severe abdominal pain and a distended (swollen) abdomen. They might act lethargic or have blood in their bowel movements. Causes of obstruction include:

•Intussusception – This is when one part of the intestine slides ("telescopes") into an adjacent part of the intestine. It usually happens in babies or toddlers and requires urgent treatment.

•Malrotation – This is a condition that a child is born with that can cause a sudden obstruction (due to twisting of the intestine). If an obstruction happens, it requires immediate attention. The obstruction is more common in babies and young children but can happen at any age including adulthood.

●Functional nausea and functional vomiting – Some people have nausea and/or vomiting without an underlying reason. This is called "functional" nausea or vomiting and is more common in people with anxiety or depression. The nausea might be worse in the morning and improves during the day, and there is usually little or no abdominal pain. This disorder is diagnosed by reviewing the patterns and excluding other causes for the symptoms. It often improves with emotional support and relaxation strategies.

Other illnesses that can cause vomiting include gastroesophageal reflux, peptic ulcer disease, appendicitis, cyclic vomiting syndrome, eosinophilic esophagitis, and inflammatory bowel disease. A health care provider can usually diagnose these disorders by doing an examination, learning about the child's symptoms, and, sometimes, ordering tests. (See "Patient education: Acid reflux (gastroesophageal reflux) in babies (Beyond the Basics)" and "Patient education: Gastroesophageal reflux disease in children and adolescents (Beyond the Basics)".)

Adolescents — All of the disorders described under "older infants and children" above can also cause nausea and vomiting in adolescents. Gastroenteritis is also the most common cause, as in all age groups. (See 'Older babies and children' above.)

Other causes of vomiting that should be considered in adolescents are pregnancy, self-induced vomiting (eg, as seen with bulimia), frequent use of cannabis (marijuana), or consumption of toxic substances (eg, overdose).

WHEN TO SEEK HELP — You should call your doctor or nurse immediately if your child has any of the symptoms listed below.

●Vomiting patterns and appearance:

•Forceful vomiting in a young baby (newborn to three months old)

•Frequent vomiting that continues for more than 24 hours, especially in a baby or young child

•Vomit that contains bile (looks green) or blood (looks red, brown, or black or like it has coffee grounds in it)

●Fever:

•In a young baby (newborn to three months old), temperature of 100.4°F (38°C) or higher

•In older babies or children, fever higher than 102°F (39°C) once, or fever higher than 101°F (38.4°C) for more than three days

●Other symptoms:

•Abdominal pain that is severe, even if it comes and goes

•Bloody bowel movements

•Behavior changes, including lethargy or being hard to wake up

•Headache or vomiting that usually happens when the child is waking up

●Signs of dehydration:

•If a baby refuses to eat or drink anything for more than a few hours

•Signs of moderate to severe dehydration, such as dry mouth, no tears when crying, dark-colored urine, and not urinating in four to six hours (for babies and young children) or not urinating in six to eight hours (for older children)

If your child has other symptoms that concern you, call their health care provider and ask for advice. If they have nausea and vomiting without other concerning symptoms, they most likely do not need to be seen by a health care provider right away and you can take care of them at home and monitor their symptoms. (See 'Home care for nausea and vomiting' below.)

Most children with vomiting will start to get better within approximately 24 hours. You should talk to a health care provider if the vomiting is getting worse or is not getting better within 24 hours, or if you have any other questions or concerns.

EVALUATION — If a health care provider evaluates your child, they will review your child's medical history and do an examination. This will help them determine the most likely cause(s) of the vomiting and whether your child might be dehydrated. They might order blood or urine tests to confirm the cause or to check for dehydration.

HOME CARE FOR NAUSEA AND VOMITING — The following are some simple recommendations to help care for children with nausea and vomiting at home.

Monitor for dehydration — Dehydration (fluid loss) can develop in children with vomiting.

Signs of mild dehydration include:

●Slightly dry mouth

●Thirst

Children who are mildly dehydrated do not need immediate medical attention but should be monitored for signs of worsening dehydration.

Signs of moderate or severe dehydration include:

●Decreased urination – Not urinating or no wet diaper in four to six hours (for babies and young children) or not urinating in six to eight hours (for older children)

●No tears when crying

●Dry mouth

●Sunken eyes

●Cool or clammy hands and feet

●Listlessness

A child who is moderately or severely dehydrated should be evaluated by a doctor or nurse as soon as possible (ie, within a few hours).

Dietary recommendations — Children who are vomiting but are not dehydrated can continue to drink fluids as tolerated to maintain their hydration, as outlined below. If a child is dehydrated, meaning that their body has lost a lot of water and salt, they will need treatment to replace fluids. (See 'Oral rehydration therapy' below.)

Children less than one year old

●If your baby is breastfed, you can continue to breastfeed. If they vomit immediately after nursing, you can try to breastfeed more frequently and for a shorter time. For example, breastfeed every 30 minutes for 5 minutes. If that doesn't work, you can try giving small amounts of breast milk (1 to 2 teaspoons, or 5 to 10 mL) every 10 to 15 minutes, using a spoon, cup, or syringe. If the vomiting improves after two to three hours, you can resume the usual breastfeeding schedule.

●If your baby drinks formula, you can initially give them 1/2 to 1 ounce of an oral rehydration solution (eg, Pedialyte) every 15 minutes for two to three hours. If they vomit, wait 30 minutes and try again. If the vomiting improves, you can resume feeding with full-strength infant formula (do not add extra water to dilute the formula).

If vomiting worsens or does not improve within 24 hours, call your child's doctor or nurse. (See 'When to seek help' above.)

Older babies and children

●Fluids – Encourage your child to drink fluids. The best fluids are the commercially prepared rehydration drinks (eg, Pedialyte) because these keep the right balance of water and salt that the body needs (see 'Oral rehydration therapy' below). Start with small amounts of fluid and build up to 1 ounce (30 mL) per hour, then 2 ounces (60 mL) per hour, until the child is able to drink normally.

Avoid giving full-strength juice and other beverages with high sugar content because these can worsen diarrhea (table 1). Also, avoid sports drinks (eg, Gatorade) because they do not have the appropriate levels of sugar and electrolytes for someone who has vomiting and/or diarrhea.

●Food – It is common for children to have little or no appetite during a vomiting illness. There is no need to force your child to eat, especially during the first 24 hours. When they are ready to eat something, the best foods to offer are a combination of complex carbohydrates (rice, wheat, potatoes, bread), lean meats, yogurt, fruits, and vegetables. Avoid high-fat foods at first because these are more difficult to digest.

It is not necessary to give a special diet, such as giving only clear liquids or the "BRAT" diet (bananas, rice, applesauce, toast). Although these and similar foods might help to decrease diarrhea, they do not help with vomiting and do not contain enough nutrients for a child.

Oral rehydration therapy — Children who are dehydrated require treatment to restore their fluid balance. If they are in the hospital or emergency department, the treatment is usually given intravenously (IV). In many cases, effective treatment can also be given by mouth, using specially designed rehydration drinks, also known as oral rehydration solution (ORS). ORS can be given at home or in a medical care setting.

●When to give ORS – You can give ORS at home if your child is mildly dehydrated; refusing to eat a normal diet; or has vomiting, diarrhea, or both. ORS does not cure vomiting or diarrhea, but it does help to prevent and treat the dehydration that can develop when the body loses a lot of water and salt.

●What to buy – ORS is a beverage containing a carefully balanced amount of glucose (a sugar) and electrolytes (sodium, potassium, chloride), which are lost during vomiting and diarrhea. You can buy ORS without a prescription at most pharmacies and grocery stores. A few widely available ORS brands include Ceralyte, Enfalyte, and Pedialyte, although generic brands work equally well (table 1).

Do not try to prepare ORS recipes at home, because the formulas must be exact to work properly. Gelatin, tea, fruit juice, rice water, and other beverages are not recommended in children who are dehydrated.

●How to give ORS – You can give ORS in frequent, small sips or small amounts by spoon, bottle, or cup over three to four hours. Your child's doctor or nurse might provide specific instructions for giving oral rehydration. One method is described below:

•The recommended amount of ORS depends on the child's body weight, as shown in the table (table 2). This is approximately 1 cup (8 ounces) of ORS for every 10 pounds of body weight (or 500 milliliters per 10 kilograms). This amount should be given gradually, spread out over approximately four hours.

•Measure the solution with a standardized medicine syringe or measuring cup or spoon, rather than a regular cup or spoon.

•Give the fluid a few sips at a time. At first, try 1 teaspoon (5 milliliters each) every one to two minutes. If that stays down, you can try giving slightly larger amounts. If your child vomits, wait 30 minutes and then try again.

•After you give the whole amount, the child can drink fluids as tolerated and eat a normal diet as they feel ready.

Children who refuse to drink ORS or who vomit immediately after drinking it should be monitored closely for worsening dehydration. Children who are not dehydrated can continue to drink ORS between episodes of vomiting to prevent dehydration. (See 'Monitor for dehydration' above.)

Medications — Medications to reduce nausea and vomiting, called "antiemetics," might be recommended in certain situations (to reduce the risk of dehydration in children who vomit repeatedly or to reduce motion sickness). These medicines require a prescription, and you should not give them to an infant or child unless a health care provider has recommended them. Nonprescription treatments for nausea or vomiting are not recommended for infants or children.

Preventing spread of illness — If your child is vomiting because of a viral infection, it's important to be careful to avoid spreading the infection to yourself and others.

●Hygiene measures – Frequent handwashing is very effective and is the best way to prevent the spread of infection. Wet your hands with water and plain or antimicrobial soap and rub them together for 15 to 30 seconds. Pay special attention to the fingernails, between the fingers, and the wrists. Rinse your hands thoroughly, dry them with a paper towel, and throw away the paper towel.

Alcohol-based hand sanitizers are an acceptable alternative for disinfecting hands if a sink is not available. Sanitizers are available as a liquid or wipe in small, portable sizes that are easy to carry in a pocket or handbag. Spread the hand sanitizer over the entire surface of your hands, fingers, and wrists until dry. If your hands are visibly dirty, you should wash them with soap and water.

●School and daycare – Keep sick children out of school or daycare. Children with vomiting caused by gastroenteritis should stay out of school or daycare until they have not vomited for 24 hours.

WHERE TO GET MORE INFORMATION — Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Spitting up and GERD in babies (The Basics)
Patient education: Pyloric stenosis in babies (The Basics)
Patient education: Appendicitis in children (The Basics)
Patient education: Motion sickness (The Basics)
Patient education: Dehydration in children (The Basics)
Patient education: Nausea and vomiting in adults (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Acid reflux (gastroesophageal reflux) in babies (Beyond the Basics)
Patient education: Acute diarrhea in children (Beyond the Basics)
Patient education: Foodborne illness (food poisoning) (Beyond the Basics)
Patient education: Gastroesophageal reflux disease in children and adolescents (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Approach to the infant or child with nausea and vomiting
Gastroesophageal reflux in infants
Infantile hypertrophic pyloric stenosis
Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents
Cyclic vomiting syndrome
Management of gastroesophageal reflux disease in children and adolescents
Oral rehydration therapy

Websites — The following organizations also provide reliable health information:

●National Library of Medicine

(www.medlineplus.gov/nauseaandvomiting.html)

●GI Kids (from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition)

(www.gikids.org)

●National Institute of Diabetes and Digestive and Kidney Diseases

(www.niddk.nih.gov/health-information/digestive-diseases)

●American Academy of Pediatrics

(www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/default.aspx)

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