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The Stomach flu
Dehydration & Rehydration
Other Medications
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February 2013
The Stomach Flu
Late winter through early spring is commonly the time for gastroenteritis, otherwise known as the "stomach bug" or "stomach flu."  Gastroenteritis is an infection of the intestines that typically presents with vomiting and diarrhea.  The most common causes of gastroenteritis are viral, and cannot be treated with antibiotics. Vomiting and diarrhea are actually the body's functional way of getting rid of the offending virus. These viruses are extremely contagious!
Gastroenteritis frequently begins as a vague, crampy belly pain. Some children will complain of being nauseated, but more frequently they will lose interest in eating, hold their stomachs, and can have episodes of vomiting and diarrhea that seem to come out of nowhere. Fever can be a part of gastroenteritis as well and typically lasts between 2-5 days.
Gastroenteritis moves through the gut from the top to the bottom. It starts out with nausea and vomiting and then leads to diarrhea. The vomiting usually lasts 1-2 days but is quite powerful and can lead quickly to dehydration and discomfort. The diarrhea can last for a week and sometimes longer. Children who have been vomiting should stay out of school or daycare until they have had no vomiting and no fever for 24 hours. Children with diarrhea can return to school or daycare as long as the diarrhea can be controlled and contained.
Dehydration and Re-hydration 
The main danger of gastroenteritis with vomiting is dehydration, or not enough fluid in the body. The only real "medicine" for vomiting is fluids. In the case of severe dehydration, children will need to have fluids given to them intravenously (directly into the bloodstream) at the hospital. In some cases, they will also get an anti-nausea medication, but this is typically reserved for patients who cannot keep anything down. Oral re-hydration - liquids by mouth - is the tried and true method of recovery from the stomach bug!
So, how do you hydrate? Water, our usual go-to choice for hydration, is not a good choice for children under 6 months of age, or for children who are vomiting excessively. Once children start to recover from the gastroenteritis and begin to eat a more varied diet, you can certainly return to using water for hydration. The body needs sugar (for the brain) and salt (to keep the water in the blood stream), so the fluid you are using to treat vomiting must have both of these. We call these liquids oral re-hydration solutions (ORS).
Good choices for ORS include Pedialyte, Gatorade, and soup broth. Because of the salt content of Pedialyte, some children do not like the taste. You can certainly use Pedialyte popsicles, or add a splash of Crystal Light (or other beverage powder) or a small amount of fruit juice to the liquid solution. Infants can drink Pedialyte, and you can mix formula with Pedialyte for infants who refuse the Pedialyte alone. Straight juice is a poor choice for re-hydration. The sugar content of juice is too high and can even worsen diarrhea and dehydration.
Most parents are concerned about how to get fluids into a child who is constantly vomiting. Unfortunately, gastroenteritis causes the stomach to stop moving things along in the correct direction, and dehydration worsens this problem. If you give a large volume of fluids to a vomiting child, they are thirsty enough to drink it, but the stomach can't handle it. The only way to rehydrate is SLOWLY and STEADILY -- give small amounts of ORS frequently. Start with a sip or a teaspoonful every 5 minutes - set a timer. Then, If your child is able to tolerate this amount of fluid for 30 minutes, you can increase to a tablespoon every 10 minutes, or an ounce every 15 minutes. If vomiting returns, wait 5 minutes then start again back at the beginning.
When can you restart solid foods? Let your child lead the way. When they are feeling up to eating, you can certainly let them eat. We used to recommend a bland "BRAT" diet (banana, rice, applesauce, toast) for recovering from gastroenteritis, however, new data supports reintroducing typical foods as soon as kids are interested in eating.  
Other Medications
If your child has fever, you can certainly use acetaminophen or ibuprofen to manage the symptoms. However, we recommend limiting ibuprofen use in a child who is dehydrated. Immodium and Pepto-Bismol should NOT be used for children with gastroenteritis. These medications stop the stool from escaping and therefore keep the virus inside the body. This can have significant and medically dangerous consequences.

Concerning Symptoms
If your child has symptoms that are severe or last a long time, they should certainly be evaluated either at our office or more urgently at the Children's Hospital or MGH Emergency Department. We would specifically be concerned about the following:
  • Prolonged fever - temperatures above 104 or fevers that last more than 5 days.
  • Excess fatigue or difficulty waking up
  • Decreased urine production - fewer than 3 in a 24 hour period 
  • Dark brown or strong-smelling urine
  • Crying without tears
  • Dry or "sticky" mouth
  • Sharp or severe belly pain - especially if it makes your child visibly tense up when you touch their belly  
  • Blood in stool or vomit
  • Sunken eyes or sunken "soft spot" on an infant's head  
  • Slow and steady re-hydration wins the race 
  • Use Pedialyte, Gatorade, and Popsicles
  • Avoid plain water in infants less than 6 months old or if children are unable to eat solid foods because of the vomiting.
  • Call immediately with any concerning symptom.