Health Update from Your Nurses
Drs. Gordon, Nussbaum, and Lappin

November 23, 2010

The Long and Winding G.I.Tract Gone Wrong: Gastroenteritis

Welcome to the Wonderful World of Vomiting and Diarrhea: 

The fancy name for this very common childhood ailment is gastroenteritis (gastro=stomach, enter=intestines and itis=infection or inflammation.)  Most cases are caused by a virus that is swallowed into the G.I. tract which basically takes control of everything down there for a time!  The virus spreads easily from person to person if they share something mouth to mouth, or hand or object to mouth, and results in the thoroughly unpleasant symptoms of nausea, vomiting, and/or diarrhea, with or without fever, and your child may look pale, shaky, weak and just plain sicker than you have ever seen before. (A good reason to remember our favorite advice: wash hands, wash hands, wash hands).

It can be stressful to experience, and worrisome to watch as a parent.   Mercifully, it is usually a brief illness that rarely dehydrates enough to require a hospital or doctor's office visit, and sometimes it is mild enough to only cause some cramps and general tummy distress for a few days.  It may seem to suddenly begin out of nowhere, or be preceded by a loss of appetite, lower energy, a stomach ache, or fever.  There may be other causes for these symptoms -- more on that later!  Also, the stomach contents of infants and young children just come up more easily because of age and anatomy -- sometimes something may come up that just was too much or didn't agree with them, so one episode may not be very diagnostic.  Repeated vomiting, however, seems more like the real deal.  (Vomiting FUN FACT:  Rabbits cannot vomit! - it's not really a blessing though as pet bunnies usually end up at the vet to move things through!)

So, What Brings on all this Drama: 

Once a particular type of virus gets into our G.I. tract, this scenario might follow:  A meal, a snack, birthday cake- whatever - goes down just fine. Sometime later, the stomach acids have done their job and the next step in digestion is about to kick in - onto the small intestine!  But wait - NO!  Nothing is moving along!  The stomach is getting very unhappy with this acidic brew sitting there and is asking itself  "What is up with that!?  I'm going to tolerate this just so long - if I get no cooperation down here I'm launching Plan B" (vomiting.)  Or, the stomach itself is so affected that it can't digest anything and again, Plan B (vomiting.)  This goes on until the stomach empties itself, and may even continue beyond that with just stomach fluids coming up as yellow-green bile, or just dry heaves.  Great! 

What to Do:

First and foremost, the priority is preventing dehydration by replacing lost fluids, but done in a way that doesn't provoke more vomiting. 

Wait a bit after a vomiting episode to offer fluid - about 45 minutes to an hour.  If you are breastfeeding, please continue but do short, frequent feedings - a minute or two may be all your child can comfortably absorb at first, but you can do it every 5 to 10 minutes.  It's difficult to interrupt a feeding so quickly, especially when your child is so needy for comfort, clingy and thirsty, but a long feeding will likely come back up.  If breaking up those nursings so often becomes stressful, occasionally you can spoon in teaspoons of pumped breast milk or Pedialyte instead.  The only allowable fluids are breastmilk and clear fluids, such as water, electrolyte solutions (e.g. Pedialyte), dilute clear fruit juice such as clear apple juice or very weak tummy teas like peppermint, spearmint or chamomile.  Ice chips or frozen juice popsicles may be more appealing to your child and work as well. No other milks or drinks that require any digestion should be given -- remember - digestion's on hold for the moment!

Food will also have to wait for now.  These clear fluids should be given measured as one teaspoon every 10 to 15 minutes.  If you hand your child a bottle or cup to sip from, they are likely to drink much more than that at a time, so at first spoon-feed them only.  These small amounts are usually absorbed well but don't stimulate the vomiting reflex the way a larger drink would.  Gradually as the vomiting spaces out or seems to be over, a slightly larger amount of fluid can be tried - but if a tablespoon comes back up, resume teaspoons again for a while.  Your child's threshold for increasing amounts is really experimental -- you can always cut back if the larger amount doesn't stay down.  If all goes well, as the hours pass you can keep increasing the amount but not to normal levels yet - the stomach will be too touchy for now!  Small and frequent is the best plan.  If you go too far too fast, the stomach will let you know!

Once you've progressed beyond the acute phase, it will be tempting to try some food, especially if your child acts interested, but there is no actual rush.  Food too soon could provoke vomiting again.  However, if several hours have elapsed without vomiting, and larger drinks or nursings are staying down, AND your child is actually feeling hungry rather than too nauseated to eat, again you can cautiously experiment.  Depending on the age of the child, a tiny bite of something bland and easily digested is most likely to work - avoid dairy products (all milk and milk products other than human!), protein foods, and fats.  Try a spoonful of applesauce, a little banana or yam, a saltine cracker, a corner of white bread or toast - at this particular time those fiber-rich whole grains we otherwise recommend are much harder to digest and more laxative.  Again, these are tiny snacks, not meals - no normal amounts or normal meals for a day or so -- even after vomiting stops the stomach may not be up to it yet.

And if all that Wasn't Enough - the Lower G.I. May be Affected as Well  (Diarrhea):

This will take the form of cramps, gassiness, and often diarrhea.  Normally, the stools forming in the lower G.I. emerge in solid form one or more times a day (except in breastfed only infants!), but the body reacts to this illness with a much speedier exit time, so speedy in fact that the colon has no time to remove water from what's zipping through.  This results in watery, frequent stools that may resemble "toxic waste!"- especially stronger smelling than usual.

Treatment for that again is fluid replacement and the same bland, starchy diet as above, with the same restrictions- but eating can only be tried when food can be tolerated.  Other helpful interventions may be something warm on the tummy (think good old-fashioned hot water bottles or the like, while carefully protecting the skin), and herbal teas such as chamomile and mint.  Protecting the rectal area with a thick layer of diaper cream, even if your child is out of diapers, will help prevent  local irritation and rashes.  Like all viral illnesses, time (diarrhea can take seven days to clear up and still be considered 'normal')  and our own immune systems do the rest, but keeping your child hydrated and comfortable is so important too.  Over-the-counter medications for all these symptoms may be acceptable for adults at times, but are really not safe or effective for little ones.  Please call us if you have questions about any of these products.


Anyone with GI illness can experience some level of dehydration temporarily - losing all those precious body fluids faster than you can replace them is a reality at times.  Following the above protocol should help prevent this - but sometimes not.  Sometimes, despite your best efforts, the vomiting persists without letup, and more severe dehydration can result.  It may not be possible at that point to replace enough lost body fluid by drinking as directed.  You can try nothing by mouth for one hour, then resume the teaspoons again.  If that still doesn't work, please call. 

If true dehydration is setting in, it shows itself in several ways -- a greatly reduced urine output, for example.  Check your child's diapers or otherwise observe -- the urine may be more scanty and darker colored, but some output should happen every 6-8 hours or so.  Too little would be fewer than 6 wet diapers per day for infants and no wet diapers or trips to the bathroom for 8 hours in toddlers and older kids. The paler the urine the better the hydration level.  Dry mouth and lips, even chapped-looking, can also be indicators of poor hydration, as can no tears when crying.  Most importantly, your child's level of energy and personality can be the biggest clue - if your child is limp like a rag doll, be sure to call -- a visit in-person will help assess hydration and there may be an anti-nausea medication we can offer.  Sometimes only I.V. fluids will do - but this is not typical for most cases.  Home care almost always gets you through.  Call us whenever some guidance will help!


Fever may or may not be present with this illness, and can pose some new challenges if your child can't handle oral medications as usual for a time.  Again, all viral illnesses can cause fever, and if your child is tolerating the temperature fairly well, reducing it is not medically necessary.  However, fever can interfere with your  child's ability to sleep and rest, may make a child too sluggish or cranky to hydrate well, or make it difficult to accurately assess just how sick your child really is. 

Fever all by itself can result in a very miserable looking and acting child.  For these reasons, it is worthwhile to do what you can to cool your child off.  A long lukewarm bath lowers the body temperature without having to use medication - keep your child lightly dressed as well.  If things have progressed to where something might stay down, you can try a dose of Tylenol (acetaminophen.)   Advil or Motrin (ibuprofen) is more irritating to the stomach, especially when it's empty, and  therefore not the first choice.  An over-the-counter product called Feverall for infants and children is a rectal suppository form of Tylenol and is very handy for bypassing the tummy during vomiting. It's a good one to have on hand just in case so you don't find yourself searching for it in the middle of the night at 24 hour pharmacies. 

Note:  fever in an infant 2 months or younger should always be reported to us -- not only during this particular illness!  In fact, due to their tinier size, infants with vomiting and/or diarrhea must always be watched carefully - again, call us!

Other Reasons for Vomiting and Diarrhea:

While the majority of children with these G.I. symptoms have a "stomach virus," other general illnesses can also cause them.  Vomiting may accompany severe coughs and colds, bladder infections, ear infections, be a sign of motion sickness, or even rarely, intestinal obstruction, meningitis, or appendicitis.  Diarrhea can be caused by other viral illness such as the common cold, by teething, food sensitivities or allergies, a momentary overindulgence in some treat, or even unwelcome bacteria or parasites.  We can help you by phone to sort out what may be going on with your child, and an office visit can do the rest.

General Guidelines for Calling Us Are:

IF:  Vomiting persists despite your careful hydration - or persists beyond 24 hours even if occasional (past 6 hours in children under one, 12 hours one through 3 years, and 16 - 24 hours in children four and older;)

Signs of dehydration as described above;

Blood in the vomit;

Vomiting is one symptom among others, such as severe headache, pain or stiffness in the neck or back, with high fever;

Diarrhea persists more than a week despite following the dietary plan as above or there is bloody diarrhea;

Severe, persistent abdominal pain or urinary discomfort;

OR any time you have questions or concerns!

Again, while a dramatic and uncomfortable illness, a  G.I. virus tends to be fairly brief and benign.  Observing a few basic protocols should make it as bearable as possible and have your child perking up soon! 


Your Nurses
Quick Facts for Quick Reference:

  • Vomiting is dramatic and worrisome, but it's your child's body's way of reacting to a virus and is usually brief and benign.
  • Prevent dehydration by replacing lost fluids in a way that doesn't provoke more vomiting
  • Wait about an hour after a vomiting episode to offer clear fluids given measured as one teaspoon every 10 to 15 minutes.
  • If breastfeeding: short, frequent feedings - a minute or two every 10 to 15 minutes.
  • Allowable fluids are breastmilk and clear fluids only, such as water, electrolyte solutions (eg. Pedialyte), or a dilute clear fruit juice such as clear apple juice, ice chips, weak tummy teas, or popsicles
  •  As vomiting spaces out or seems to be over, a slightly larger amount of fluid can be tried - but if a tablespoon comes back up, resume teaspoons again for a while.
  • As the hours pass increase the amount but not to normal levels yet
  • Once beyond the acute phase, don't rush food which too soon may provoke vomiting again.  When several hours have elapsed without vomiting, and larger drinks or nursings are staying down, AND your child is actually feeling hungry rather than too nauseated to eat, again you can cautiously experiment. 
  • Begin with tiny bite of something bland and easily digested is most likely to work
  • Avoid dairy products. Try spoonful of applesauce, a little banana or yam, a saltine cracker, a corner of white bread or toast.
  • Treat diarrhea with fluid replacement and the same bland diet as for vomiting. Over-the-counter medications are really not safe or effective for little ones. 
  • We can't stress enough how important good hand washing is  to prevent spreading of these kinds of viral illnesses (and if feasible, the GI sick child would get her own bathroom until the illness has passed).    
  • Call us whenever you need reassurance, but also please see general guidelines above for when you must call us.  (310) 393-9784.