What is vomitting and diarrhea?
First when describing gastrointestinal symptoms, it is important to be precise. Vomiting implies the forceful elimination of food through the mouth. Spitting up is where food slowly dribbles out of the mouth and is often associated with gastrointestinal reflux (GER), a normal condition seen in infants, in which the valve that keeps stomach contents in the stomach has not tightened up, allowing the normal pressure in the stomach to push liquids back up and out of the mouth.
Diarrhea is defined in different ways by different people. We define it as many, very loose stools. Usually, many means more than 5-6 in a 24 hour period and loose means that it soaks into the diaper or leaks all over the place.
What are the causes of vomiting and diarrhea?
The most common cause of both vomiting and diarrhea are viruses. In children under 2 years old, rotavirus is the most commonly implicated virus although Norwalk virus, adenovirus, astrovirus and calcivirus are often seen as well. In older children and adults, influenza is the most common virus causing vomiting and diarrhea. Rotavirus is rarely associated with fever or cold symptoms. Adenovirus, calcivirus and influenza on the other hand, can frequently be associated with fever (as high as 105), chills, aches and pains and cold like symptoms. All are common in the late fall and winter months and occur with greatest frequency in large day care centers. Unfortunately, there is no cure for any virus so identifying which one is affecting your child is not very helpful. The vomiting phase for all viruses usually lasts 1-2 days with diarrhea persisting in many cases, for up to 7-10 days.
What about vomiting alone?
Causes of vomiting alone include:
- Viruses - The most common cause of vomiting alone is also stomach viruses!
- Bowel obstructions - Occasionally, children with appendicitis and bowel obstructions will have vomiting alone. This type of vomiting is called bilious and is green or very dark, but despite the hoopla in parenting magazines, appendicitis and other bowel obstructions are exceedingly rare (we probably see a case only 1-2 times a year)! And non-stomach virus forms of vomiting are almost never associated with fever, cold symptoms or diarrhea. Appendicitis is most commonly seen in a school aged child with vomiting, loss of appetite and right sided severe (the worst abdominal pain in your life) pain. If the child can jump up and down, he is probably okay. Hernias can also be associated with bowel obstruction but almost always the child with an incarcerated hernia where a piece of the gut has gotten stuck in the hernia, is associated with localized redness, swelling and tenderness.
What about diarrhea alone?
Causes of diarrhea alone include:
- Viruses - The most common cause of diarrhea alone is also a stomach virus!
- Bacterial infections - If there is bloody diarrhea, especially in a child coming from a large day care, occasionally we may be dealing with bacterial infections such as Salmonella, Shigella, Yersinia or Heicobater. We rarely do anything different for children older than 3 months, but with bloody diarrhea, it is occasionally helpful to do a stool culture to prove the bacterial nature of the disease. The above 4 diseases are reportable to the Department of Health and their presence in a day care setting may be significant.
- Parasites - Chronic diarrhea (defined as more than 2 weeks) may be caused by parasites such a Giardia (seen in day care contacts) or by toxin such a C. difficile (seen after recent use of certain antibiotics). If your child has had diarrhea lasting longer than 2 weeks, it may be helpful to evaluate the stool and determine the cause. Try to bring in a fresh diaper; the yield is greatly enhanced with a fresh specimen.
When do I need to worry about dehydration?
The most common question we are asked when a child is vomiting or having diarrhea is how can dehydration be prevented? Dehydration means the lack of water. Practically speaking however, the most accurate way of diagnosing dehydration in young children is to examine the inside of the mouth. A child who has moisture inside the lips or is drooling is usually fine. Please do not look at urine output. Because urine is often mixed with diarrheal stools and because of today’s super absorbent diapers, urine production is not a helpful sign. It is very uncommon for a child with a stomach virus to become dehydrated unless it has been accompanied by vomiting for a couple of days straight. It is especially unusual for a child with diarrhea alone to become dehydrated.
Thankfully, it is uncommon for children to get significantly dehydrated. Of the 400-500 children that we see or speak to in one flu season, only 5-10 get seriously dehydrated and even then, hospitalization is rarely necessary. Although the usual toddler is taking in 24 ounces of liquid a day, he or she really only needs 8-10 to get by, so remember to be patient as the virus will pass. However if you are worried about dehydration or just worried, call and we will be happy to discuss further with you or see your child in the office.
What can I do for vomiting and diarrhea?
Since most symptoms of vomiting and diarrhea are caused from viruses, the body will get rid of the virus all on its own. However, it is important to provide comfort and hydration during the period of time. Those who have both vomiting and diarrhea are more at risk for dehydration and if significant enough may require IV fluids to recover. However, most cases can be treated at home with oral rehydration.
When hydrating the body, it usually is best to give water (or Pedialyte for children less than 6 months old). During the vomiting phase, it is best to give small amounts every 10-15 minutes. Small amounts mean small amounts: an ounce, a ½ ounce or even just a few sips. Build up slowly and if your child begins to vomit again, you probably went too far too fast. We recommend then resting the stomach for 30 minutes before starting again with small sips.
Once the vomiting has passed for at least 6-8 hours, your child can begin solid foods concentrating especially on starchy foods such as rice, macaroni, spaghetti, pasta, bread etc. For children under 1 year old, sticking to breast milk or formula diet for 1-2 days would be just fine as that is what gives them most of their nutrition anyway.
What else can I do for my child?
Recent research has suggested that the use of a probiotic is helpful in decreasing the amount and frequency of diarrhea when caused by a viral illness. This good bacteria, commonly found in yogurt but now available in powder or capsules, helps to restore the balance in the digestive system. Currently our favorite probiotic is Ultimate Flora, available at Whole Foods and online.
Unfortunately, Kaopectate and other gut stoppers are not helpful. Actually, all they do is stop the gut from moving, allowing the virus to continue to do its damage. It is better to get the virus out of the body, even if it takes a few extra days. Unfortunately, many day care centers keep a child out of school as long as there is some loose stool. This is not really the appropriate medical approach but in such situations, you are at the mercy of the particular day care policy. In a healthy appearing child, adding a tablespoon of soluble fiber (Benefiber and other generic alternatives) can help speed recovery.
Good luck and remember that vomiting and diarrhea when treated with patience is very messy but rarely dangerous!