Your normally happy and playful two-year-old has not been himself all day. He's been clingy, fussy, and has refused to eat his favorite foods. Then out of nowhere, he throws up what you think was breakfast. It doesn't stop there. For the next three hours he throws up every 10 minutes. This is replaced by dry- heaving until he finally falls asleep, exhausted. You are naturally worried. Here are some guidelines that will get you through the night.

NOTE: Vomiting in an infant 2 months or younger is very different than older infants and children. Click here if your baby is less than 2-months-old.

1. Stomach flu – by far the most common cause.

2. Food poisoning – relax, this doesn't really mean "poison", it simply means there were some bad bacteria in the food your child ate.

3. Other intestinal illnesses – there are a variety of other viral and bacterial intestinal illnesses besides the flu that can cause vomiting. Most are not serious.

4. Severe cough and cold – children can often vomit after a big coughing fit. This isn't really considered a vomiting problem but rather a coughing problem. Click on Coughs, Colds & Sinus Infections for more info.

5. Bladder infection – if your child has had a high fever for several days with occasional vomiting, and the urine burns or smells foul, consider this cause.

6. Intestinal obstruction – now DON'T PANIC. This is by far the least common cause, but it is also the most serious and is considered a surgical emergency. See below.

HOW TO DETERMINE THE CAUSE
The top four causes are very difficult to distinguish at the onset because they all start out the same – profuse vomiting every 5 to 30 minutes for the first 1 to 12 hours. Understanding the various causes and expected course of these three will help you determine the cause.

1. Stomach flu – this is a virus that causes sudden onset of vomiting, high fever and stomach pain. Diarrhea usually begins during the first or second day. The length of vomiting varies from the "12 hour flu" to the dreaded "72 hour flu". There is no blood or stool test to diagnose this.

2. Food poisoning – this is caused by bad bacteria that is present in spoiled food. The onset usually comes 2 to 12 hours after eating the food. Common food sources are: spoiled mayonnaise, chicken, fish, beef, or salad dressing. Some clues that it may be food poisoning are:

• Often there is no fever
• Usually occurs within a few hours after eating an identifiable source of bad food such as a questionable restaurant or a picnic.
• Vomiting usually does not last more than 12 hours.
• Therefore, if there is a high fever, you can't think of any bad food your child ate, and the vomiting lasts beyond 12 hours, it probably is not food poisoning. Diarrhea may or may not develop.

3. Other intestinal viruses or bacterial illnesses – there are a variety of these. Some examples include Rotavirus, Salmonella, and E-Coli. The initial vomiting pattern, stomach pain and fever of these illnesses is the same as the stomach flu and therefore difficult to distinguish from the flu. However, in the initial period of vomiting, it is not really necessary to determine which of all these illnesses is causing it. Instead, you simply need to know how to handle the vomiting.

4. Intestinal obstruction – this occurs when the intestines become twisted and is considered a medical emergency that demands immediate medical attention. The key symptom here is actually SEVERE abdominal pain. If there is only moderate or no pain, it's probably not an obstruction. Here are the symptoms:

• Sudden onset of abdominal pain
• Persistent dark-green vomiting (bile), not just light-green mucus
• Usually, but not always, projectile
• Agonizing pain that may be constant, but may also come and go
• No bowel movements
• Pale and sweaty skin
• Child is overall worsening rather than staying the same or improving

GETTING THROUGH THE NIGHT
The first thing to remember is DON'T PANIC. Vomiting is usually not dangerous and only rarely results in significant dehydration. Keep in mind it usually takes at least 12 hours of severe vomiting to make a child significantly dehydrated. These guidelines should help you get your child through the vomiting stage of his illness:

• First stage – severe vomiting every 5 – 30 minutes.
  • During this time, do not attempt to give your child any food or liquids at all because they will just come right back up. This is called total bowel rest. Let the worst of the vomiting pass.
  • If your child asks to nurse or drink something, then just offer small sips at a time, and don't expect him to keep it down.
• Second stage – the vomiting has started to slow down to every one or two hours.
  • Go ahead and offer your child small sips of liquids every 5 or 10 minutes.
  • Here are the three best liquids to try:
  • Oral electrolyte solution such as Pedialyte has the best balance of salt, sugar, and other electrolytes
  • Frozen popsickle or slushy made from an electrolyte solution
  • Breastmilk is excellent for the nursing baby

    A few other suggestions until you can get an electrolyte solution:

  • White grape juice or slushy slightly diluted with water.
  • Gatorade or similar drink
    • Again, these are not as ideal, and should be replaced with Pedialyte when possible.
    • Liquids NOT to give – apple, pear, and cherry juice may have too much sugar. This can worsen diarrhea and dehydration.
• Third stage – vomiting is now only 2 – 4 times a day or stopped altogether.
  • It is now okay to try some foods.
    • Bland foods such as crackers, toast, soup broth, etc.
    • Continue breastfeeding.
    • Restart formula if formula feeding. You can mix half formula and half Pedialyte at first. This may be more easily tolerated.
    • Continue liquids as described above.
  • Don't be alarmed if your child throws up this food. It may be too soon to start feeding again. Just take a step back to the second stage until the vomiting calms down again.
  • RECTAL ACETAMINOPHEN – if your child has a fever but can't keep down any medicine, we suggest acetaminophen suppositories. Click on it.
  • ANTI-NAUSEA MEDICATION – there are suppositories that can be prescribed by your doctor for kids two and older that can suppress the vomiting to get your child through the worst of it. These medications should only be used when absolutely needed. A commonly used brand is Phenergan.

WHEN NOT TO WORRY

• Persistent vomiting – if the vomiting seems like it's going on forever, you need to assess your child for dehydration. If he is only mildly or maybe moderately dehydrated, this generally can wait until morning to contact your doctor.
• Dehydration – keep in mind most kids will become mildly dehydrated during a vomiting illness. Mild dehydration is not serious and often does not warrant an urgent call to your doctor. Click on it for more info on how to assess the degree of dehydration and when to call your doctor.
• Vomiting comes back – what commonly happens is a child will get better for a day or two, and then begin vomiting again. This is generally okay. Assess which stage he seems to be in and treat it accordingly.
• Fever – it is normal to have even high fevers for several days. Click on fever for guidelines and treatment.
• Blood in vomitus – you may see bloody streaks in your child's vomitus. Tiny tears in the throat cause this from the pressure of vomiting. It is generally not dangerous and should pass. See below.

WHEN TO WORRY
Here are some guidelines on when to call your doctor or go to the ER:

• Persistent vomiting – you should call your doctor if stage one vomiting continues past 8 hours in children under one, 12 hours in children one through three years old, and 16 hours in kids four and older.
• Large amount of blood in vomitus – if the tears in the throat become too large from severe, high pressure vomiting, they can bleed significantly. If you think this is really happening, go to an emergency room promptly. This is very rare though, as the tears generally stay very tiny and only bleed slightly.
• Moderate to severe dehydration – click here for more guidelines, but this generally warrants a call to your doctor.
• Meningitis – a brief word here. Although vomiting is not the main sign of meningitis, it is one of them. If your child has severe headache, stiffness or pain in the BACK of the neck, high fever, and vomiting, call your doctor right away.
• Kidney infection – again, vomiting isn't the main symptom for this, but if your child has high fevers, vomiting, and is complaining of burning with urination or the urine smells foul, you should call your doctor.