Stomach Bugs
What do you do when kiddos have fluid coming out of everywhere? Kids get lots of stomach “bugs” from other kids during their early schooling years. There are different kinds of stomach “bugs.” For pediatricians our big task is figuring out if these stomach bugs are virus “bugs” or bacteria “bugs.” Not necessarily because treatment or supportive care is different, but because it is important to figure out how infectious a kiddo is and to whom based on what is causing the vomiting, tummy pain, and/or diarrhea.
Most often we are dealing with viral stomach “bugs” that are passed from one kiddo to another. The classic progression of symptoms is a kiddo letting you know their tummy hurts a few milliseconds before they puke all over your new couch. This vomiting is, at first, pretty intense as the stomach and intestines are first realizing they have a viral intruder and are unable to digest things normally while they deal with this trespasser. So, the stomach says everybody out now! And, thus, puking everywhere, often multiple times, until the tummy is more than empty. After this, the kiddo’s tummy will still be on heightened alert to prevent difficult to digest things from getting past the stomach. So, this is where the avoidance of dairy, fats, or greasy foods comes into play and the implementation of the BRAT (bananas, rice, apple sauce, toast) diet that most docs suggest at the first sign of a pukey kid. As these simple starchy foods are easily digested and don’t often cause an immediate throwing up reaction from the gut.
But, before we even think about reintroducing solid foods, our main goal for a kiddo with a viral stomach bug is to keep them hydrated. The main reason we see these kiddos in the emergency room is that they can’t keep any liquids down to stay hydrated. How much is hydrated enough? Usually, if a kiddo is peeing every 4-6 hours, they are well hydrated. So, we have to ensure kiddos are drinking electrolyte rich liquids. Why not just water? Well, without the electrolytes (sugars and salts), the water has a tougher time being absorbed by the gut and can run right through in the form of liquid diarrhea. We try to have kids rehydrate at home with Pedialyte, half water/half Gatorade mixture, or apple juice as all of these have a good salt to sugar to liquid ratio that likes to get absorbed into the kiddos body and vasculature to prevent dehydration. For the first 4-8 hours we only want to let the kiddo drink little sips of the liquid (no more than a tablespoon) every 5-10 minutes to allow these liquids to trickle in. If the stomach gets too full in this first 24-hour period, it will throw everything up because it is trying to protect the rest of the GI tract.
If your kiddo manages to keep down the little sips for 8 hours, then we can let them take bigger sips. If, after 16 hours, they are keeping all that down, we can allow them to drink in accordance with their thirst. If no more vomiting has occurred for 16-24 hours, we can start with little bites of those BRAT diet foods. Again, small (nothing bigger than the size of their fist at one time) and frequent snacks for the next 12 hours. If they keep all that food down, then increase to normal meal sized BRAT diet foods. If no vomiting occurs 12 hours after that, then we can liberalize the diet, though should still avoid dairy and foods with heavy fats for a few more days if possible.
Often times, once the vomiting subsides the diarrhea begins. This will slowly improve with the starchy foods, but if your little kiddo sneaks some dairy in, it may make the diarrhea substantially worse or back track from perceived improvement. If the diarrhea is leaking out of diapers or if your kiddo is having trouble making it to the potty, we can help solidify the poop using the equivalent of cement mix for kids’ poops - dehydrated banana chips. But remember, we want these poops out of the body, so we don’t regularly recommend any medications that slow the gut down such as Imodium or similar medications. It is not uncommon for kids to have continued diarrhea for the same stomach bug illness for 2 weeks or more. At the 2-week marker; however, we do have to start investigating to make sure we are not missing a bacterial or parasitic gut infection that may need more treatment.
This if often done using stool cultures and microscopic exams of the poop to look for evidence of bacteria or parasites. We also will do further testing if there is blood in the poop. Viral stomach bugs can cause blood in the poop, but so do bacterial tummy infections that often need closer monitoring and, sometimes, medication.
So, when do we get worried with kids with stomach bugs? If a kiddo is throwing up or pooping so much that they are not able to stay hydrated, we should see them in the clinic or emergency room. If a child throws up blood or bile (neon green oily looking liquid), we should see them in clinic or emergency room. Or, if the child is 6 months or younger with vomiting, we should see them in clinic or emergency room to evaluate for hydration status, as well as other possible gastrointestinal obstruction that could be the result of birth defects that present within the first 6 months of a child’s life. For older kids or adolescents, if we have vomiting with worsening abdominal pain, we would like to see them in clinic to rule out appendicitis or other abdominal pathologies.
Here is a quick guideline on how to slowly reintroduce fluids and solids for kids with stomach bugs from our friends at Schmitt Pediatric Guidelines LLC:
Formula Fed Babies - Give Oral Rehydration Solution (ORS) if Vomiting Continues:
If your child vomits more than once, offer ORS. If you don't have ORS, use formula in smaller amounts until you can get some.
ORS is a special fluid that can help your child stay hydrated. You can use Pedialyte or the store brand of ORS. It can be bought in food stores or drugstores.
Spoon or syringe feed ORS in small amounts. Give 1-2 teaspoons (5-10 mL) every 5 minutes.
After 2 hours without throwing up, double the amount.
Return to Formula. After 4 hours without throwing up, go back to regular formula. Start with smaller amounts.
Breastfed Babies - Reduce the Amount Per Feeding:
If vomits more than once, nurse for 5 minutes every 30 to 60 minutes. After 4 hours without throwing up, return to regular nursing.
If continues to vomit, switch to pumped breastmilk. ORS is rarely needed in breastfed babies. It can be used if vomiting becomes worse.
Spoon or syringe feed small amounts of pumped milk. Give 1-2 teaspoons (5-10 mL) every 5 minutes.
After 4 hours without throwing up, return to regular feeding at the breast. Start with small feedings of 5 minutes every 30 minutes. As your baby keeps down the smaller amounts, slowly give more.
Older Children (over 1 Year Old) - Offer Small Amounts of Clear Fluids For 8 Hours:
Water or ice chips are best for older children. Reason: water is easily absorbed in the stomach.
Other clear fluids: use half-strength Gatorade. Make it by mixing equal amounts of Gatorade and water. Can mix apple juice the same way. ORS (such as Pedialyte) is usually not needed in older children. Popsicles work great for some kids.
The key to success is giving small amounts of fluid. Offer 2-3 teaspoons (10-15 mL) every 5 minutes. Older kids can just slowly sip a clear fluid.
After 4 hours without throwing up, increase the amount.
After 8 hours without throwing up, return to regular fluids.
Caution: if vomits over 12 hours, switch to ORS or half-strength Gatorade.
Stop All Solid Foods:
Avoid all solid foods and baby foods in kids who are vomiting.
After 8 hours without throwing up, gradually add them back.
Start with starchy foods that are easy to digest. Examples are cereals, crackers and bread.
Do Not Give Medicines:
Stop using any drug that is over-the-counter for 8 hours. Reason: some of these can make vomiting worse.
Fever. Mild fevers don't need to be treated with any drugs. For higher fevers, you can use an acetaminophen suppository (such as FeverAll). This is a form of the drug you put in the rectum (bottom). Ask a pharmacist for help finding this product. Do not use ibuprofen. It can upset the stomach.
Call your doctor if: your child vomits a drug ordered by your doctor.
Try to Sleep:
Help your child go to sleep for a few hours.
Reason: sleep often empties the stomach and removes the need to vomit.
Your child doesn't have to drink anything if his stomach feels upset and he doesn't have any diarrhea.
Return to School:
Your child can return to school after the vomiting and fever are gone.
What to Expect:
For the first 3 or 4 hours, your child may vomit everything. Then the stomach settles down.
Vomiting from a viral illness often stops in 12 to 24 hours.
Mild vomiting and nausea may last up to 3 days.