Vomiting in children

Vomiting in infants under the age of two months

This is not very common. Learn how to distinguish between common spit-ups/regurgitation (read more about reflux and spit-ups in young infants here) and true vomiting.

How can you tell the difference between the two?
When a child vomits, it typically happens in a projectile manner. In contrast, spit-ups — even if they seem significant — tend to dribble from the sides of the baby’s mouth onto their clothes.

An infant who has vomited more than once, or even just once but appears unwell, must be evaluated by a physician.

Here are a couple of important reminders:
– A fever at this age requires urgent medical evaluation. So, both fever and vomiting? Definitely call your doctor (read more about this here).
– Recurrent episodes of vomiting in an infant around the age of three weeks, especially if the volume is increasing, require a workup for pyloric stenosis (read more about this here).

Vomiting in older infants and children

It’s helpful to divide this section into vomiting with and without fever.

Vomiting with fever

This usually points to an infectious cause. What’s one diagnosis you don’t want to miss? Bacterial meningitis or a serious abdominal infection.

Bacterial meningitis

I apologize for starting with this, but it’s the first diagnosis any good pediatrician will want to rule out — even though it’s not common.

What should raise concern for meningitis?
Fever (usually high), an ill-appearing child, headache, and vomiting. That’s why any child with both fever and vomiting should be seen by a pediatrician, who can determine whether meningitis is suspected.

Some parents might say, “But my child is vaccinated for meningitis.” And it’s true — routine vaccines protect against several bacteria that can cause meningitis, such as Haemophilus influenzae (part of the pentavalent vaccine), Streptococcus pneumoniae (pneumococcal vaccine), and Neisseria meningitidis (meningococcal vaccine — read more about it here).

However, no vaccine offers complete protection, and these aren’t the only bacteria that can cause severe infections in children.

To be clear: meningitis is not a common cause of fever and vomiting. So what else could it be?

Severe abdominal infection

In this case, a pediatrician needs to examine the child’s abdomen to rule out a significant abdominal infection — like appendicitis. Children with severe abdominal infections are usually ill-appearing and complain of intense abdominal pain.

Other infections

In real-life pediatrics, almost any febrile illness can cause vomiting. This includes everything from viral or bacterial throat infections, to ear infections (read more here), pneumonia (read more here), and of course, gastroenteritis.

Some children experience nausea or vomiting every time they have a fever. Regardless, these children should be evaluated by a physician each time this occurs.

Gastroenteritis

So, what about gastroenteritis?

It’s easy to assume that a child with vomiting and diarrhea — whether or not there’s a fever — has gastroenteritis. Vomiting results from upper gastrointestinal involvement, and diarrhea from lower gastrointestinal involvement.

Where’s the challenge?
The issue arises when children present during the early phase — with fever and vomiting — before diarrhea begins. This is why pediatricians actually prefer to see children with both vomiting *and* diarrhea rather than vomiting alone. It’s easier to make a diagnosis.

So, if your child is vomiting and also has fever and diarrhea (or even without fever, as we’ll discuss below), it’s most likely acute gastroenteritis.

In these cases, I pay special attention to the nature of the diarrhea.
– If the diarrhea is watery, it’s usually viral.
– If it contains mucus or blood, this may indicate dysentery (a bacterial infection).

Just keep in mind:
– Fever (especially high fever) usually accompanies viral infections that cause watery diarrhea.
– Bacterial infections are more likely to result in mucus-filled or bloody diarrhea.

So, if your child has fever, diarrhea, and vomiting, make sure to consult your doctor — and feel free to read more in my chapter about diarrhea here.

Vomiting without fever

Recurrent vomiting without fever — especially when there is no diarrhea — is something that needs to be evaluated.

What could be causing these symptoms?

A head injury

If your child experienced a head injury before the vomiting began, the symptoms may be related to that injury. It could range from a mild concussion to something more serious like intracranial bleeding. If this is the case, I recommend reading more about head injuries in children here.

Other brain-related issues

I know this is something that crosses many parents’ minds.

Sometimes, a child starts vomiting, and within a couple of hours, parents begin to fear the worst. But it doesn’t usually work that way.

Intracranial lesions typically present with a *combination* of symptoms — such as headaches (especially ones that wake the child from sleep), early morning nausea or vomiting, and occasionally neurological signs. If these symptoms have been ongoing, your pediatrician may recommend a full evaluation, including an eye exam to check for papilledema and possibly brain imaging (preferably an MRI).

Intestinal obstruction (intussusception)

This isn’t very common, but it’s an important diagnosis that should not be missed.

Intussusception — a type of intestinal obstruction — typically occurs between the ages of 5 months and 3 years. These children often present with vomiting and an absence of stools. Initially, they may appear well between episodes, but over time, the vomiting increases in frequency, and the well-appearing intervals grow shorter. Children alternate between irritability and lethargy.

Early on, they may still pass stool, but later, stooling often stops entirely. Most children appear pale and unwell.

Diagnosis starts with a pediatrician’s abdominal and rectal exam. If intussusception is suspected, an X-ray or abdominal ultrasound will confirm it. Prompt referral to the emergency department is needed for further evaluation and treatment.

Gastroenteritis

I mentioned gastroenteritis earlier when discussing vomiting with fever. But it’s important to note that gastroenteritis can also present without fever.

How should you manage a child who is vomiting?

If it was a single episode, let your child rest and go on with the day as usual.

If vomiting happens multiple times, first consider the possible causes I’ve mentioned — and see a doctor for evaluation.

In the meantime, what should your child eat or drink?

If your child is vomiting, they need something sweet.

I often see children who are vomiting arrive at my clinic clutching a bottle of water. While water is good, it’s not enough to relieve or stop vomiting. Sugar, in its simplest form, can help settle the stomach.

Give your child sugary fluids like juice, soda, sweetened iced tea, or electrolyte drinks. Ice cream or lollipops (if age-appropriate) can also help.

If vomiting is accompanied by diarrhea, also give a salty snack — pretzels, chips, or crackers (in addition to sweet fluids).

In younger infants, continue offering formula or breast milk.

How much fluid does a vomiting child need?

There are no strict rules. But giving a large volume (say, 250 ml) all at once is likely to trigger more vomiting.

Instead, be patient and go slowly. Use a small syringe or teaspoon and offer tiny amounts every few minutes.

Remember this simple guideline:
– Vomiting? Give sugar.
– Diarrhea? Give salt.
– Both? Give a combination — and see a doctor.

Are there other treatment options for vomiting?

Yes, there are medications that can help stop vomiting, but in children, their use is very limited. Pediatricians are generally cautious about prescribing anti-emetics to young patients.

In my opinion, the most important step is reaching the correct diagnosis and proceeding accordingly. I haven’t found any anti-emetic that is both safe and consistently effective in children.

When can a child return to daycare after vomiting?

This depends on the underlying cause and how the child is feeling.

Vomiting is unpleasant, and kids need time to recover. Here’s my general rule:

A child who has vomited twice within 24 hours should *not* return to daycare unless a pediatrician has confirmed that the cause is non-infectious and the child is well enough to return to a group setting.

Also, remember that the child must be fever-free for at least 24 hours, along with meeting all other return-to-daycare guidelines (which I discuss elsewhere on the site).

How shall we summarize this chapter?

Pediatricians actually prefer to see children who have both vomiting and diarrhea — the diagnosis is usually clearer, and it’s often a self-limiting viral illness that responds well to supportive care.

In most cases, pediatricians also find it easier to evaluate children who have a low-grade fever without signs of meningitis than those who are vomiting with no fever — where the cause may be less obvious.

So, here are two key takeaways for parents:

A. Red flags that require an immediate doctor’s assessment include high fever, abdominal pain, an ill-appearing child, signs of dehydration, very young age, and more.
B. Helpful ways to manage vomiting include sweetened drinks for vomiting, salty snacks for diarrhea, and a combination of both when they occur together.

May we all stay healthy and safe!