Vomiting: how to keep fluids down until it passes

Almost nobody dies of the virus that caused the vomiting; they get into trouble from not being able to keep fluid down. The technique that actually works, what to eat back first, and the signs that end this at home.

The rule that matters: tiny volumes, very often

A stomach that is in spasm ejects anything that stretches it, and a full glass of water stretches it. So the trick is volume control, and it works better than any medicine.

• Wait twenty minutes after a vomit with nothing at all, not even a sip. The stomach needs the spasm to pass.
• Then start with 5 to 10 millilitres, which is one teaspoon, or two small sips from a glass. Every five minutes. That is roughly one glass over an hour, and it sounds absurd until it is you.
• If that stays down for an hour, double the amount and stretch the interval. Most people are holding down 200 millilitres at a sitting within four to six hours of this.
• Sucking on ice chips, a slice of lemon or a small piece of ice candy gets fluid in without triggering the reflex and is a legitimate way to start.
• If you vomit again, go back twenty minutes and restart at the smaller volume. It is not a failure; this takes an evening.

What to drink, and in what strength

ORS is the right fluid because it uses the sodium-glucose pump to pull water across the gut even while it is inflated, and plain water replaces no salt. One full sachet in exactly one litre of water, measured, not a heaped spoon in a steel bowl; too concentrated makes vomiting worse. If there is no sachet at hand, homemade is safe and effective: one litre of clean water, six level teaspoons of sugar and half a level teaspoon of salt. It should taste no saltier than tears and no sweeter than that. Make a fresh litre every day, keep it covered. Coconut water, clear soups, weak tea with a little sugar, and well-diluted buttermilk are all reasonable extras once the teaspoons are working. Fruit juice, cola and sports drinks are too concentrated in sugar and make loose motions worse; if cola is the only thing a person will keep down, flat and diluted, then so be it, but it is not rehydration.

Bringing food back, which is sooner than people think

Total fasting beyond the first few hours slows recovery, because the gut lining feeds on what passes through it. Once you have kept fluids down for six to eight hours, start food: curd rice, moong dal khichdi, overcooked chhawal with salt, banana, dry toast or roti without ghee, boiled potato, plain rice with dal water, steamed apples. Small portions, five or six times a day, and stop before you feel full. Add back normal eating over two to three days. Two temporary things to expect: milk can sit badly for a week or so because the enzyme that digests lactose is stripped off the inflamed lining, and curd and buttermilk are usually tolerated fine; and greasy, spicy and fried food will announce itself for several days. Continue breastfeeding through anything. In a formula-fed child, continue the usual feed at smaller volumes and more frequency rather than diluting it.

What is probably causing it

Vomiting alone for 24 to 48 hours in a household where several people are ill is usually a viral gastroenteritis and settles by itself. Vomiting within one to six hours of a meal, with cramps and retching and no fever, points to a pre-formed toxin, classically from stale fried rice or cream pastries, and it ends within a day. Vomiting with fever and loose motions starting 12 to 72 hours after eating out is a bacterial infection. Projectile vomiting with nausea and headache, relieved by darkness, is migraine. Morning vomiting in a woman with a missed period is pregnancy until proved otherwise, and if it is severe enough that nothing stays down for a day, that is a treatable condition and not something to endure. Medicines cause it constantly: metformin started at a full dose, iron tablets on an empty stomach, antibiotics, painkillers, opioids. And in a person with diabetes, vomiting with high sugars and deep rapid breathing is ketoacidosis, not a stomach bug.

The medicine question, honestly

An anti-emetic prescribed for a specific episode, such as ondansetron, is genuinely useful and can be the difference between drinking and drip. It is not something to keep in the drawer and take at the first burp; domperidone has heart-rhythm risks in some people and metoclopramide causes distressing muscle spasm reactions in children and young women. Do not take an antibiotic for vomiting and loose motions; most causes are not bacterial and an antibiotic prolongs the disturbance of the gut flora. Do not take loperamide to stop loose motions if there is fever or blood in the stool, or in a young child.

The cramps, the retching, and comfort measures

• A warm compress over the epigastrium eases the cramping between episodes.
• Sit upright or propped on pillows, or lie on your side. Do not lie flat on your back while drowsy or medicated, because aspiration of vomit is the real danger in that state.
• Fresh air and a cool cloth on the forehead reduce nausea through a different pathway than the stomach, and neither can hurt.
• Small sips of ginger tea, or chewing a piece of ginger, helps the queasiness in pregnancy for many women and in general for some.
• Rinse the mouth after vomiting and do not brush immediately; stomach acid softens enamel for about half an hour.

The signs that mean stop managing this at home

Vomit that is green or bright yellow and bitter, which means bile and, with distension and no wind or stool, suggests a blockage. Blood or dark coffee-ground material. Severe, constant abdominal pain, or a belly that is hard and tender to a light touch. A stiff neck with fever and headache, or a rash, or confusion or drowsiness after vomiting. Vomiting after a head injury, especially in a child or anyone on blood thinners. Nothing retained for 24 hours in an adult, or 8 hours in a child. No urine for eight hours, dark urine, dizziness on standing, a dry tongue, sunken eyes, absent tears in a child or a soft sunken fontanelle in a baby. In a young infant, forceful projectile vomiting after every feed. Fever above 39 degrees with loose motions and vomiting. Anyone pregnant who cannot keep down their medicines. A person with diabetes and sugars over 300 or ketones. Kidney disease, heart failure, a transplant, chemotherapy or steroids. And in any frail older person, because they dehydrate faster and complain less. Chest pain or pain radiating to the jaw or arm with nausea and sweating needs an emergency evaluation, not a hot water bag, because a heart attack in the lower wall presents as indigestion and vomiting far more often than people expect.

How we look at it at Aksa

How long, how much has been retained, what the vomit looked like, where the pain sits, what was eaten and who else is ill, and then the two numbers that decide everything: the pulse and the blood pressure lying and standing, plus how long ago you passed urine. Bloods for sugar, ketones, kidney function and electrolytes when there has been real fluid loss. For anything atypical, an ultrasound or an X-ray rather than reassurance. Vomiting is usually self-limited and our job in the first two days is to keep you drinking and to notice the small minority who are not vomiting from a stomach bug at all. Where the tendency to nausea and slow digestion is chronic, that is a different conversation and one where our own tradition has genuinely useful things to offer, but never in place of the scan that rules out the surgical cause.