Anti-emetics in the Vomiting Child

March 2007

Anti-emetics in the Vomiting Child

Search Strategy: You are aware of two recent randomized controlled trials in New England Journal of Medicine & Academic Emergency Medicine. Utilizing PubMed (1996-present) you come up with 95 additional studies from your initial search using “children gastroenteritis antiemetics”. The first article on the list is a systematic review which references one additional relevant article. Finally, you search the Cochrane Database and locate a Cochrane Systematic Review.

While working a busy overnight shift in the ED you get an overhead page for “line 11”. You pick up the phone and the 8 West intern begins complaining about all of his gastroenteritis admissions that night, intimating that there seems to be a bunch if sieves working in the ED. Knowing that you worked twice as hard when you were an intern you ignore him and begin seeing the next patient:

  • HPI: A 22 month old female is brought to the ED with her mother because she has been suffering from repeated vomiting and diarrhea for the past 24 hours. Over the past 8 hours she has vomited approximately 12 times. The emesis has been nonbilious and nonbloody. Her urine output is significantly decreased.
  • Vital signs: Temp 38.7, HR 155, BP 82/46, RR 30, 100% on RA

Physical exam is remarkable for sunken eyes, dry mucous membranes and dry skin. Abdominal exam reveals normoactive bowel sounds, is soft and nontender with no hepatosplenomegaly. There are no rashes present.

Unfortunately there are no more inpatient beds so you think about coming up with a new strategy. Despite the tradition of limited use of antiemetics in pediatric patients you wonder if there is any data showing improved outcomes if they are used. You tackle the problem online.

PICO Question

Population: Pediatric patients presenting to ED with persistent vomiting

Intervention: Antiemetic use

Comparison: Traditional therapy of hydration without antiemetic use

Outcome: discharge home from the ED, successful oral rehydration without the need for IV placement, decreased frequency of vomiting

Years

First years: A randomized clinical trial comparing oral Ondansetron with placebo in children with vomiting from acute gastroenteritis. Annals of Emergency Medicine 2002;39(4):397-403

Second years: Oral ondansetron for gastroenteritis in a pediatric emergency department. New England Journal of Medicine 2006;354(16):1698-705

Third years: Emergency department treatment of viral gastritis using intravenous ondansetron or dexamethasone in children. Acad Emerg Med 2006 Oct;13(10):1027-33

Fourth years: Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database of Systematic Reviews 2006, Issue 3.

Articles

Article 1: Randomized Controlled Trial Comparing Oral Ondansetron with Placebo in Children Vomiting from Acute Gastroenteritis, Annals EM 2002; 39: 397-403
ANSWER KEY

Article 2: Oral Ondansetron for Gastroenteritis in a Pediatric ED NEJM 2006; 354: 1698-1705
ANSWER KEY

Article 3: Emergency Department Treatment of Viral Gastritis Using Intravenous Ondansetron or Dexamethasone in Children, Acad EM 2006; 13: 1027-1033
ANSWER KEY

Article 4: Antiemetics for Reducing Vomiting Related to Acute Gastroenteritis in Children and Adolescents. Cochrane Database of Systematic Reviews 2006. Issue 4. Article No.: CD005506, DOI 10.1002/14651858.CD005506.pub3
ANSWER KEY

Bottom Line

A single dose of ondansetron in children with vomiting and diarrhea and suspected gastroenteritis improves oral hydration success compared with placebo with a Number Needed to Treat of about 5 to prevent post-treatment vomiting in one child. The major disadvantage of ondansetron is the expense: (Zofran ODT $658 for 30, Zofran 4mg tablet $244 for 10). The American Academy of Pediatric 1996 consensus opinion was based upon pre-ondansetron anti-emetics (metoclopramide, prochlorperazine, etc.) with higher adverse drug related effects in children than adults and probably ought to be revised with substantially more data now available as represented by these meta-analyses and individual clinical trials.

n an attempt to assess the first component of Knowledge Translation we conducted an informal post-Journal Club (show of hands) survey of how this data would change practice patterns. Results:

Would not use any ondansetron preparation:0%
Would use PO ondansetron preparations (tablet or ODT):60%
Would use IV ondansetron: