Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents

Abstract

BACKGROUND: Vomiting is a common manifestation of acute gastroenteritis in children and adolescents. When untreated, it can be a hindrance to oral rehydration therapy, which is the cornerstone in the management of acute gastroenteritis. Evidence is needed concerning the safety and efficacy of antiemetic use for vomiting in acute gastroenteritis in children. OBJECTIVES: To assess the safety and effectiveness of antiemetics on gastroenteritis induced vomiting in children and adolescents. SEARCH STRATEGY: We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register comprising references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conferences. The search was re-run and is up to date as on 20 July 2010. SELECTION CRITERIA: Randomized controlled trials comparing antiemetics with placebo or no treatment, in children and adolescents under the age of 18, for vomiting due to gastroenteritis. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. MAIN RESULTS: We included seven trials involving 1,020 participants. Mean time to cessation of vomiting in one study was 0.34 days less with dimenhydrinate suppository compared to placebo (P value = 0.036). Pooled data from three studies comparing oral ondansetron with placebo showed: a reduction in the immediate hospital admission rate (RR 0.40, NNT 17, 95% CI 10 to 100) but no difference between the hospitalization rates at 72 hours after discharge from the Emergency Department (ED); a reduction in IV rehydration rates both during the ED stay (RR 0.41, NNT 5, 95% CI 4 to 8), and in follow-up to 72 hours after discharge from the ED stay (worst-best scenario for ondansetron RR 0.57, NNT 6, 95% CI 4 to 13) and an increase in the proportion of patients with cessation of vomiting (RR 1.34, NNT 5, 95% CI 3 to 7). No significant difference was noted in the revisit rates or adverse events, although diarrhea was reported as a side effect in four of the five ondansetron studies. In one study the proportion of patients with cessation of vomiting in 24 hours was (58%) with IV ondansetron, (17%) placebo and (33%) in the metoclopramide group (P value = 0.039). AUTHORS' CONCLUSIONS: Oral ondansetron increased the proportion of patients who had ceased vomiting and reduced the number needing intravenous rehydration and immediate hospital admission. Intravenous ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate as a suppository reduced the duration of vomiting.

Acute gastroenteritis: from guidelines to real life

“…The most recent Cochrane meta-analysis was performed by Alhashimi and colleagues who used very strict inclusion criteria and excluded the studies by Reeves et al and Stork et al76 The authors came to a similar conclusion, that ondansetron may reduce the amount of acute vomiting as well as reducing the number of children who required intravenous rehydration, and admission for acute gastroenteritis. However, participants in the ondansetron group did have more diarrhea than in the placebo group.…”

Childhood Diarrhoea: Failing Conventional Measures, what Next?

“…The aim is not only to reduce the distress of vomiting, but also to lower water and electrolyte loss from the already dehydrated child. They are however not commonly recommended for use in infants, as they have been shown to increase diarrhoea [20]. …”

Oral Ondansetron Administration in Emergency Departments to Children with Gastroenteritis: An Economic Analysis

“…The 2009 Cochrane Review included four clinical trials, did not include a meta-analysis, and had a primary objective that was not dealt with by any of the studies (time to achieve cessation of vomiting) [17]. The review concluded that while ondansetron may reduce the amount of vomiting, and the numbers of children requiring intravenous rehydration and hospitalization, it stressed the need to conduct a cost analysis [17]. A meta-analysis published in 2007, which also included four trials, concluded that ondansetron use is associated with some clinical benefit [16].…”

“…An increase in stool output without a concomitant increase in health care utilization was reported in some studies. Despite these benefits, clinical practice guidelines continue to recommend against the use of antiemetics in gastroenteritis [1],[2],[15], stating that evidence of cost savings would further support the argument for ondansetron administration [1],[2],[14]–[17]. In April 2009, the National Institute for Health and Clinical Excellence of the United Kingdom listed a cost analysis as a key research priority in pediatric gastroenteritis [15].…”