Gastroenteritis Therapies in Developed Countries: Systematic Review and Meta-Analysis

Abstract

ContextGastroenteritis remains a leading cause of childhood morbidity.ObjectiveBecause prior reviews have focused on isolated symptoms and studies conducted in developing countries, this study focused on interventions commonly considered for use in developed countries. Intervention specific, patient-centered outcomes were selected.Data SourcesMEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, trial registries, grey literature, and scientific meetings.Study SelectionRandomized controlled trials, conducted in developed countries, of children aged <18 years, with gastroenteritis, performed in emergency department or outpatient settings which evaluated oral rehydration therapy (ORT), antiemetics, probiotics or intravenous fluid administration rate.Data ExtractionThe study was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. Data were independently extracted by multiple investigators. Analyses employed random effects models.Results31 trials (4,444 patients) were included. ORT: Compared with intravenous rehydration, hospitalization (RR 0.80, 95%CI 0.24, 2.71) and emergency department return visits (RR 0.86, 95%CI 0.39, 1.89) were similar. Antiemetics: Fewer children administered an antiemetic required intravenous rehydration (RR 0.40, 95%CI 0.26, 0.60) While the data could not be meta-analyzed, three studies reported that ondansetron administration does increase the frequency of diarrhea. Probiotics: No studies reported on the primary outcome, three studies evaluated hospitalization within 7 days (RR 0.87, 95%CI 0.25, 2.98). Rehydration: No difference in length of stay was identified for rapid vs. standard intravenous or nasogastric rehydration. A single study found that 5% dextrose in normal saline reduced hospitalizations compared with normal saline alone (RR 0.70, 95% CI 0.53, 0.92).ConclusionsThere is a paucity of patient-centered outcome evidence to support many interventions. Since ORT is a low-cost, non-invasive intervention, it should continue to be used. Routine probiotic use cannot be endorsed at this time in outpatient children with gastroenteritis. Despite some evidence that ondansetron administration increases diarrhea frequency, emergency department use leads to reductions in intravenous rehydration and hospitalization. No benefits were associated with ondansetron use following emergency department discharge.

Rotavirus infection

“…Most meta-analyses suggest a modest benefit of probiotics in reducing the duration of diarrhoea by ~1 day and up to 2 days for rotavirus-induced diarrhoea, although studies have been performed largely in middle-income and high-income countries 3 , and some studies did not report a clear benefit 150,151 . The mechanisms underlying this have been postulated to include the activation of antigen-presenting cells, a reduction in the levels of pro-inflammatory cytokines, the modulation of effector T cell and regulatory T cell immune responses, innate immune signalling (through interactions with several TLRs) and the promotion of enterocyte proliferation and/or migration 152 .…”

“…Recommendations for the use of anti-emetics (such as metoclopramide, dimenhydrinate and ondansetron) for children with rotavirus disease have progressed from ‘not recommended’ to ‘possibly recommended’ owing to their effects of reducing the number of vomiting episodes and reducing the need for intravenous rehydration and hospitalization 150,159 . Indeed, one dose of ondansetron reduces the likelihood of needing intravenous rehydration, although this can increase diarrhoea output.…”

Gastro-entérite aiguë chez l’enfant hospitalisé : réduction des durées de réhydratation et d’hospitalisation grâce à la réhydratation par sonde naso-gastrique

“…Cette diminution a été de 16,5 heures, soit 40 % de la durée d'hospitalisation en cas de RIV. Ces résultats sont en accord avec 2 [9,10] des 3 méta-analyses ayant comparé réhydratation orale/entérale et intraveineuse [9][10][11]. Les méta-analyses de Fonseca et al Dans notre étude, la diminution du temps d'hospitalisation n'a pas été observée chez les enfants nécessitant une hospitalisation secondaire dans un service d'hospitalisation conventionnelle.…”

Efficacy of Synbiotics for Treatment of Bacillary Dysentery in Children: A Double-Blind, Randomized, Placebo-Controlled Study

“…In spite of the fact that there are numerous studies about probiotics as a treatment for infectious diarrhea, there are some unsolved problems related to the dysentery description, remission criteria, probiotic type, probiotic potent dose, study quality, and probiotic effectiveness evaluation [23]. Recent studies using different probiotics have shown variable effects and meta-analyses show uncertain results due to inequality of studies [24–26]. This suggests that each probiotic has its unique efficacy, so each probiotic needs to be tested to assess its efficacy in specific conditions [27].…”

“…Recent systematic reviews recommend further studies of probiotics in an outpatient setting [24, 28]. There are some meta-analyses which have assessed the results of probiotics in the treatment of AGE.…”