The Role of Oral Ondansetron in Children With Vomiting as a Result of Acute Gastritis/Gastroenteritis Who Have Failed Oral Rehydration Therapy: A Randomized Controlled Trial

Predictors of Hospital Admissions and Return Visits in Children with Suspected Dehydration Presenting to the Emergency Department

BACKGROUND

Dehydration is a primary cause of visits to pediatric emergency departments (PED).

OBJECTIVES

1) To identify predictors of hospital admission and return visits (RV) in PED patients with all-cause dehydration. 2) To explore the association between dehydration and serum bicarbonate (HCO3) levels.

METHODS

This single-center prospective cohort study included patients under 18 years with dehydration from any cause, presenting to the PED of a tertiary center from November 2018 to March 2020. The primary outcome was hospital admission; the secondary outcome was RV to the PED. HCO3 was measured for all visits. Bivariate and multivariate analyses were conducted.

RESULTS

The study included 324 patients: most with mild dehydration (199/324, 61%). Of these, 74 (22.8%) were admitted, while 250 (77%) were discharged, 25 of which (10.8%) returned to the PED. Predictors of hospital admission included physician-estimated dehydration >5% (adjusted odds ratio [aOR] = 2.9; 95% CI: 1.5-5.8), ≥1 intravenous (IV) fluid bolus (aOR = 5.4; 95% CI: 1.2-23.8), antibiotics (aOR = 11.92; 95% CI: 3.4-35.5), and HCO3 ≤16 mmol/L (aOR = 4.4; 95% CI: 1.3-14.7). Admitted patients had lower mean HCO3 levels (19.94 ± 3.38 mmol/L vs. 20.98 ± 2.65 mmol/L, p = 0.017). Dry mucous membranes at the index visit were the only significant predictor of RV (12% vs. 35.5%, p = 0.023). Antipyretics/analgesics were associated with RV (76% vs. 51.9%, p = 0.03). Gastritis was inversely associated (4.0% vs. 22.3%, p = 0.03) with RV, but these were nonsignificant in multivariate analysis.

CONCLUSION

In this PED cohort, we found no predictors for RV to the PED. However, HCO3 ≤16 mmol/L, physician-estimated dehydration >5%, ≥1 IV fluid bolus, and PED antibiotics were associated with increase hospital admission. If replicated, these findings can help clinicians make faster disposition decisions when caring for dehydrated pediatric patients.

Course of uncomplicated acute gastroenteritis in children presenting to out-of-hours primary care

Background

The aim of this article is to describe the courses of vomiting, diarrhea, fever, and clinical deterioration, in children with uncomplicated gastroenteritis at presentation. This study was performed as a 7-day prospective follow-up study in an out-of-hours primary care service. The course of vomiting, diarrhea, and fever was analyzed by generalized linear mixed modeling. Because young children (≤ 12 months) and children with severe vomiting are at increased risk of dehydration, the potentially more complicated courses of these groups are described separately. The day(s) most frequently associated with deterioration and the symptoms present in children who deteriorated during follow-up were also described.

Results

In total, 359 children presented with uncomplicated acute gastroenteritis to the out-of-hours primary care service. Of these, 31 (8.6%) developed a complicated illness and needed referral or hospitalization. All symptoms decreased within 5 days in most children (> 90%). Vomiting and fever decreased rapidly, but diarrhea decreased at a somewhat slower pace, especially among children aged 6–12 months. Children who deteriorated during follow-up had a higher frequency of vomiting at presentation and higher frequencies of vomiting and fever during follow-up.

Conclusions

The frequency of vomiting, not its duration, appears to be the more important predictor of deterioration. When advising parents, it is important to explain the typical symptom duration and to focus on alarm symptoms. Clinicians should be vigilant for children with higher vomiting frequencies at presentation and during follow-up because these children are more likely to deteriorate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01739-2.

Comparison of the Effectiveness of Ondansetron and Domperidone in Cessation of Vomiting in Children Presenting With Acute Gastroenteritis: A Meta-Analysis

Acute gastroenteritis is one of the common diseases of childhood. Dehydration is the most frequent consequence of acute gastroenteritis, and vomiting is the most distressing clinical manifestation. Various anti-emetic agents are used in practice to control vomiting. However, not all anti-emetic agents are safe and effective. This meta-analysis aims to compare the effectiveness of ondansetron and domperidone in the cessation of vomiting in children with acute gastroenteritis. The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search strategy was developed to identify prospective studies that compared the effectiveness of ondansetron and domperidone in the cessation of vomiting in children with acute gastroenteritis. The primary outcome was the number of children in whom there was a cessation of vomiting. The secondary outcomes included a number of children who required an additional dose of the assigned anti-emetic and the number of children who required intravenous rehydration therapy. Overall, seven randomized trials were included in the current meta-analysis. The pooled sample size of enrolled patients was 1,262, of which 639 patients were randomized to the ondansetron group and 623 were randomized to the domperidone group. In the ondansetron group, a higher number of children experienced cessation of vomiting (risk ratio [RR]: 1.22, 95% CI: 1.08-1.37, p-value=0.002), a lower proportion of children needed an additional dose of the assigned anti-emetic (RR=0.50, 95% CI: 0.33-0.77, p-value=0.002), and a lower number of children received intravenous rehydration (RR: 0.37, 95% CI: 0.16-0.83, p-value=0.02) as compared to domperidone group. Compared to domperidone, ondansetron was found to have better efficiency in aiming cessation of vomiting in children with gastroenteritis.

Paediatrics: how to manage viral gastroenteritis

Background

Viral gastroenteritis is the most common diarrhoeal disorder seen in general practice and emergency departments. This article aims to provide a narrative updated review on the evaluation and management of viral gastroenteritis in children.

Methods

A PubMed search was performed with Clinical Queries using the key term 'viral gastroenteritis'. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to the English literature and the paediatric population.

Results

Acute viral gastroenteritis is usually self-limiting. However, it can lead to dehydration and electrolyte imbalance if not properly treated. Adequate fluids containing physiological concentrations of glucose and electrolytes should be provided to compensate for gastrointestinal losses and cover maintenance needs. Oral rehydration therapy is as effective as intravenous (IV) fluid therapy for rehydration for children with mild-to-moderate dehydration. Measurements of serum electrolytes, creatinine and glucose are usually not necessary and should only be considered in a subset of children with severe dehydration who require hospitalization and IV therapy. Judicious use of ondansetron can increase the success rate of oral rehydration therapy and minimize the need for IV therapy and hospitalization.

Conclusion

Acute viral gastroenteritis is associated with substantial morbidity in developed countries and significant mortality in developing countries. Physicians should educate caregivers on proper personal hygiene and handwashing to prevent faecal to oral transmission of the pathogen as well as the importance of rotavirus vaccine in the prevention of rotavirus gastroenteritis. Several norovirus vaccines are currently undergoing clinical trials with promising results. It is hoped that development of an effective norovirus vaccine will further reduce the incidence of viral gastroenteritis.

Single-dose of ondansetron for vomiting in children and adolescents with acute gastroenteritis-an updated systematic review and meta-analysis

This review aimed to meta-analyze evidence of efficacy and safety of one single dose of ondansetron for vomiting in children and adolescents with acute gastroenteritis. Database searches of MEDLINE (PubMed), Scopus (Elsevier), Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov up to November 2019 were performed. Only randomized clinical trials versus placebo were considered. Fixed and random effect models were used for the analyses of pooled data. Thirteen randomized clinical trials (2146 patients) were finally included. One single dose of ondansetron showed to produce (1) higher chance of vomiting cessation within 8 h (RR 1.41, 95% CI 1.19-1.68; low-quality evidence); (2) lower chances of oral rehydration therapy failure (RR 0.43, 95% CI 0.34-0.55; high-quality evidence), intravenous hydration needs (RR 0.44, 95% CI 0.34-0.57; high-quality evidence), and hospitalization rates within 8 h (RR 0.49, 95% CI 0.32-0.75; high-quality evidence); and (3) no statistically significant differences in return visits to emergency department (RR 1.14, 95% CI 0.74-1.76; high-quality evidence) compared with placebo. Further studies are necessary to better assess long term efficacy and safety of ondansetron in this context.Conclusions: Mixed evidence was found via few studies about the efficacy and safety of a single dose of ondansetron in the pediatric population.What is known:• Ondansetron use for vomiting in pediatric acute gastroenteritis is increasing worldwide.• Actual convictions come from studies evaluating one and more than one dose of the drug.What is new:• This is the first review to collect data about the effects of one single dose of ondansetron on strong and temporally homogeneous clinical outcomes.• This study supports the use of one dose of ondansetron in pediatric acute gastroenteritis.• Further studies are necessary to assess its long-term efficacy and safety.

Vomiting Children: It's Not Always Gastroenteritis

Emesis is a common presentation in children. Many diagnostic considerations need to be made in a child with emesis and no diarrhea, particularly if lasting longer than 24 hours. The differential diagnosis includes trauma, increased intracranial pressure, obstruction, and metabolic abnormalities such as diabetic ketoacidosis. Prompt recognition with appropriate testing and management is needed. [Pediatr Ann. 2020;49(5):e233-e241.].

Antiemetics in Children With Acute Gastroenteritis: A Meta-analysis

CONTEXT

Several antiemetics have been used in children with acute gastroenteritis. However, there is still controversy over their use.

OBJECTIVE

To determine the effectiveness and safety of antiemetics for controlling vomiting in children with acute gastroenteritis.

DATA SOURCES

Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Latin America and the Caribbean Literature on Health Sciences, and gray literature, until December 2018.

STUDY SELECTION

We selected randomized clinical trials comparing metoclopramide, ondansetron, domperidone, dexamethasone, dimenhydrinate, and granisetron.

DATA EXTRACTION

Two reviewers independently screened abstracts and full texts, extracted the data, and assessed the risk of bias. We performed pairwise and network meta-analysis using the random-effects model.

RESULTS

Twenty-four studies were included (3482 children). Ondansetron revealed the largest effect in comparison to placebo for cessation of vomiting (odds ratio = 0.28 [95% credible interval = 0.16 to 0.46]; quality of evidence: high) and for hospitalization (odds ratio = 2.93 [95% credible interval = 1.69 to 6.18]; quality of evidence: moderate). Ondansetron was the only intervention that reduced the need for intravenous rehydration and the number of vomiting episodes. When considering side effects, dimenhydrinate was the only intervention that was worse than placebo.

LIMITATIONS

Most treatment comparisons had low- or very low-quality evidence, because of risk of biases and imprecise estimates.

CONCLUSIONS

Ondansetron is the only intervention that revealed an effect on the cessation of vomiting, on preventing hospitalizations, and in reducing the need for intravenous rehydration. Ondansetron was also considered a safe intervention.

Oral Ondansetron Administration to Dehydrated Children in Pakistan: A Randomized Clinical Trial

BACKGROUND

Ondansetron is an effective antiemetic employed to prevent vomiting in children with gastroenteritis in high-income countries; data from low- and middle-income countries are sparse.

METHODS

We conducted a randomized, double-blind, placebo-controlled superiority trial in 2 pediatric emergency departments in Pakistan. Dehydrated children aged 6 to 60 months with ≥1 diarrheal (ie, loose or liquid) stool and ≥1 vomiting episode within the preceding 4 hours were eligible to participate. Participants received a single weight-based dose of oral ondansetron (8-15 kg: 2 mg; >15 kg: 4 mg) or identical placebo. The primary outcome was intravenous administration of ≥20 mL/kg over 4 hours of an isotonic fluid within 72 hours of random assignment.

RESULTS

All 918 (100%) randomly assigned children completed follow-up. Intravenous rehydration was administered to 14.7% (68 of 462) and 19.5% (89 of 456) of those administered ondansetron and placebo, respectively (difference: -4.8%; 95% confidence interval [CI], -9.7% to 0.0%). In multivariable logistic regression analysis adjusted for other antiemetic agents, antibiotics, zinc, and the number of vomiting episodes in the preceding 24 hours, children administered ondansetron had lower odds of the primary outcome (odds ratio: 0.70; 95% CI, 0.49 to 1.00). Fewer children in the ondansetron, relative to the placebo group vomited during the observation period (difference: -12.9%; 95% CI, -18.0% to -7.8%). The median number of vomiting episodes (P < .001) was lower in the ondansetron group.

CONCLUSIONS

Among children with gastroenteritis-associated vomiting and dehydration, oral ondansetron administration reduced vomiting and intravenous rehydration use. Ondansetron use may be considered to promote oral rehydration therapy success among dehydrated children in low- and middle-income countries.

Bimodal Release Ondansetron for Acute Gastroenteritis Among Adolescents and Adults: A Randomized Clinical Trial

IMPORTANCE

Vomiting resulting from acute gastroenteritis is commonly treated with intravenous antiemetics in acute care settings. If oral treatment were beneficial, patients might not need intravenous administered hydration or medication. Furthermore, a long-acting treatment could provide sustained relief from nausea and vomiting.

OBJECTIVE

To determine whether an experimental long-acting bimodal release ondansetron tablet decreases gastroenteritis-related vomiting and eliminates the need for intravenous therapy for 24 hours after administration.

DESIGN, SETTING, AND PARTICIPANTS

This placebo-controlled, double-blind, randomized clinical trial included patients from 19 emergency departments and 2 urgent care centers in the United States from December 8, 2014, to February 17, 2017. Patients 12 years and older with at least 2 vomiting episodes from presumed gastroenteritis in the previous 4 hours and symptoms with less than 36 hours' duration were randomized using a 3:2 active to placebo ratio. Analyses were performed on an intent-to-treat basis and conducted from June 1, 2017, to November 1, 2017.

INTERVENTION

Bimodal release ondansetron tablet containing 6 mg of immediate release ondansetron and 18 mg of a 24-hour release matrix for a total of 24 mg of ondansetron.

MAIN OUTCOMES AND MEASURES

Treatment success was defined as no further vomiting, no need for rescue medication, and no intravenous hydration for 24 hours after bimodal release ondansetron administration.

RESULTS

Analysis included 321 patients (mean [SD] age, 29.0 [11.1] years; 195 [60.7%] women), with 192 patients in the bimodal release ondansetron group and 129 patients in the placebo group. Treatment successes were observed in 126 patients in the bimodal release ondansetron group (65.6%) compared with 70 patients in the placebo group (54.3%), with an 11.4% (95% CI, 0.3%-22.4%) absolute probability difference. The proportion of treatment success was 21% higher among patients who received bimodal release ondansetron compared with those who received a placebo (relative risk, 1.21; 95% CI, 1.00-1.46; P = .04). In an analysis including only patients with a discharge diagnosis of acute gastroenteritis and no major protocol violations, there were 123 treatment successes (69.5%) in the bimodal release ondansetron group compared with 67 treatment successes (54.9%) in the placebo group (relative risk, 1.27; 95% CI, 1.05-1.53; P = .01). Adverse effects were infrequent and similar to the known safety profile of ondansetron.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that a long-acting bimodal release oral ondansetron tablet was an effective antiemetic among adolescents and adults with moderate to severe vomiting from acute gastroenteritis. The drug benefits extended to 24 hours after administration. Bimodal release ondansetron may decrease the need for intravenous access and emergency department care to manage acute gastroenteritis.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02246439.

A 17-Year-Old Boy With High-Functioning Autism, Gastrointestinal Illness, and Seizures

A healthy 17-year-old boy with a high-functioning pervasive developmental disorder presented to the emergency department after having a 4-minute episode of seizure-like activity in the setting of presumed viral gastroenteritis. Within an hour of emergency department arrival, he developed a forehead-sparing facial droop, right-sided ptosis, and expressive aphasia, prompting stroke team assessment and urgent neuroimaging. Laboratory results later revealed a serum sodium of 119 mmol/L. Neurologic deficits self-resolved, and a full physical examination revealed diffuse abdominal tenderness in the lower abdomen with rebound tenderness in the right-lower quadrant. The patient was admitted to the PICU for electrolyte management and monitoring. A computed tomography (CT) scan of the abdomen obtained the following morning revealed the patient's final diagnosis.

Oral Ondansetron Administration to Nondehydrated Children With Diarrhea and Associated Vomiting in Emergency Departments in Pakistan: A Randomized Controlled Trial

Study objective

We determine whether single-dose oral ondansetron administration to children with vomiting as a result of acute gastroenteritis without dehydration reduces administration of intravenous fluid rehydration.

Methods

In this 2-hospital, double-blind, placebo-controlled, emergency department–based, randomized trial conducted in Karachi Pakistan, we recruited children aged 0.5 to 5.0 years, without dehydration, who had diarrhea and greater than or equal to 1 episode of vomiting within 4 hours of arrival. Patients were randomly assigned (1:1), through an Internet-based randomization service using a stratified variable-block randomization scheme, to single-dose oral ondansetron or placebo. The primary endpoint was intravenous rehydration (administration of ≥20 mL/kg of an isotonic fluid during 4 hours) within 72 hours of randomization.

Results

Participant median age was 15 months (interquartile range 10 to 26) and 59.4% (372/626) were male patients. Intravenous rehydration use was 12.1% (38/314) and 11.9% (37/312) in the placebo and ondansetron groups, respectively (odds ratio 0.98; 95% confidence interval [CI] 0.60 to 1.61; difference 0.2%; 95% CI of the difference –4.9% to 5.4%). Bolus fluid administration occurred within 72 hours of randomization in 10.8% (34/314) and 10.3% (27/312) of children administered placebo and ondansetron, respectively (odds ratio 0.95; 95% CI 0.56 to 1.59). A multivariable regression model fitted with treatment group and adjusted for antiemetic administration, antibiotics, zinc prerandomization, and vomiting frequency prerandomization yielded similar results (odds ratio 0.91; 95% CI 0.55 to 1.53). There was no interaction between treatment group and age, greater than or equal to 3 stools in the preceding 24 hours, or greater than or equal to 3 vomiting episodes in the preceding 24 hours.

Conclusion

Oral administration of a single dose of ondansetron did not result in a reduction in intravenous rehydration use. In children without dehydration, ondansetron does not improve clinical outcomes.

Effect of Intravenous Ondansetron on the QT Interval of Patients' Electrocardiograms

OBJECTIVE

Ondansetron improves the success of oral rehydration in children with gastroenteritis. In postoperative adults, ondansetron has been shown to prolong the corrected QT (QTc). The aim of the study was to evaluate the effect of ondansetron on the QT at peak effect and at 1-hour postpeak effect in pediatric patients.

METHODS

This was an observational study looking at patients aged 6 months to 18 years receiving intravenous ondansetron for nausea, vomiting, or the inability to take fluids in the emergency department. Patients had electrocardiogram performed at baseline, at ondansetron's peak effect, and 1 hour postpeak effect. A paired samples Student t test compared QTc change at peak effect to zero. Peak effect of intravenous ondansetron is 3 minutes.

RESULTS

One hundred patients were included. Fifty-five percent of patients were female with a mean age of 8.3 years. The mean (range) baseline QTc was 435 (388 to 501) milliseconds. The mean (range) change in QTc at peak effect of ondansetron was 3 (-40 to 65) milliseconds (P = 0.072). The change in QTc 1-hour postpeak effect of ondansetron was 3 (-43 to 45) milliseconds (P = 0.082). No change at peak effect or 1-hour postpeak effect was clinically significant.

CONCLUSIONS

Ondansetron does not affect the QTc of pediatric patients receiving the medication for nausea, vomiting, or inability to take fluids in the emergency department. No changes in the QTc are clinically significant. To date, there have been no studies evaluating the effect of ondansetron in this acutely ill population; therefore, a larger study should be completed to confirm these data.

Ondansetron treatment reduces rotavirus symptoms-A randomized double-blinded placebo-controlled trial

Background

Rotavirus and norovirus cause acute gastroenteritis with severe diarrhoea and vomiting, symptoms that may lead to severe dehydration and death. The objective of this randomized double-blinded placebo-controlled study was to investigate whether ondansetron, a serotonin receptor antagonist could attenuate rotavirus- and norovirus-induced vomiting and diarrhoea, which would facilitate oral rehydration and possibly accelerate recovery and reduce need for hospitalization.

Methods

Children with acute gastroenteritis, aged 6 months to 16 years where enrolled (n = 104) and randomized to one single oral dose (0.15mg/kg) of ondansetron (n = 52) or placebo (n = 52). The number of diarrhoea and vomiting episodes during the 24 hours following treatment was reported as well as the number of days with symptoms. Pathogens in faeces were diagnosed by real-time PCR. Outcome parameters were analyzed for rotavirus- and norovirus-positive children.

Results

One dose of oral ondansetron reduced duration of rotavirus clinical symptoms (p = 0.014), with a median of two days. Furthermore, ondansetron reduced diarrhea episodes, most pronounced in children that had been sick for more than 3 days before treatment (p = 0.028).

Conclusion

Ondansetron may be a beneficial treatment for children with rotavirus gastroenteritis.

Trial registration

European Clinical Trial Database EudraCT 2011-005700-15.

Effect of intravenous ondansetron on QTc interval in children with gastroenteritis

BACKGROUND

The potential for ondansetron to cause QT prolongation and fatal dysrhythmia is well-reported, including a 2011 FDA report on the topic. Few clinical trials evaluating this phenomenon in the ED setting exist, and only one is pediatric.

OBJECTIVE

We have sought to determine the effect of a standardized dose of intravenous ondansetron on the QTc duration of children under 14years of age treated for gastroenteritis-associated vomiting in a pediatric ED. This study is modeled closely after an FDA "thorough QT study".

METHODS

EGCs were obtained before and 15, 30, 45, and 60min after a 0.15mg/kg IV dose of ondansetron given for gastroenteritis-associated vomiting. QT intervals were measured manually with digital calipers, and the QTc interval calculated both by Bazett's (QTcB) and Fridericia's (QTcF) correction. A paired t-test comparing QTc was conducted, and frequency of categorical outcomes of prolongation>30msec, >60 msec, and absolute prolongation >450 msec, >480 msec, and >500msec were evaluated.

RESULTS

In a 4-month period, 134 patients were included in the study, 46% were male. The average QTc prior to ondansetron administration was: QTcB 415 msec (95% CI 343-565) and QTcF 373 (95% CI 304-499). The mean difference in QTc after ondansetron was 0.4msec for QTcB (95% CI -35-45msec) and 0.1msec for QTcF (95% CI -40-18msec).

CONCLUSION

In these children, 0.15mg/kg of intravenous ondansetron did not cause prolongation of QTcB or QTcF measured 15min after administration, nor at later times.

Clinical Pathway Produces Sustained Improvement in Acute Gastroenteritis Care

BACKGROUND AND OBJECTIVES

Despite widespread use of the rotavirus vaccine in the last decade, dehydrating illnesses impact almost 2 billion children worldwide annually. Evidence supports oral rehydration therapy as a first-line treatment of mild to moderate dehydration. Ondansetron has proven to be a safe and effective adjunct in children with vomiting. We implemented a clinical pathway in our pediatric emergency department (ED) in January 2005 to improve care for this common condition. Our objective in this study was to determine the long-term impact of the pathway for acute gastroenteritis (AGE) on the proportion of patients receiving intravenous (IV) fluids and ED length of stay (LOS) for discharged patients.

METHODS

Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. We used statistical process control to analyze process and outcome measures for 2 years before and 10 years after pathway implementation.

RESULTS

We included 30 519 patients. We found special cause variation with a downward shift in patients receiving IV fluids after initiation of the pathway and later with addition of ondansetron to the pathway from 48% to 26%. Mean ED LOS for discharged patients with AGE decreased from 247 to 172 minutes. These improvements were sustained over time.

CONCLUSIONS

Implementation of a clinical pathway emphasizing oral rehydration therapy and ondansetron for children with AGE led to decreased IV fluid use and LOS in a pediatric ED. Improvements were sustained over a 10-year period. Our results suggest that quality-improvement interventions for AGE can have long-term impacts on care delivery.

Polymer-based oral rehydration solution for treating acute watery diarrhoea

BACKGROUND

Acute diarrhoea is one of the main causes of morbidity and mortality among children in low-income countries. Glucose-based oral rehydration solution (ORS) helps replace fluid and prevent further dehydration from acute diarrhoea. Since 2004, the World Health Organization (WHO) has recommended the osmolarity of less than 270 mOsm/L (ORS ≤ 270) versus greater than 310 mOsm/L formulation (ORS ≥ 310). Polymer-based ORS (for example, prepared using rice or wheat) slowly releases glucose and may be superior to glucose-based ORS.

OBJECTIVES

To compare polymer-based oral rehydration solution (polymer-based ORS) with glucose-based oral rehydration solution (glucose-based ORS) for treating acute watery diarrhoea.

SEARCH METHODS

We searched the following sources up to 5 September 2016: the Cochrane Infectious Diseases Group (CIDG) Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 9), MEDLINE (1966 to 5 September 2016), EMBASE (1974 to 5 September 2016), LILACS (1982 to 5 September 2016), and mRCT (2007 to 5 September 2016). We also contacted researchers, organizations, and pharmaceutical companies, and searched reference lists.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of people with acute watery diarrhoea (cholera and non-cholera associated) that compared polymer-based and glucose-based ORS (with identical electrolyte contents).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the search results and risk of bias, and extracted data. In multiple-treatment arms with two or more treatment groups, we combined outcomes as appropriate and compared collectively with the control group.

MAIN RESULTS

Thirty-five trials that included 4284 participants met the inclusion criteria: 28 trials exclusively included children, five included adults, and two included both adults and children. Polymer-based ORS versus glucose-based ORS (osmolarity ≤ 270) Eight trials (752 participants) evaluated this comparison, and seven trials used rice as a polymer source. Polymer-based ORS may decrease mean stool output in the first 24 hours by 24 mL/kg (mean difference (MD) -24.60 mL/kg, 95% CI -40.69 to -8.51; one trial, 99 participants, low quality evidence). The average duration of diarrhoea may be reduced by eight hours (MD -8.24 hours, 95% CI -13.17 to -3.30; I² statistic = 86%, five trials, 364 participants, low quality evidence) with polymer ORS but results are heterogeneous. Limited trials showed no observed difference in the risk of unscheduled use of intravenous fluid (RR 0.66, 95% CI 0.43 to 1.02; I² statistic = 30%; four trials, 376 participants, very low quality evidence), vomiting (very low quality evidence), and hyponatraemia (very low quality evidence). Polymer-based ORS versus glucose-based ORS (osmolarity ≥ 310) Twenty-seven trials (3532 participants) evaluated this comparison using a variety of polymers. On average, polymer ORS may reduce the total stool output in the first 24 hours by around 65 mL/kg (MD -65.47 mL/kg, 95% CI -83.92 to -47.03; 16 trials, 1483 participants, low quality evidence), and may reduce the duration of diarrhoea by around eight hours (MD -8.57 hours; SD -13.17 to -4.03; 16 trials, 1137 participants, low quality evidence) with substantial heterogeneity. The proportion of participants that required intravenous hydration was low in most trials with fewer in the polymer ORS group (RR 0.75, 95% CI 0.57 to 0.98; 19 trials, 1877 participant, low quality evidence) . Subgroup analysis by type of pathogen suggested an effect on unscheduled intravenous fluid in those infected with mixed pathogens (RR 0.63, 95% CI 0.41 to 0.96; 11 trials, 928 participants, low quality evidence), but not in participants positive for Vibrio cholerae (RR 0.94, 95% CI 0.66 to 1.34; 7 trials, 535 participants, low quality evidence). No difference was observed in the number of patients who developed vomiting (RR 0.91, 95% CI 0.72 to 1.14; 10 trials, 584 participants, very low quality evidence), hyponatraemia (RR 1.82, 95% CI 0.52 to 6.44; 4 trials, 385 participants, very low quality evidence), hypokalaemia (RR 1.29, 95% CI 0.74 to 2.25; 2 trials, 260 participants, low quality evidence), or persistent diarrhoea (RR 1.28, 95% CI 0.68 to 2.41; 2 trials, 885 participants, very low quality evidence).

AUTHORS' CONCLUSIONS

Polymer-based ORS shows advantages compared to glucose-based ORS (at ≥ 310 mOsm/L). Comparisons favoured polymer-based ORS over ORS ≤ 270 but analysis was underpowered.

Oral Ondansetron versus Domperidone for Acute Gastroenteritis in Pediatric Emergency Departments: Multicenter Double Blind Randomized Controlled Trial

The use of antiemetics for vomiting in acute gastroenteritis in children is still a matter of debate. We conducted a double-blind randomized trial to evaluate whether a single oral dose of ondansetron vs domperidone or placebo improves outcomes in children with gastroenteritis. After failure of initial oral rehydration administration, children aged 1–6 years admitted for gastroenteritis to the pediatric emergency departments of 15 hospitals in Italy were randomized to receive one oral dose of ondansetron (0.15 mg/kg) or domperidone (0.5 mg/kg) or placebo. The primary outcome was the percentage of children receiving nasogastric or intravenous rehydration. A p value of 0.014 was used to indicate statistical significance (and 98.6% CI were calculated) as a result of having carried out two interim analyses. 1,313 children were eligible for the first attempt with oral rehydration solution, which was successful for 832 (63.4%); 356 underwent randomization (the parents of 125 children did not give consent): 118 to placebo, 119 to domperidone, and 119 to ondansetron. Fourteen (11.8%) needed intravenous rehydration in the ondansetron group vs 30 (25.2%) and 34 (28.8%) in the domperidone and placebo groups, respectively. Ondansetron reduced the risk of intravenous rehydration by over 50%, both vs placebo (RR 0.41, 98.6% CI 0.20–0.83) and domperidone (RR 0.47, 98.6% CI 0.23–0.97). No differences for adverse events were seen among groups. In a context of emergency care, 6 out of 10 children aged 1–6 years with vomiting due to gastroenteritis and without severe dehydration can be managed effectively with administration of oral rehydration solution alone. In children who fail oral rehydration, a single oral dose of ondansetron reduces the need for intravenous rehydration and the percentage of children who continue to vomit, thereby facilitating the success of oral rehydration. Domperidone was not effective for the symptomatic treatment of vomiting during acute gastroenteritis.

Fatal Cardiac Arrest in 2 Children: Possible Role of Ondansetron

INTRODUCTION

Ondansetron is commonly used to treat vomiting in gastroenteritis, but has a United States Food and Drug Administration black box warning for risk of Q wave to T wave time interval (QT) prolongation. We report 2 pediatric cases of fatal refractory cardiac arrest after administration of ondansetron.

CASES

A 10-year-old previously healthy boy presented to the emergency room with gastroenteritis symptoms. After intravenous fluids, morphine, antibiotics, and 2 doses of ondansetron, the patient became unresponsive with agonal respirations and a wide complex tachycardia consistent with ventricular tachycardia. In a second case, an 86-day-old infant with previously unidentified congenital cardiomyopathy presented to our emergency department with gastroenteritis symptoms. The patient received ondansetron and subsequently experienced repeated bouts of supraventricular tachycardia which progressed to ventricular fibrillation. Resuscitation efforts failed in each case, and both patients expired.

DISCUSSION

Ondansetron can cause dose-dependent QT prolongation effects, which are more clinically relevant when other proarrhythmic elements are present. There is very limited published experience on use of ondansetron in children younger than 2 years. Our 2 cases join 2 previous case reports of death after ondansetron administration for gastroenteritis. The pharmacology of ondansetron's cardiac effects and drug-induced QT prolongation is discussed.

CONCLUSIONS

Patients may have hidden risk factors that, together with ondansetron, could result in a proarrhythmic state that could lead to adverse effects, such as arrhythmias. Administration of ondansetron should be individualized and used cautiously in patients with risk factors for arrhythmia.

Ondansetron Oral Dissolve Tab vs. Oral Solution in Children Presenting to the Emergency Department with Gastroenteritis

BACKGROUND

Ondansetron is often used in the emergency department (ED) to promote oral rehydration in children with acute gastroenteritis (AGE), yet medication solutions administered orally may be poorly tolerated in this population.

OBJECTIVES

We compared the tolerability of ondansetron oral dissolve tab (ODT) to oral solution (OS) in children presenting to the ED with AGE.

METHODS

Using alternate-day controlled clinical trial design, children aged 3 months to 10 years received either ondansetron ODT or OS. Our primary outcome was early vomiting (within 15 min of drug administration). The secondary outcome was intravenous (i.v.) fluid administration.

RESULTS

There were 462/534 eligible children who met study criteria. Demographics, severity, and duration of illness were similar between groups. Using intention-to-treat analysis, early vomiting occurred in 8/209 ODT vs. 19/253 OS children (3.8% vs. 7.5%; odds ratio [OR] 0.49; 95% confidence interval [CI] 0.18-1.21). Using as-treated analysis, 6/222 (2.7%) children receiving ODT experienced early vomiting, compared with 21/221 (9.5%) of the OS group (OR 0.26; 95% CI 0.09-0.70). The proportion of children discharged without i.v. fluids was not different (intention-to-treat: ODT = 91.4% (191/209), OS = 94.1% (238/253), OR 1.49, 95% CI 0.69-3.28; as-treated: ODT = 92.3% (205/222), OS = 93.2% (206/221), OR 0.88, 95% CI 0.40-1.93).

CONCLUSIONS

Using a conservative intention-to-treat analysis, we found that children presenting to an ED with AGE did not have statistically less early vomiting with ondansetron ODT as compared with OS. However, our as-treated analysis demonstrates that children receiving ondansetron ODT experienced early vomiting approximately one-third as often as those receiving OS. The rate of i.v. fluid administration was no different between groups regardless of the type of analysis used.

Systematic review with meta-analysis: ondansetron for vomiting in children with acute gastroenteritis

BACKGROUND

Vomiting in children with acute gastroenteritis is a common symptom, and it is considered to be the main cause of failure of oral rehydration therapy.

AIM

To systematically update evidence on the effects of ondansetron (5-HT3 serotonin antagonist) for vomiting in children with acute gastroenteritis.

METHODS

The Cochrane Library, MEDLINE and EMBASE databases were searched up to April 2016, with no language restrictions, for randomised controlled trials (RCTs). Reference lists of reviews and included studies were examined.

RESULTS

Ten RCTs involving 1215 participants were included. Treatment with ondansetron compared with placebo increased the chance for vomiting cessation up to 1 h after drug administration, relative risk, RR, 1.49 (95% confidence interval 1.17-1.89), but there was no difference between the groups after 4, 24 and 48 h. Treatment with ondansetron compared with placebo reduced the risk of failure of oral rehydration therapy, RR 0.5 (0.37-0.69), increased the intake of oral rehydration solution in 1 h and 4 h, mean difference: 43 mL/1 h (15.5-70.5), and 91 mL/4 h (35-147), respectively, reduced the risk of hospitalisation, RR 0.53 (0.29-0.97), and reduced the need for intravenous rehydration, RR 0.45 (0.31-0.63); however, it had no effect on the need for return visits to the emergency department, RR 1.14 (0.72-1.8). Adverse effects were similar in both groups.

CONCLUSIONS

Compared with placebo, ondansetron administration for vomiting in children with acute gastroenteritis can improve the efficacy of oral rehydration therapy.

Effect of Oral Dimenhydrinate in Children with Acute Gastroenteritis: A Clinical Trial

OBJECTIVES

One of the major causes of mortality in children is acute gastroenteritis. Vomiting is common in early stages of the disease. The aim of this study was to determine the effect of oral dimenhydrinate (DH) in the control of vomiting in cases of acute gastroenteritis in children.

METHODS

This double-blind, randomized, clinical trial was conducted in a university-affiliated hospital in a western province of Iran. Two hundred children aged one to 12 years old were randomly assigned to either drug or placebo groups. Children in the drug group received oral DH as four doses of 1 mg/kg every six hours (maximum 200 mg), and children in the placebo group received a placebo drug. The patients variables were compared 24 hours after receiving the first dose and at seven and 14 days after discharge.

RESULTS

The mean number of episodes of vomiting was 4.4±2.5 in the drug group versus 4.4±2.1 in the placebo group, which was not statistically significant (p<0.050). The mean number of episodes of diarrhea was 7.4±3.2 and 10.1±2.8 in the drug and placebo groups, respectively, (p<0.050). The duration of diarrhea, side effects, need to revisit, and parent's satisfaction in both groups were also significantly different (p>0.050).

CONCLUSIONS

Oral DH in children with acute gastroenteritis does not reduce the number and duration of vomiting. However, our results showed that consumption of DH in acute gastroenteritis patients was effective in reducing the frequency and duration of diarrhea and further investigation into this is warranted.

Norovirus: new developments and implications for travelers' diarrhea

Noroviruses are the leading cause of acute gastroenteritis in the United States and are responsible for at least 50 % of acute gastroenteritis outbreaks occurring worldwide each year. In addition, noroviruses have caused outbreaks on cruise ships, in nursing homes and hospitals, and in deployed military personnel, but its role in the etiology of travelers’ diarrhea is not well defined. The aim of this review is to describe the role of noroviruses in travelers’ diarrhea in terms of epidemiology, current diagnostics, treatment and vaccine development efforts. Studies have shown prevalence rates of noroviruses in travelers’ diarrhea cases ranging from 10–65 %. It is likely that norovirus prevalence rates are highly underestimated in travelers’ diarrhea due to rapid onset, short duration of the illness, limited availability of laboratory facilities, and the fact that most clinical laboratories lack the diagnostic capability to detect noroviruses in stool. Further, additional studies are needed to accurately determine the true prevalence rates of norovirus as an etiologic agent of diarrhea among travelers to different regions around the world. With the rapid progress in the development of a norovirus vaccine, travelers could serve as an ideal population for future norovirus clinical trials.

Effect of Randomized Clinical Trial Findings on Emergency Management

OBJECTIVES

Research findings are not consistently adopted in the clinical setting and there is a gap between best evidence and clinical practice across a range of conditions and settings. A number of factors may contribute to this discrepancy, including the direction of the research findings (i.e., whether positive or negative for an intervention). The objectives of this study were to measure the translation of results from randomized controlled trials (RCTs) into clinical care and to determine whether the direction of the trial findings influence the uptake of research reports into clinical practice.

METHODS

This was a retrospective study of clinical care provided in emergency departments (EDs) across the United States with data collected by the National Hospital Ambulatory Medical Care Survey from 1992 to 2010. RCTs published in journals with the highest impact factors and conducted in ED settings were selected and data were extracted on the interventions under study, the patient populations examined, and the trial findings. Changes in clinical practice corresponding to the RCT results were measured by comparing the rates of treatment with the intervention during the 3-year period before and after publication of the trial.

RESULTS

Twenty-one RCTs met the inclusion criteria. Ten studies reported positive interventions, of which nine (90%) were associated with an increased ED use of the intervention after trial publication. Four studies showing the lack of benefit of interventions were not used in ED practice prior to the trial and practice did not change in the postpublication period. The remaining eight trials presented negative findings or results comparing two different interventions, and of these, three (38%) were associated with small changes in the ED use of the interventions, consistent with the trial results.

CONCLUSIONS

In the ED setting, results of RCTs published in high-impact journals are more likely to be translated into clinical care when they demonstrate the benefits of an intervention. Our findings indicate that direction of research evidence is an important factor when evaluating knowledge uptake into clinical practice.

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

Context

Gastroenteritis remains a leading cause of childhood morbidity.

Objective

Because 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 Sources

MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, trial registries, grey literature, and scientific meetings.

Study Selection

Randomized 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 Extraction

The 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.

Results

31 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).

Conclusions

There 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.

Effectiveness of granisetron in controlling pediatric gastroenteritis-related vomiting after discharge from the ED

OBJECTIVE

The objective of the study is to determine the efficacy of oral granisetron (a long-acting 5-HT3 receptor antagonist) in stopping vomiting subsequent to discharge from emergency department (ED), in 6-month-old to 8-year-old patients with gastroenteritis-related vomiting and dehydration, who had failed an initial trial of oral rehydration (ORT).

METHODS

Eligible patients were offered ORT on a slowly advancing schedule. Patients who tolerated the initial ORT were discharged home. Patients who vomited were randomized to receive either 40 μg/kg of granisetron or placebo, and ORT was resumed. Patients who tolerated the postrandomization ORT were discharged home with another dose of the study drug. Parents were contacted by telephone every 24 hours until complete resolution of symptoms. The primary outcome was the proportion of patients with vomiting at 24 hours.

RESULTS

Of the 900 eligible patients, 537 (60%) tolerated the initial ORT and were discharged home. Of the patients who vomited during the initial ORT, 165 were included in the final study sample (placebo, n = 82; granisetron, n = 83). There was no statistically significant difference in the proportion of patients with vomiting at 24 hours (granisetron, n = 38; placebo, n = 45; odds ratio, 0.64; 95% confidence interval, 0.34-1.19; P = .16). A similar trend in the proportion of patients with vomiting was noted for the entire follow-up period (granisetron, n = 43; placebo, n = 47; odds ratio, 0.73; P = .33; 95% confidence interval, 0.39-1.36).

CONCLUSION

Granisetron was not effective in controlling gastroenteritis-related vomiting subsequent to discharge from ED. It did not change the expected course of the illness.

Randomized study of ondansetron versus domperidone in the treatment of children with acute gastroenteritis

Background

Acute gastroenteritis (AGE) is a common condition among children that is frequently accompanied by vomiting. Symptomatic control of vomiting is important as it improves patient’s general condition and reduces the need for intravenous therapy and hospitalization. Antiemetic agents including ondansetron and domperidone are used to provide symptomatic relief but the existing studies do not provide enough evidence of better efficacy for one over another.

Methods

Seventy-six Thai children under the age of 15 with AGE were randomized to receive either ondansetron or domperidone. The primary outcome of the study was the proportion of the patients in each group who had no episode of vomiting 24 hours after the start of treatment.

Results

Primary outcome was met in 62% of patients in ondansetron group and 44% of patients in domperidone group (P = 0.16). Patients in domperidone group received more doses of the drug within 24 hours after the start of the treatment compared to ondansetron group (P = 0.01). No adverse effect was observed in any of the two groups.

Conclusions

Ondansetron can be considered a safe comparable alternative to commonly-used domperidone in Thai children who suffer from symptoms of gastroenteritis. Larger clinical trials are needed to further explore the effectiveness of the two medications.

The effect of antiemetics in childhood gastroenteritis

Introduction

Diarrheal diseases are the second leading cause of childhood morbidity and mortality in developing countries and an important cause of malnutrition. An estimated 0.75 million children below 5 years of age die from diarrhea. Vomiting associated with acute gastroenteritis (AGE) is a distressing symptom and limits the success of oral rehydration in AGE leading to an increased use of intravenous rehydration, prolonged emergency department stay and hospitalization. In this review we estimate the effect of antiemetics in gastroenteritis in children.

Methods

We conducted a systematic review of all the efficacy and effectiveness studies. We used a standardized abstraction and grading format and performed meta-analyses for all outcomes with more than two studies. The estimated effect of antiemetics was determined by applying the standard Child Health Epidemiology Reference Group (CHERG) rules.

Results

We included seven studies in the review. Antiemetics significantly reduced the incidence of vomiting and hospitalization by 54%. Antiemetics also significantly reduced the intravenous fluid requirements by 60%, while it had a non-significant effect on the ORT tolerance and revisit rates.

Conclusion

Antiemetics are effective for the management of gastroenteritis in children and have the potential to decrease morbidity and mortality burden due to diarrhea, when introduced and scaled up.

Clinical and economic impact of oral ondansetron for vomiting in a pediatric emergency department

In this study, we determine the clinical impact of 1 dose of oral ondansetron for children with vomiting and evaluate the economic consequences of its use. The strategies compared were administering oral ondansetron in addition to oral rehydration therapy (group A) versus oral rehydration solution alone (group B) in children attended to for vomiting in a pediatric emergency department. The study population was 1871 children between 0 and 14 years of age treated for vomiting during a 2-year period (2009-2010). Outcome measures were need for intravenous rehydration, length of stay in the emergency department, return visits, and hospitalization. Estimates of the costs in the emergency department and hospitalization were derived from administrative databases. During the study period, 580 (31%) of 1871 patients received oral rehydration therapy. Oral ondansetron before oral rehydration solution was used in 109 (18.8%) of 580 patients. An equal number of patients not receiving ondansetron were randomized and analyzed for comparison (group B). Patients of group A had a significantly decreased risk of hospitalization (relative risk, 0.22; 95% confidence interval, 0.08-0.63) and intravenous rehydration (relative risk, 0.31; 95% confidence interval, 0.14-0.63), but there were no differences in the length of stay or return visits to the emergency department. There were no differences in the medical costs between both groups in the emergency department (US $22,078 vs US $21,987, respectively). The hospitalization cost was US $9600 for group A and US $25,079 for group B, providing a 73.7% saving. In conclusion, the administration of oral ondansetron to children with vomiting in the emergency department is clinically effective and results in significant economic savings.

The use of ondansetron for nausea and vomiting after head injury and its effect on return rates from the pediatric ED

BACKGROUND

The use of ondansetron in children with vomiting after a head injury has not been well studied. Concern about masking serious injury is a potential barrier to its use.

OBJECTIVE

The aim of this study was to evaluate the use of ondansetron in children with head injury and symptoms of vomiting in the pediatric emergency department (PED) and its effect on return rates and masking of more serious injuries.

DESIGN/METHODS

Visits to 2 PEDs from 2003 to 2010 with a diagnosis of head injury were evaluated retrospectively. Patients discharged home after a head computed tomography (CT) are the primary cohort for the study. A logistic regression model was used to analyze ondansetron's effects on the likelihood of return to the PED within 72 hours for persistent symptoms. A secondary analysis was performed on patients with a diagnoses of head injury who did not receive a head CT and were discharged.

RESULTS

A total of 6311 patients had a diagnosis of head injury, had a head CT performed, and were discharged from the PED. The use of ondansetron increased significantly from 3.7% in 2003 to 22% in 2010 (P < .001). After controlling for demographic/acuity differences, receiving ondansetron in the PED was associated with a lower likelihood of returning within 72 hours (0.49, 95% confidence interval [0.26-0.92]). In patients with head injury who did not have a head CT performed and were sent home, the use of ondansetron in the PED was not associated with an increased risk of missed diagnoses.

CONCLUSION

Ondansetron use in children with a CT scan who are dispositioned home is relatively safe, does not appear to mask any significant conditions, and significantly reduces return visits to the PED.

Emergency department use of oral ondansetron for acute gastroenteritis-related vomiting in infants and children

Acute gastroenteritis is one of the most common causes of emergency room visits. Although it is usually a self-limited infection, vomiting related to this illness can cause various degrees of dehydration, leading to intravenous insertion, electrolyte abnormalities and/or hospital admission. Ondansetron is a highly potent antiemetic drug that is effective in preventing chemotherapy-and radiation-induced nausea and vomiting with a very low risk of adverse effects. Recently, ondansetron has been used to control vomiting related to acute gastroenteritis. The present article examines evidence for the use of oral ondansetron for acute gastroenteritis-related vomiting in infants and children, and provides a recommendation for treatment based on the evidence-based review.

Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework

OBJECTIVE

To assess the evidence for the safety and effectiveness of antiemetics on gastroenteritis-induced vomiting in children and adolescents.

DESIGN

Systematic review.

DATA SOURCES

The Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE searched from 1980 to March 2012.

METHODS

Methods included comprehensive searches, data synthesis, meta-analysis and mixed treatment comparisons (MTC).

REVIEW METHODS

Reference lists were checked, and missing or inconsistent data were sought from trial investigators. Randomised controlled trials comparing antiemetics in participants younger than 18 years and who were vomiting due to acute gastroenteritis. Four meta-analyses and three MTC were carried out.

RESULTS

10 trials (1479 participants) and five treatments were included: dexamethasone, dimenhydrinate, granisetron, metoclopramide and ondansetron. There was clear evidence that ondansetron (oral or intravenous) compared with placebo increased the proportion of patients with cessation of vomiting (orally administered) (RR 1.44, 95% CI 1.29 to 1.61), reduced the immediate hospital admission rate (orally administered) (RR 0.40, 95% CI 0.19 to 0.83) and the need for intravenous rehydration therapy (orally administered) (RR 0.41, 95% CI 0.29 to 0.59). No significant difference was noted in the revisit rates, but ondansetron was associated with an increase in episodes of diarrhoea. There was no evidence for the use of dexamethasone or metoclopramide and limited evidence that dimenhydrinate or granisetron increased the cessation of vomiting. The MTC analysis suggested that ondansetron was the most likely treatment to stop the child vomiting. Nine studies were carried out in secondary care and one in primary care.

CONCLUSIONS

This systematic review used a method novel to this clinical area and found clear evidence that ondansetron was the most likely treatment to allow oral rehydration therapy to commence. Given the significance of these results, the authors urge healthcare policy makers to consider the wider use of ondansetron in secondary care. Furthermore, randomised controlled trials are needed to investigate the effectiveness of antiemetic treatment in primary care (including ambulatory care interventions).

Dehydration treatment practices among pediatrics-trained and non-pediatrics trained emergency physicians

OBJECTIVES

We sought to survey emergency physicians in the United States regarding the management of pediatric dehydration secondary to acute gastroenteritis. We hypothesized that responses from physicians with dedicated pediatric training (PT), that is, board certification in pediatrics or pediatric emergency medicine, would differ from responses of physicians with no dedicated pediatric training (non-PT).

METHODS

An anonymous survey was mailed to randomly selected members of the American College of Emergency Physicians and sent electronically to enrollees of Brown University pediatric emergency medicine listserv. The survey consisted of 17 multiple-choice questions based on a clinical scenario depicting a 2-year-old with acute gastroenteritis and moderate dehydration. Questions asked related to treatment preferences, practice setting, and training information.

RESULTS

One thousand sixty-nine surveys were received: 997 surveys were used for data analysis, including 269 PT physicians and 721 non-PT physicians. Seventy-nine percent of PT physicians correctly classified the scenario patient as moderately dehydrated versus 71% of non-PT physicians (P = 0.063). Among those who correctly classified the patient, 121 PT physicians (58%) and 350 non-PT physicians (68%) would initially hydrate the patient with intravenous fluids. Pediatrics-trained physicians were more likely to initially choose oral or nasogastric hydration compared with non-PT physicians (P = 0.0127). Pediatrics-trained physicians were less likely to perform laboratory testing compared with the non-PT group (n = 92, 45%, vs n = 337, 66%; P < 0.0001).

CONCLUSIONS

Contrary to established recommendations for the management of moderately dehydrated children, significantly more PT physicians, compared with non-PT physicians, follow established guidelines.

Ondansetron use in the pediatric emergency room for diagnoses other than acute gastroenteritis

BACKGROUND

Ondansetron is widely used in the pediatric emergency department (PED) for vomiting and acute gastroenteritis (GE). Little is known about the spectrum of its use in diagnoses other than acute GE.

OBJECTIVE

The objective of this study was to evaluate the spectrum of diagnoses for which ondansetron is used in the PED.

METHODS

Medical records from 2 tertiary care PEDs from January 2006 to December 2008 were retrospectively reviewed. Patients 3 months to 18 years of age given ondansetron in the PED were identified. Patients without a primary discharge diagnosis (based on International Classification of Diseases, Ninth Revision code) of vomiting or GE were defined as non-GE. Patient age, initial triage level (1 = lowest acuity, 5 = highest), route of administration (enteral vs parenteral), primary diagnosis, disposition, and prescription for ondansetron at discharge were recorded; GE and non-GE patients were compared based on age and triage acuity.

RESULTS

There were 32,971 patients who received ondansetron in the PED; 12,620 (38%) were non-GE patients. Non-GE patients were older (8.3 vs 4.3 years, P < 0.001) and of higher average initial triage level (2.95 vs 2.33, P < 0.001) compared with GE patients. Within non-GE patients, 79% received ondansetron enterally, 71% were discharged, and 37% of those discharged received an ondansetron prescription. The most common primary diagnoses for non-GE discharged patients were fever (15%), abdominal pain/tenderness (13%), head injury/concussion (7%), pharyngitis (6%), viral infection (6%), migraine variants (5%), and otitis media (5%). The most common diagnoses of patients admitted were appendicitis (11%), asthma (6%), pneumonia (4%), and diabetes (4%).

CONCLUSIONS

Although ondansetron is a widely accepted treatment for GE in children, this study identifies a broader spectrum of primary diagnoses for which ondansetron is being used.

Time-series analysis of ondansetron use in pediatric gastroenteritis

OBJECTIVE

Emergency department use of ondansetron in children with gastroenteritis is increasing; however, its effect on clinical outcomes is unknown. We aimed to determine whether increasing ondansetron usage is associated with improved outcomes in children with gastroenteritis.

METHODS

A retrospective cohort study was conducted at The Hospital for Sick Children, Toronto, Canada. Eligible children included those younger than 18 years old with gastroenteritis who presented to an emergency department between 2003 and 2008. There were 22,125 potentially eligible visits; 20% were selected at random for chart review. The primary outcome measure, the intravenous rehydration rate, was evaluated using an interrupted time-series analysis with segmented logistic regression. Secondary outcomes included emergency department revisits, hospitalization, and length of stay.

RESULTS

A total of 3508 patient visits were included in the final analysis. During the study period, there was a significant reduction in intravenous rehydration usage (27%-13%; P < 0.001) and an increase in ondansetron administration (1%-18%; P < 0.001). Time-series analysis demonstrated a level break (P = 0.03) following the introduction of ondansetron. The mean length of stay for children declined from 8.6 ± 3.4 to 5.9 ± 2.8 hours, P = 0.03. During the week following the index visit, there was a reduction in return visits (18%-13%; P = 0.008) and need for intravenous rehydration (7%-4%; P = 0.02).

CONCLUSIONS

Ondansetron use has increased significantly and is associated with reductions in the use of intravenous rehydration, emergency department revisits, and length of stay. The selective use of ondansetron is associated with improved clinical outcomes.

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

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.

Metoclopramide versus ondansetron for the treatment of vomiting in children with acute gastroenteritis

OBJECTIVE

To compare the efficacy and safety of ondansetron versus less expensive metoclopramide in the treatment of children with persistent vomiting with acute gastroenteritis.

MATERIALS AND METHODS

A double-blind trial including consecutive consented patients ages 1 to 14 years was conducted in an urban infirmary setting from June 2008 through December 2008. Children were randomized to receive a single dose of intravenous ondansetron or metoclopramide. The primary efficacy outcome was the proportion of patients with cessation of vomiting shortly after completion of the study medication infusion in each group. Observed adverse effects and diarrhea frequency during admission and in follow-up were recorded to assess safety.

RESULTS

One hundred sixty-seven previously healthy children (median age 3 years) diagnosed as having acute gastroenteritis with persistent vomiting completed treatment and observation. Cessation of vomiting was achieved in 68/84 patients (81%) of the ondansetron and 60/83 (72%) of the metoclopramide groups, P = 0.14. Mean time to complete cessation of vomiting was 39 minutes (SD 111) for ondansetron, and 61 minutes (SD 110) for metoclopramide, P = 0.2. The mean length of infirmary stay was 550 minutes (SD 427) for ondansetron and 575 minutes (SD 449) for metoclopramide, P = 0.71. Revisit rate, readmissions rate, and frequency of diarrhea after discharge were similar in the 2 treatment groups. No adverse reaction or other safety concerns were identified.

CONCLUSIONS

In the sample size tested, intravenous metoclopramide therapy did not differ from ondansetron in the treatment of persistent vomiting for children with gastroenteritis admitted for intravenous fluid hydration.

Use of antiemetics in children with acute gastroenteritis: Are they safe and effective?

The use of antiemetics is a controversial topic in treatment of pediatric gastroenteritis. Although not recommended by the American Academy of Pediatrics, antiemetics are commonly prescribed by physicians. A review of the literature shows side effects of promethazine, prochlorperazine, and metoclopramide are common and potentially dangerous. Ondansetron has recently been studied as an adjunct to oral rehydration therapy in treatment of acute gastroenteritis with mild to moderate dehydration. Although studies are limited, early research suggests the medication is safe when used in a single dose and can be effective to prevent vomiting, the need for intravenous fluids, and hospital admission.

Pediatric rapid fluid resuscitation

PURPOSE OF REVIEW

Intravenous and enteral fluid resuscitation are frequently used therapies in the management of pediatric patients in emergency departments and critical care settings. Any state of intravascular fluid deficit, ranging from mild dehydration due to gastroenteritis to fulminant septic shock, requires careful assessment and early restoration of hemodynamic stability. Rapid fluid resuscitation has gained increased recognition since the most recent pediatric shock management guidelines. We sought to review the evidence for rapid fluid resuscitation and to outline its clinical indications, implementation, and potential associated risks.

RECENT FINDINGS

Rapid fluid resuscitation benefits pediatric patients with severe dehydration or signs of shock. Studies have proven the modality to be safe and efficacious and to reduce morbidity and mortality. Initial and frequent clinical assessments are key in reducing potential complications of overhydration or clinically significant electrolyte disturbances. Rapid enteral rehydration may be used in the uncomplicated, mildly to moderately dehydrated patient. Antiemetics may facilitate rehydration efforts by limiting further fluid losses.

SUMMARY

Rapid fluid resuscitation is most commonly used for children with moderate-to-severe dehydration, or for patients in shock to restore circulation. Concerns regarding potential for fluid overload and electrolyte disturbances and regarding the method of rehydration (i.e., enteral versus parenteral) raise some debate about the safety and efficacy of rapid fluid resuscitation in the pediatric patient. Recent studies show that early, aggressive fluid resuscitation of up to 60 ml/kg within 1-2 h may be necessary to replenish circulating intravascular fluid volume. Complications of severe electrolyte disturbances, cerebral edema, or uncontrolled hemorrhage are uncommon and can often be avoided with early clinical assessment and reassessments throughout the resuscitation. In the mildly to moderately dehydrated child, enteral fluid resuscitation with the aid of an antiemetic such as ondansetron can be as effective and efficient as intravenous fluid resuscitation.

Vomiting, diarrhea, constipation, and gastroenteritis

Diseases that cause vomiting, diarrhea, constipation, and gastroenteritis are major problems for populations worldwide. Patients, particularly infants, elderly, and immunocompromised individuals, may present at any point in a wide spectrum of disease states, underscoring the need for the clinician to treat these ailments aggressively. Several promising new treatment modalities, from oral rehydration solutions to antiemetic therapies, have been introduced over the past decade. Future directions include the use of probiotic agents and better tolerated rehydration solutions. Gastrointestinal disease will continue to be a focus worldwide in the search for better ways to cure illnesses associated with vomiting and diarrhea.

Oral ondansetron versus domperidone for symptomatic treatment of vomiting during acute gastroenteritis in children: multicentre randomized controlled trial

Background

Vomiting in children with acute gastroenteritis (AG) is not only a direct cause of fluid loss but it is also a major factor of failure of oral rehydration therapy (ORT). Physicians who provide care to paediatric patients in the emergency department (ED) usually prescribe intravenous fluid therapy (IVT) for mild or moderate dehydration when vomiting is the major symptom. Thus, effective symptomatic treatment of vomiting would lead to an important reduction in the use of IVT and, consequently, of the duration of hospital stay and of frequency of hospital admission. Available evidence on symptomatic treatment of vomiting shows the efficacy of the most recently registered molecule (ondansetron) but a proper evaluation of antiemetics drugs largely used in clinical practice, such as domperidone, is lacking.

Objectives

To compare the efficacy of ondansetron and domperidone for the symptomatic treatment of vomiting in children with AG who have failed ORT.

Methods/Design

Multicentre, double-blind randomized controlled trial conducted in paediatric EDs. Children aged from 1 to 6 years who vomiting, with a presumptive clinical diagnosis of AG, and without severe dehydration will be included. After the failure of a initial ORS administration in ED, eligible children will be randomized to receive: 1) ondansetron syrup (0,15 mg/Kg of body weight); 2) domperidone syrup (0,5 mg/Kg of body weight); 3) placebo. The main study outcome will be the percentage of patients needing nasogastric or IVT after symptomatic oral treatment failure, defined as vomiting or fluid refusal after a second attempt of ORT. Data relative to study outcomes will be collected at 30 minute intervals for a minimum of 6 hours. A telephone follow up call will be made 48 hours after discharge. A total number of 540 children (i.e. 180 patients in each arm) will be enrolled.

Discussion

The trial results would provide evidence on the efficacy of domperidone, which is largely used in clinical practice despite the lack of proper evaluation and a controversial safety profile, as compared to ondansetron, which is not yet authorized in Italy despite evidence supporting its efficacy in treating vomiting. The trial results would contribute to a reduction in the use of IVT and, consequently, in hospital admissions in children with AG. The design of this RCT, which closely reflect current clinical practice in EDs, will allow immediate transferability of results.

Trial Registration

ClinicalTrials.gov: NCT01257672

Ondansetron dosing in pediatric gastroenteritis: a prospective cohort, dose-response study

BACKGROUND

Ondansetron is increasingly used to prevent emesis in children with acute gastroenteritis; however, the optimal dose is unknown.

OBJECTIVE

To determine if higher doses of oral ondansetron are associated with greater efficacy or side effects.

METHODS

We analyzed data from a prospective clinical trial performed between January 2004 and April 2005. Data were collected on 105 children with dehydration due to gastroenteritis who received an ondansetron oral disintegrating formulation. The following outcomes of efficacy were analyzed: number of vomiting episodes, volume of oral rehydration fluids consumed, percent weight gain, and the proportions of children who had ongoing vomiting, received intravenous rehydration, and were hospitalized. In addition, the number of episodes of diarrhea was evaluated to measure whether there were dose-dependent side effects.

RESULTS

Participants were aged 0.5-8.2 years and the dose ranged between 0.13 and 0.26 mg/kg. There was no significant association between the dose of ondansetron and the outcomes of number of vomiting episodes, volume of fluids consumed, increase in bodyweight, or number of diarrhea episodes/hour. The mean dose of ondansetron (mg/kg) administered was not different amongst those who did and did not have ongoing vomiting, undergo hospitalization, and receive intravenous rehydration.

CONCLUSIONS

Within the dose range of 0.13-0.26 mg/kg, higher doses of ondansetron were not superior to lower doses, nor were they associated with increased side effects. Thus, ondansetron in this dose range was shown to result in a similar reduction in emesis in children with acute gastroenteritis.

Oral ondansetron administration in emergency departments to children with gastroenteritis: an economic analysis

BACKGROUND

The use of antiemetics for children with vomiting is one of the most controversial decisions in the treatment of gastroenteritis in developed countries. Ondansetron, a selective serotonin receptor antagonist, has been found to be effective in improving the success of oral rehydration therapy. However, North American and European clinical practice guidelines continue to recommend against its use, stating that evidence of cost savings would be required to support ondansetron administration. Thus, an economic analysis of the emergency department administration of ondansetron was conducted. The primary objective was to conduct a cost analysis of the routine administration of ondansetron in both the United States and Canada.

METHODS AND FINDINGS

A cost analysis evaluated oral ondansetron administration to children presenting to emergency departments with vomiting and dehydration secondary to gastroenteritis from a societal and health care payer's perspective in both the US and Canada. A decision tree was developed that incorporated the frequency of vomiting, intravenous insertion, hospitalization, and emergency department revisits. Estimates of the monetary costs associated with ondansetron use, intravenous rehydration, and hospitalization were derived from administrative databases or emergency department use. The economic burden in children administered ondansetron plus oral rehydration therapy was compared to those not administered ondansetron employing deterministic and probabilistic simulations. We estimated the costs or savings to society and health care payers associated with the routine administration of ondansetron. Sensitivity analyses considered variations in costs, treatment effects, and exchange rates. In the US the administration of ondansetron to eligible children would prevent approximately 29,246 intravenous insertions and 7,220 hospitalizations annually. At the current average wholesale price, its routine administration to eligible children would annually save society US$65.6 million (US$49.1-US$81.1) and health care payers US$61.1 million (US$46.2-US$76.3). In Canada the administration of ondansetron to eligible children would prevent 4,065 intravenous insertions and 1,003 hospitalizations annually. Its routine administration would annually save society CDN$1.72 million (CDN$1.15-CDN$1.89) and the health care system CDN$1.18 million (CDN$0.88-CDN$1.41).

CONCLUSIONS

In countries where intravenous rehydration is often employed, the emergency department administration of oral ondansetron to children with dehydration and vomiting secondary to gastroenteritis results in significant monetary savings compared to a no-ondansetron policy. Please see later in the article for the Editors' Summary.