Antiemetics for acute gastroenteritis in children

Outcomes and predictors of early emergency department discharge among children with acute gastroenteritis and moderate dehydration

Background

Gastroenteritis is one of the most common diseases that affects children and remains a leading cause of morbidity and mortality around the world. There is conflicting evidence regarding the effect of rapid intravenous fluid regimen on the clinical outcome of patients with acute gastroenteritis. This study aimed to assess the current practice of intravenous hydration on the clinical outcomes of pediatric patients with acute gastroenteritis and determine the predictive factors for early discharge and emergency department (ED) revisit.

Methods

A cohort study was carried out among children aged from 1 month to 14 years who presented to the ED in a tertiary care hospital between September 2015 and September 2017. Children diagnosed with acute gastroenteritis and moderate dehydration who require intravenous hydration were included in the study. The patients were followed up until discharge from ED, admission to the hospital or revisit to the ED. Collected variables were demographics, presenting symptoms, biochemical marker, amount of intravenous fluid (IVF) received and prescription of anti-emetics. Descriptive statistics were summarized as mean, standard deviation for continuous variables and proportions for categorical variables. Logistic regression was used to identify risk factors.

Results

Out of 284 patients, 148 (52%) were males, 20 (7%) were infants, 80 (28%) were toddlers, 90 (32%) were in preschool, 88 (31%) were in school and 6 (2.1%) were adolescents. No significant difference was observed in the admission rate, discharge within 12 h or less and ED revisits for those who received IVF ≥40 ml/kg as compared to those who received <40 ml/kg. Patients with bicarbonate level closer to normal are more likely to be discharged after 4 h (odds ratio (OR) 1.2 and 95% CI 1.12–1.43). Patients presenting only with vomiting/diarrhoea were less likely to revisit ED (OR 0.33 (95% CI 0.143 - 0.776), while patients with an increase in CO₂ level (OR 1.19 and 95% CI 1.0 -1.436) and anion gap (OR 1.29 and 95% CI 1.08–1.54) were more likely to revisit within 1 week post discharge.

Conclusion

This study did not show any additional benefits of receiving IVF ≥ 40 ml/kg over 4 h neither in early discharge nor in reducing the ED revisit. CO₂ closer to normal was a significant predictor for early discharge in 4 h where the closer level of CO₂ and AGAP were associated with an increase in the chance of a revisit to the ED within 1 week after discharge.

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.

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.