Update: Antiemetics for Vomiting Associated With Acute Gastroenteritis in Children

Abstract

Oral or intravenous ondansetron is an effective treatment for the management of children with vomiting from acute gastroenteritis. This was an update of a previous Cochrane review. The authors of the review searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to July 2005), and EMBASE (1980 to July 2005).1Fedorowicz Z. Jagannath V.A. Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents.Cochrane Database Syst Rev. 2011; (CD005506)https://doi.org/10.1002/14651858.CD005506.pub5Crossref Google Scholar They also hand searched published abstracts from relevant conference proceedings and contacted content experts for unpublished data. This search was rerun up to July 2010, yielding 3 additional trials and 3 ongoing studies. There were no language restrictions. Only randomized controlled trials comparing antiemetics or placebo in children and adolescents younger than 18 years and with vomiting caused by gastroenteritis were included. Two reviewers independently assessed trial quality and extracted data. Outcomes were assessed at 2 points: during the emergency department (ED) visit and 72 hours after ED discharge. Unclear data at the later point were imputed with the worst-case scenario for ondansetron and best-case scenario for placebo. Tabled 1Medication comparisons found in the review.Investigated MedicationComparatorNumber of StudiesRouteDrugRouteProductOralOndansetronOralPlacebo4IVOndansetronIVSaline2IVOndansetronIVMetoclopramide1IVDexamethasoneIVSaline1IVMetoclopramideIVSaline1SuppositoryDimenhydrinateSuppositoryPlacebo1IVOndansetronIVDexamethasone1IV, Intravenous route of administration. Open table in a new tab Tabled 1Ondansetron (administered orally or intravenously) efficacy compared with that of placebo.OutcomeStudies (No. of Participants)Relative Risk (95% CI)Number Needed to Treat (95% CI)⁎Number needed to treat was calculated by using the placebo group to estimate the typical baseline risk.Cessation of vomiting6 (686)1.42 (1.22–1.66)4 (3–6)Immediate IVF administration5 (598)0.41 (0.29–0.58)7 (4–17)Later IVF administration†Seventy-two hours from discharge. Worst/best sensitivity analysis scenario.5 (594)0.56 (0.42–0.74)8 (5–25)Immediate hospitalization5 (664)0.36 (0.18–0.70)15 (9–100)Later hospitalization†Seventy-two hours from discharge. Worst/best sensitivity analysis scenario.5 (660)0.53 (0.31–0.93)13 (8–50)CI, Confidence interval; IVF, intravenous fluid. Number needed to treat was calculated by using the placebo group to estimate the typical baseline risk.† Seventy-two hours from discharge. Worst/best sensitivity analysis scenario. Open table in a new tab IV, Intravenous route of administration. CI, Confidence interval; IVF, intravenous fluid. The review included 7 comparisons of antiemetic medications (Table 1). Seven trials involving 1,020 participants were included in the Cochrane review; 2 had an unclear risk of bias and 5 were considered to be at high risk of bias, largely because of industry sponsorship. Acute gastroenteritis has been estimated to account for more than 200,000 children being hospitalized in the United States and approximately 16% of all pediatric presentations to United Kingdom EDs.2Armon K.S. Stephenson T.J. Macfaul R. et al.Determining the common presenting problems to paediatric accident and emergency departments.Pediatr Today. 1999; 7: 20Google Scholar, 3Malek M.A. Curns A.T. Holman R.C. et al.Diarrhea- and rotavirus-associated hospitalizations among children less than 5 years of age: United States, 1997 and 2000.Pediatrics. 2006; 117: 1887-1892Crossref PubMed Scopus (157) Google Scholar Although current US and United Kingdom guidance recommends oral rehydration therapy as the first-line management for acute gastroenteritis in children, antiemetics could often be used to stop the vomiting. A recent large study reported that using ondansetron reduced the use of intravenous fluids by half, and an economic analysis suggested that this could reduce US health care costs by $65.6 million.4Freedman S.B. Steiner M. Chan K.J. Oral ondansetron administration in emergency departments to children with gastroenteritis: an economic analysis.PLoS Med. 2010; 7: e1000350Crossref PubMed Scopus (52) Google Scholar, 5Freedman SB, Tung C, Rumantir M, et al. Time series analysis of ondansetron use in pediatric gastroenteritis. J Pediatr Gastroenterol. In press.Google Scholar This Cochrane review update reinforces previous findings that the use of antiemetics is safe and effective in reducing emesis in children with acute gastroenteritis. Although there were no serious adverse reactions reported, there was an unexplained increase of diarrhea. These trials were not powered to detect rare adverse events. There were inadequate data to support the use of agents such as cyclizine, dexamethasone, dimenhydrinate, domperidone, or metoclopramide. Ondansetron, however, was shown to be an effective antiemetic compared with placebo, with a number needed to treat of 4. Ondansetron also reduced the number of children who required intravenous fluids and hospitalization. Individual placebo-controlled trials provided limited evidence that metoclopramide and dimenhydrinate also reduced vomiting. There was insufficient evidence compared between antiemetics to determine superiority for any one agent, which should be addressed with future research. Although this update found a limited number of trials, the evidence consistently showed that the use of ondansetron in children with acute gastroenteritis is a safe and cost-effective management option in the ED as an adjutant to standard rehydration protocols.6Freedman S.B. Parkin P.C. Willan A.R. et al.Rapid versus standard intravenous rehydration in paediatric gastroenteritis: pragmatic blinded randomised clinical trial.BMJ. 2011; 343: d6976Crossref PubMed Scopus (26) Google Scholar