Are antiemetics still contraindicated for gastroenteritis in children? Solid evidence now supports the safe use of ondansetron
- Correspondence to James E Colletti
Department of Emergency Medicine, Mayo Clinic, 200 First St, NW Rochester, MN 55902, USA;
Implications for practice and research
■ In children presenting with vomiting from acute gastroenteritis, ondansetron is a reasonable therapy to allow for successful oral rehydration.
■ Further research on ondansetron and rehydration should investigate the effects of different dosing regimens, time to cessation of vomiting after antiemetic administration, as well as a cost-effectiveness analysis.
Acute gastroenteritis (AGE) is a common reason for a child to require emergency care and hospitalisation. In children under the age of 5 years, dehydration secondary to AGE is responsible for as many as 200 000 hospitalisations in the USA and 24 000 in the UK each year.1 2
In the paediatric population, vomiting is a common presentation of AGE. The mainstay of therapy for AGE is oral rehydration; continued vomiting is a significant barrier to successful rehydration. Traditionally, administration of antiemetics (particularly the older generation of antiemetics) has been discouraged because of associated adverse reactions (sedation and extrapyramidal side effects), as well as the potential to mask a more serious illness. Furthermore, the 1996 American Academy of Pediatrics (AAP) guidelines discouraged the use of antiemetics in children younger than 5 years of age.3 Fedorowicz et al conducted this systematic review to determine the safety and efficacy of antiemetic used for vomiting in the child with AGE.
The objectives of the review were to assess the clinical effectiveness and safety of antiemetics for children with AGE-induced vomiting by comparing clinical outcomes expressed as cessation of vomiting, reduction in the need for intravenous rehydration or hospitalisation and resumption of oral rehydration therapy. They identified 2443 trials by searching several electronic databases The authors only included randomised controlled clinical trials in children and adolescents under 18 years of age who were presented with vomiting and a confirmed diagnosis of gastroenteritis. Vomiting from other causes was excluded. The authors reviewed randomised controlled trials comparing antiemetics with placebo or no therapy.
Two review authors independently assessed trial quality and extracted data. The authors included seven randomised, double blinded, placebo-controlled trials involving 1020 participants. Six of the seven trials were carried out in emergency departments. The age of participants included in the study ranged from five months to 12 years, and in all seven studies the inclusion criteria were similar. The trials differed with regards to time period conducted, the manner in which gastroenteritis was diagnosed, how a diagnosis of gastroenteritis was confirmed, the manner of administration and dose of ondansetron, and type and timing of rehydration therapy.
The systematic review provides evidence that administration of ondansetron (as a single dose (0.1 mg/kg)) to children presenting with dehydration from vomiting secondary to gastroenteritis appears to be effective in decreasing the rate of vomiting. It also improves the success of oral hydration, as well as minimising the need for intravenous hydration and decreasing admission rates.
Fedorowicz et al have undertaken a rigorous and well-conducted systematic review. The objectives of the review were clearly stated and defined. Only one of the included studies reported the primary outcome for the review (time taken from the first administration of treatment measure until cessation of vomiting) and only one reported on the secondary outcome of parental satisfaction. The eligibility criteria were defined, and all of the studies included in the review matched the eligibility criteria. The search for relevant studies that met eligibility criteria was detailed and exhaustive with 2443 trials identified, seven trials included in the qualitative synthesis and three studies included in the quantitative synthesis (meta-analysis). Characteristics of each of the seven trials were tabulated and potential biases were outlined. Results of three of the trials were analysed using statistical synthesis of data (meta-analysis). In conclusion, this review supports the findings of a growing body of literature that ondansetron is a viable and effective therapy to promote oral rehydration in children presenting with vomiting from AGE.