Consultations & Comments

Managing a Child’s Vomiting: Which Outpatient Therapies Are Best?

Linda S. Nield, MD
Jennifer J. Zatezalo
Volume 14 - Issue 3 - March 2015

Author:
Jennifer J. Zatezalo and Linda S. Nield, MD—Series Editor

Citation:
Zatezalo JJ, Nield LS. Managing a child’s vomiting: which outpatient therapies are best? Consultant for Pediatricians. 2015;14(3):134,136.

 

A Parent Asks

My 3-year-old daughter has been vomiting all night. My friend says she received a medication from the emergency room doctor to stop the vomiting. Can you prescribe something that will stop my daughter’s vomiting?

The Parent Coach Advises

A vomiting child can be disconcerting for the caregiver as worries about dehydration loom. Every parent will experience this at some point—each year, 30 million U.S. children get acute viral gastroenteritis.1 It is a leading cause of vomiting in pediatric patients2 and annually prompts 1.5 million outpatient medical visits and 220,000 hospital admissions.3

Rehydration Therapy

Although parents like this one often ask about the use of medications to treat their child’s vomiting, it must be emphasized that the American Academy of Pediatrics (AAP) established a practice parameter in 1996 highlighting that oral rehydration therapy (ORT) is crucial for the recovery of a vomiting child.4 The aim is to restore electrolyte disturbances, restore hydration, and maintain age-appropriate food intake.4 The most effective means of reestablishing hydration is initially administering frequent (every 1-2 minutes) doses of a glucose-electrolyte solution in the amount of 5 mL/dose.4 As the child’s hydration status improves and vomiting lessens, parents can increase the dosage and administer it at longer intervals.4

In 2004, the AAP retired its practice parameter and adopted the 2003 guideline of the Centers for Disease Control and Prevention (CDC).5,6 The CDC guideline stratifies appropriate treatment based on dehydration severity.6 For minimal and no dehydration, the appropriate goals are to continue an age-appropriate dietary regimen and to ensure adequate fluid intake. The fluid intake is 1 mL of fluids for every 1 g of output (vomiting or diarrhea). If the output is not easily measured, parents can add 2 mL/kg of fluids based on the child’s body weight.6

Mild to moderate dehydration in a child must be approached more carefully to ensure hydration. An approach similar to the AAP’s 1996 ORT practice parameter4 is recommended, beginning with frequent, small doses of fluids until rehydration begins and the child can tolerate higher dosages.6 It is imperative to ensure a more rapid process of rehydration so that the severity of dehydration does not progress, which may have devastating consequences. Severe dehydration is considered a medical emergency, and it necessitates immediate intravenous (IV) fluids.

A 2009 study examining adherence to the AAP/CDC guideline for the treatment of acute gastroenteritis found that emergency department (ED) visits and hospitalizations are avoidable if the ORT regimen is followed carefully in the home.3 For children who sought emergency care, the hospitals that adhered closely to the guideline had a reduction in admission rates and 50% lower ED costs. Approximately 69% of the 188,873 patients followed in the study were found to have received appropriate treatment in accordance with the guideline.3

Medical Therapy

In rare instances, a child cannot tolerate ORT despite close adherence to the guidelines.6 The use of antiemetic medications can be considered to combat the vomiting in these cases. Antiemetics include dopamine antagonists, antihistamines, 5-HT3 receptor antagonists, and anticholinergic agents.

Pediatricians and emergency physicians often prescribe the antiemetic ondansetron,7 which works by antagonizing the 5-HT3 (serotonin) receptors in the brain. A meta-analysis of the abilities of various antiemetics to decrease or cease gastroenteritis-related vomiting in children found ondansetron to be the medication most likely to stop emesis.2 Clinical studies have indicated that ondansetron’s ability to relieve vomiting allow a child ample opportunity to increase oral fluid intake, improving hydration status.2

Ondansetron is available by prescription only and was first approved for use in the United States in 1991 in both oral and IV formulations. The Food and Drug Administration has approved ondansetron for the prevention of nausea and vomiting following chemotherapy administration and postoperative emesis. However, this medication more commonly is used off-label in EDs to combat gastroenteritis-associated nausea than for standard therapy.8

Studies of ondansetron use in the pediatric outpatient and ED settings are ongoing. In 2002, Reeves and colleagues published the results of a randomized controlled trial examining the antiemetic effects of IV ondansetron on young patients with acute gastroenteritis in the ED.1 The patients’ ages ranged from 1 month to 20 years, and single-dose ondansetron at 0.15 mg/kg was administered in conjunction with IV rehydration.1 The results revealed that this dosage plus IV rehydration therapy yielded a statistically significant decrease in vomiting compared with IV rehydration plus placebo (70% vs 51%; P = .04) and a decreased rate of admission (7% vs 23%; P = .04).1

In recent years, the use of ondansetron to cease gastroenteritis-related vomiting has increased significantly (38,000 doses in 1995 compared with 12.6 million doses in 2009).9 The use of this drug in the pediatric population has greatly increased in U.S. EDs, totaling more than 2 million doses annually.9 Compared with placebo, IV and oral ondansetron were both effective at stopping emesis in pediatric patients with gastroenteritis. The majority (> 85%) of these doses are administered orally.9 Oral ondansetron is linked with significantly fewer hospital admissions from the ED and thus has been deemed a cost-effective strategy.2 The results of a 2012 meta-analysis showed a decrease in the need for IV rehydration in children who received oral ondansetron.2

The recommended pediatric oral dosage is based on the child’s weight as follows: 8-15 kg, 2 mg; 15-30 kg, 4 mg; and > 30 kg, 6-8 mg.10 ORT should begin or resume in the 15 to 30 minutes following administration.10 In most instances, one dose of ondansetron is sufficient for the cessation of vomiting and to permit adequate time for ORT to resume.7

Even as research continues into optimum dosing, an informal survey at our institution revealed that the vast majority of outpatient general pediatricians agreed that at least a one-time dose of oral ondansetron should be considered in the stable and mild to moderately dehydrated child who is having difficulty tolerating ORT.

Adverse Effects

Ondansetron typically is a well-tolerated medication, assuming it is administered in the appropriate dosage.2 In studies examining the role of ondansetron for the cessation of vomiting in pediatric patients, diarrhea was the most commonly observed adverse effect.2 Other adverse effects and precautions include hypersensitivity reactions, serotonin syndrome, cardiac complications including QT interval prolongation, and GI issues, including the concealment of ileus and gastric distention. Although QT prolongation may be an issue when ondansetron is taken in the presence of certain preexisting conditions, studies have shown that QT prolongation and cardiac arrhythmias have not resulted from one-time administration of ondansetron for nausea relief.9 Cardiac adverse effects, including QT prolongation, should be monitored more carefully in patients with known arrhythmia risk factors such as electrolyte imbalances, congenital QT interval prolongation, heart failure, and the concurrent use of certain medications.9

The Bottom Line

If a pediatric patient is suspected of experiencing acute gastroenteritis, it is important to carefully evaluate the child’s hydration status. For mild to moderate dehydration, ORT is recommended as first-line treatment. As long as the child remains hydrated and can tolerate ORT, no further intervention is necessary. If a mild to moderately dehydrated child with difficulty tolerating ORT is seen in the in the primary care setting, the clinician can consider administering a dose of ondansetron to expedite the cessation of vomiting, allowing ORT to commence.11 It is recommended that the dose be administered 15 to 30 minutes before beginning or resuming ORT.10 If a child is exhibiting symptoms of severe dehydration, administration of IV fluids is crucial. 

Jennifer J. Zatezalo is a medical student at the West Virginia University School of Medicine in Morgantown, West Virginia.

Linda S. Nield, MD—Series Editor, is a professor of pediatrics at the West Virginia University School of Medicine.

Acknowledgement: The authors thank pediatric gastroenterologist Brian D. Riedel, MD, for his expert review of this work.

REFERENCES

  1. Reeves JJ, Shannon MW, Fleisher GR. Ondansetron decreases vomiting associated with acute gastroenteritis: a randomized, controlled trial. Pediatrics. 2002;109(4):e62.
  2. Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework. BMJ Open. 2012;2(4):e000622.
  3. Tieder JS, Robertson A, Garrison MM. Pediatric hospital adherence to the standard of care for acute gastroenteritis. Pediatrics. 2009;124(6):e1081-e1087.
  4. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Practice parameter: the management of acute gastroenteritis in young children. Pediatrics. 1996;97(3):424-435.
  5. American Academy of Pediatrics. Statement of endorsement: managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. Pediatrics. 2004;114(2):507.
  6. King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16.
  7. Leung AKC, Robson WLM. Acute gastroenteritis in children: role of anti-emetic medication for gastroenteritis-related vomiting. Paediatr Drugs. 2007;9(3):175-184.
  8. Hartley S, Kuhn L, Valley S, et al. Off-label use of ondansetron in hospitalized medical patients: prevalence, patterns, and predictors. J Clin Outcomes Manag. 2013;20(9):400-406.
  9. Freedman SB, Uleryk E, Rumantir M, Finkelstein Y. Ondansetron and the risk of cardiac arrhythmias: a systematic review and postmarketing analysis. Ann Emerg Med. 2014;64(1):19.e6-25.e6.
  10. Cheng A. Emergency department use of oral ondansetron for acute gastroenteritis-related vomiting in infants and children. Paediatr Child Health. 2011;16(3):177-182.
  11. Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for gastroenteritis in a pediatric emergency department. N Engl J Med. 2006;354(16):1698-1705.