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An 18 month old female is brought to the emergency department by her mother. She has been suffering from repeated vomiting and diarrhoea for the past 24 hours. Over the past eight hours she has vomited approximately 12 times. The vomitus has not contained any bile or blood. The little girl appears mildly dehydrated. Her stool tests positive for rotavirus. You wonder whether administration of an antiemetic may lessen her symptoms and increase the likelihood that oral rehydration therapy will be successful.
Structured clinical question
In an 18 month old girl with rotavirus gastroenteritis [patient], does the administration of antiemetic medication [intervention] decrease vomiting and increase the likelihood that oral rehydration therapy will be successful [outcome]?
Search strategy and outcome
Secondary sources: none.
Medline 1966–July, 2004 using OVID interface: ondansetron OR promethazine OR metoclopramide OR antiemetics AND exp rotavirus infections OR exp Norwalk virus OR exp gastroenteritis OR exp enteritis OR exp transmissible gastroenteritis virus OR exp rotavirus
Limits: human, English language, all infant (birth to 23 months) or preschool child (2 to 5 years) or child (6 to 12 years).
No systematic reviews. Seventy papers were identified, four of which were relevant.
See table 2.
No study expressly answered the question as to whether antiemetics lessen the vomiting associated specifically with rotavirus gastroenteritis infection in children and increase the likelihood that oral rehydration therapy will be successful. In the one study in which the authors attempted to identify the cause of gastroenteritis,3 approximately half of the enrolled children were suffering from rotavirus gastroenteritis. It is reasonable to assume that at least similar numbers of children in the other studies were suffering from rotavirus infection.
In one study,2 oral ondansetron (1.6–4 mg/dose depending on the child’s age) or placebo was administered in the emergency department and then every eight hours for up to two days. Compared to the controls, children that received ondansetron experienced less vomiting while they were in the emergency department, were less likely to require intravenous fluid therapy, and were less likely to be admitted to the hospital. In another study,1 a single dose of intravenous ondansetron (0.15 mg/kg) or placebo was given in the emergency department. All of the children in this study also received intravenous fluids. The children who received ondansetron had significantly less vomiting in the emergency department than did the children who received placebo. Hospitalisation rates were comparable in the two groups; however when the authors excluded children who had a serum CO2 less than 14 mEq/l or had received intravenous fluids prior to their emergency room visit, those who received ondansetron were significantly less likely to be admitted to the hospital than were children who were treated with placebo.
Cubeddu and colleagues3showed that in children hospitalised with gastroenteritis, a single dose of intravenous ondansetron (0.3 mg/kg) decreased the frequency of vomiting over the subsequent 24 hours compared to a single dose of metoclopramide (0.3 mg/kg) or placebo. Van Egan and colleagues4 showed that in children hospitalised with gastroenteritis, 30 mg domperidone suppositories decreased the amount of vomiting compared 10 mg metoclopramide suppositories or placebo. In both of these two studies, metoclopramide was not superior to placebo.
In these four studies comprising 358 patients, no serious side effects were associated with the administration of ondansetron, metoclopramide, or domperidone; however only 140 patients received ondansetron, 32 received metoclopramide, and 20 received domperidone, and follow up was limited to no more than seven days. In the study by Cubeddu and colleagues,3 hospitalised children who received ondansetron or metoclopramide experienced more episodes of diarrhoea during the 24 hour study period than did children who received placebo. Similarly, in the study by Ramsook and colleagues,2 children who received ondansetron had significantly more diarrhoea during the 48 hour study period than did children who received placebo. In two of the studies,23 children who received ondansetron experienced more diarrhoea than did children who received placebo.
CLINICAL BOTTOM LINE
There is currently insufficient evidence to justify the use of oral or intravenous ondansetron in children suffering from acute viral gastroenteritis. A large, well constructed prospective study is needed to answer this question.
Ondansetron given intravenously (0.15–0.3 mg/kg/dose) or orally (1.2–4 mg/dose given every eight hours) probably decreases vomiting in children suffering from viral gastroenteritis.
Serious complications appear to occur in less than 1% of children given ondansetron, but studies in gastroenteritis are limited.
Ondansetron given intravenously (a single dose of 0.15–0.3 mg/kg) or orally (1.2–4 mg/dose given every eight hours) may decrease the need for hospitalisation in children suffering from vomiting associated with acute viral gastroenteritis.
Metoclopramide given intravenously or as a suppository does not decrease vomiting in children suffering from viral gastroenteritis.
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