Can ondansetron help children with vomiting due to gastroenteritis?

Vol 58: FEBRUARY ^• FÉVRIER 2012

|

167

Tools for Practice

Tools for Practice articles in Canadian Family Physician are adapted from articles published twice monthly on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in Canadian Family Physician are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician. Feedback is welcome and can be sent to toolsforpractice@cfpc.ca. Archived articles are available on the ACFP website:

www.acfp.ca.

Can ondansetron help children with vomiting due to gastroenteritis?

G. Michael Allan

Erin Wilson

Noah Ivers

Clinical question

In children presenting with vomiting associated with gastroenteritis, what are the benefits and harms of ondansetron?

Evidence

A systematic review¹ of 6 RCTs (5 in emergency depart- ment [ED] setting and 1 inpatient; N = 745) examined oral and intravenous (IV) administration of ondansetron.

• Ondansetron significantly (P < .05) improved

-admission rates (7.5% with ondansetron vs 14.6%

with placebo, number needed to treat [NNT] = 14);

-need for IV fluids (13.9% vs 33.9%, NNT = 5); and -continued vomiting in the ED (16.9% vs 37.8%, NNT = 5).

• There was no change in return to care.

• There was increased diarrhea (no numbers given).

An updated Cochrane systematic review² considered 6 RCTs (5 RCTs from above review and 1 new RCT, N = 777), all in the ED.

• Only oral treatments were analyzed, with similar results:

-Statistically significant (P < .05) reduction in admission (NNT = 17), need for IV rehydration (NNT = 5), and persistent vomiting (NNT = 5), but no reduction in return to care.

Context

• Evidence for other medications for vomiting due to gas- troenteritis in pediatric populations is poor or limited.¹ -A more recent RCT found dimenhydrinate supposito-

ries helped stop vomiting (NNT = 5) but did not reduce admission rates.³

• Ondansetron appears cost-effective in the ED setting.⁴

• An evidence-based review of ondansetron for gastro- enteritis by the Canadian Paediatric Society⁵ recom- mended

-a single oral dose of ondansetron for children (aged 6 months to 12 years)

—with mild to moderate dehydration or failed oral rehydration and

—not predominantly moderate to severe diarrhea.

• Ondansetron can be administered by IV or orally (dis- solving formulations are available).

-Oral dose examples: 2 mg if patient weighs 8 to 15 kg, 4 mg if patient weighs 15 to 30 kg, and 6 to 8 mg if patient weighs more than 30 kg.

Bottom line

While most cases of pediatric gastroenteritis are

self-limiting, studies from the emergency setting show that a single dose of oral ondansetron can help reduce vomiting, the need for IV fluids, and hospital admission.

Implementation

In stable children with dehydration due to gastroenteri- tis, oral rehydration therapy (ORT) is the cornerstone of treatment.⁶ Very frequent and very small doses of ORT are recommended; handouts are available from the Canadian Paediatric Society⁷ to guide parents on signs of dehydration and use of ORT. A non-randomized Canadian study⁸ suggested that standardized pathways for managing dehydration due to gastroenteritis in the ED might reduce IV use and length of stay with no effect on revisit rates. Adding ondansetron to such standard- ized gastroenteritis treatment pathways might benefit patients further.

Dr Allan is Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton. Ms Wilson is a family nurse practitioner and Assistant Professor at the University of Northern British Columbia. Dr Ivers is a family physician at Women’s College Hospital in Toronto, Ont.

The opinions expressed in this Tools for Practice article are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

References

1. DeCamp LR, Byerley JS, Doshi N, Steiner MJ. Use of antiemetic agents in acute gastroenteritis: a systematic review and meta-analysis. Arch Pediatr Adolesc Med 2008;162(9):858-65.

2. Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev 2011;(9):CD005506.

3. Uhlig U, Pfeil N, Gelbrich G, Spranger C, Syrbe S, Huegle B, et al. Dimenhydrinate in children with infectious gastroenteritis: a prospective, RCT. Pediatrics 2009;124(4):e622-32.

4. Freedman SB, Steiner MJ, Chan KJ. Oral ondansetron administration in emergency departments to children with gastroenteritis: an economic analysis. PLoS Med 2010;7(10):e1000350.

5. Cheng A. Emergency department use of oral ondansetron for acute gastroenteritis- related vomiting in infants and children. Paediatr Child Health 2011;16(3):177-9.

6. Spandorfer PR, Alessandrini EA, Joffe MD, Localio R, Shaw KN. Oral versus intrave- nous rehydration of moderately dehydrated children: a randomized, controlled trial.

Pediatrics 2005;115(2):295-301.

7. Canadian Paediatric Society. Dehydration and diarrhea in children: prevention and treatment. Ottawa, ON: Canadian Paediatric Society, 2011. Available from: www.

caringforkids.cps.ca/handouts/dehydration_and_diarrhea. Accessed 2011 Oct 31.

8. Doan Q, Chan M, Leung V, Lee E, Kissoon N. The impact of an oral rehydra- tion clinical pathway in a paediatric emergency department. Paediatr Child Health 2010;15(8):503-7.