Question: In light of the Choosing Wisely campaign regarding oral antiemetic medications in children with acute gastroenteritis, does the literature suggest that we administer IV fluids too freely?

A 2021 study by Freedman et al evaluated 1,415 children ages 3–48 months.¹ The study was a preplanned secondary analysis of two multicenter pediatric ED studies—one in Canada and one in the United States. These studies were performed by Pediatric Emergency Research Canada (PERC) and Pediatric Emergency Care Applied Research Network (PECARN) and included six sites in Canada and 10 sites in the United States. The initial study protocols were both prospective randomized trials evaluating probiotics and acute gastroenteritis (AGE). The authors incorporated a preplanned secondary analysis of these studies with a primary outcome of evaluating return visits within seven days in patients who received oral antiemetics. Secondary outcomes evaluated IV insertion and hospitalization. Clinical dehydration scale scores were recorded and include characteristics of general appearance, eyes, mucous membranes, and tears.

ED and primary care revisits within seven days of enrollment did not differ (adjusted odds ratio [aOR], 0.72; 95 percent confidence interval [CI] 0.50–1.02). While the revisit odds were similar, IV placement for fluid administration was higher in the U.S. cohort compared to the Canadian cohort (aOR 17.0 percent vs 8.2 percent; difference 8.8 percent; 95 percent CI 5.2–12.4 percent). There was no difference in the proportion of children receiving IV rehydration in the seven days following the index visit and no difference in the requirement for hospitalization, suggesting that the administration of oral antiemetics did not mask significant dehydration requiring IV fluid administration. Ondansetron was the antiemetic of choice in this study. This study suggests that U.S. pediatric emergency departments more liberally administer parenteral IV fluids and that resource allocation may be better utilized elsewhere initially with a trial of oral antiemetics for AGE without harming patient outcomes.

On a similar note, a 2016 meta-analysis by Tomasik et al further evaluated the effects of oral antiemetics on AGE outcomes in children.² Ondansetron was the antiemetic evaluated in this study and compared to placebo. The study included 10 randomized controlled trials with 1,215 total patients. Ondansetron increased the likelihood that vomiting would cease at one hour (relative risk [RR], 1.49; 95 percent CI, 1.17–1.89). Ondansetron reduced the risk of failure of oral rehydration therapy (RR, 0.5; 95 percent CI, 0.37–0.69) and increased the intake of oral rehydration therapy at one hour and four hours after administration. A trial of oral ondansetron for AGE reduced the risk of hospitalization (RR, 0.53; 95 percent CI, 0.29–0.97) and demonstrated a reduction in the risk of need for IV placement for fluids (RR, 0.45; 95 percent CI, 0.31–0.63). Compared to placebo, there were no differences in return visits to the emergency department (RR, 1.14; 95 percent CI, 0.72–1.80), again suggesting that it does not appear to harm care.

Summary

Oral antiemetic treatment should be trialed first in children with AGE and mild-to-moderate dehydration before IV placement for IV fluid administration. This is consistent with the ACEP Choosing Wisely initiative.

References

1. Freedman SB, Roskind CG, Schuh S, et al. Comparing pediatric gastroenteritis emergency department care in Canada and the United States. Pediatrics. 2021;147(6):e2020030890.
2. Tomasik E, Ziólkoska E, Kolodziej M, et al. Systematic review with meta-analysis: ondansetron for vomiting in children with acute gastroenteritis. Aliment Pharmacol Ther. 2016;44(5):438-446.
3. Gelfand AA, Goadsby PJ. A neurologist’s guide to acute migraine therapy in the emergency department. Neurohospitalist. 2012;2(2):51-59.