Download Pediatric Gastroenteritis: Is That IV Really Necessary?

Pediatric Gastroenteritis:
Is That IV Really Necessary?
Wendy Woolley, DO
Pediatric Grand Rounds
Albany Medical Center
January 14, 2009
Objectives
 Review the management of acute
uncomplicated gastroenteritis in the
pediatric population
 Discuss the options for rehydration
therapy
 Review the literature on the use of
antiemetic agents
Epidemiology
 Annually in the US, AGE accounts for
 ~2-3 million physician visits
 ~220,000 hospital admissions
 ~300 deaths
 Worldwide, AGE causes
 ~125 million physician visits
 ~9 million hospital admissions
 ~1.8 million deaths
Etiology
 Viral
 Typically low grade fever, vomiting and copious,
watery diarrhea lasting ~5-7 days
 Bacterial
 More likely to have high fevers, shaking chills and
bloody diarrhea than viral causes
 Parasitic
 Giardia and Cryptosporidium most common in US
Pathophysiology - Diarrhea
 Pathogen invades the
mucosal cells of the GI
tract
 Normal sodium and
osmotic balance are
disrupted
 Intestinal fluid output
overwhelms the
absorptive ability of the GI
tract
Pathophysiology - Vomiting
 Receptors in the GI
tract and
neurotransmitters
stimulate the
chemoreceptor
trigger zone and
vomiting center of
the brain
 The vomiting center
stimulates salivation
and the pharyngeal,
GI and abdominal
muscles
So What Should We Do?
AAP Recommendations
 ORT as first
line therapy
 Rehydration
 Replacement
 Nutrition
Based on CDC guidelines from MMWR Recommendations and Reports, Nov.
21, 2003. Managing Acute Gastroenteritis Among Children. Oral Rehydration,
Maintenance, and Nutritional Therapy
Managing Acute Gastroenteritis Among Children
MMWR Recommendations and Reports, November 21, 2003.
 ORS treatment is simple and can be started
at home
 Early intervention can reduce complications of
dehydration and malnutrition
 This can decrease the amount of physician visits,
hospital admissions and morbidity associated with
AGE
 An age-appropriate diet should be continued
to maintain adequate nutrient intake.
Rehydration Therapy
 Oral Rehydration
Therapy (ORT)
 Rehydration: replacing
losses of fluids and
electrolytes
 Maintenance: replace
ongoing losses with
adequate nutrition
Oral Rehydrating Solutions
Carbs
NA
K
Cl
Base
Osm
WHO (2002)
13.5
75
20
65
30
245
Pedialyte
25
45
20
35
30
250
Rehydralyte
25
75
20
65
30
305
Apple juice
120
0.4
44
45
N/A
730
Coca-Cola
112
1.6
N/A
N/A
13.4
650
Therapy Based on Degree of
Dehydration
Rehydration
Replacement
Nutrition
Minimal or No
Dehydration
None required
<10kg: 60-120 Age
mL/episode
Appropriate,
>10kg: 120-240 unrestricted diet
ml/episode
Mild to
Moderate
Dehydration
50-100 ml/kg
ORS over 3-4
hours
Same as above
Same as above
Severe
Dehydration
IV LR or NS at
20ml/kg until
perfusion and
MS improve
Same as above
Or D5 1/4NS +
20 mEq KCl IV
Same as above
Hydration Evaluation
Clinical Dehydration Scale
Goldman et al, Pediatrics 2008; 122; 545-549
Score 0
Score 1
Score 2
General appearance
Normal
Thirsty, restless, or
lethargy but irritable
when touched
Drowsy, limp, cold or
sweaty; comatose or
not
Eyes
Normal
Slightly sunken
Very sunken
Mucous Membranes
(tongue)
Moist
Sticky
Dry
Tears
Normal
Decreased
Absent
Score of 0: No dehydration
Score 1-4: Some dehydration
Score 5-8: Moderate/severe dehydration
Clinical Dehydration Scale
Goldman et al, Pediatrics 2008; 122; 545-549
 Prospective, observational
study to validate the CDS of
children 1 month-5 years of
age with suspected AGE
Patient CDS scores
120
No
Dehydration
100
80
Some
Dehydration
60
40
Moderate to
Severe
Dehydration
20
0
Length of Stay
600
No
Dehydration
500
400
Some
Dehydration
300
200
100
0
LOS (min)
Moderate to
Severe
Dehydration
90
80
70
60
50
40
30
20
10
0
No Dehydration
Some
Dehydration
Moderate to
Severe
Dehydration
% Requiring IVF
Clinical Dehydration Scale
Goldman et al, Pediatrics 2008; 122; 545-549
 May be an adjunct to determine
dehydration severity category for
patients presenting with AGE
 May be added to a treatment algorithm
to predict longer LOS and need for IV
hydration
Managing Acute Gastroenteritis Among Children
MMWR Recommendations and Reports, November 21, 2003.
 ORT should be
started at home
at first sign of
diarrhea
 When should
they seek
evaluation?
 When do they
need hospital
admission?
What About Medications?
 Pharmacologic Therapy
 Antimicrobial therapy usually not indicated
 Antidiarrheal and antimotility agents have
significant side effects associated with use
 Antiemetics are “usually unnecessary in
acute diarrhea management”
 “Ondansetron….can be effective in decreasing
vomiting and limiting hospital admission”
Managing Acute Gastroenteritis Among Children
MMWR Recommendations and Reports, November 21, 2003.
Where Do We Stand?
We Should Be
Drinking…..
….Why Aren’t
We?
Does ORT take too long?
 RCT with 73 patients enrolled.
 ORT demonstrating noninferiority to IVF for successful
rehydration at 4 hours
Spandorfer et al. Pediatrics , 2005;
115;295-301
ORT
IVF
How About Vomiting?
Does ORT Still Work?
 “Weak and unreliable evidence
regarding the clinical effectiveness and
safety of antiemetics prescribed for
children with vomiting due to AGE”
 Ondansetron may reduce the amount of
children requiring IV hydration and
admission rates
Cochrane review 2006
Oral Ondansetron for Gastroenteritis in a
Pediatric Emergency Department
Freedman et al, NEJM 2006;354:1698-1705
 Randomized control trial of children 6 months
- 10 years treated for AGE and dehydration
 215 children enrolled
 Ondansetron (ODT) vs. placebo
 ORT trial 15 minutes after medication
administration
Oral Ondansetron for Gastroenteritis in a
Pediatric Emergency Department
Freedman et al, NEJM 2006;354:1698-1705
35
1.4
30
1.2
1
25
0.8
20
ODT
ODT
Placebo
0.6
Placebo
15
0.4
10
0.2
5
0
0
Vomiting (%)
IVF (%)
Vomiting
(episodes)
Diarrhea
(episodes)
Treatment with a single dose of ODT ondansetron
was found to be beneficial in children with vomiting
and mild to moderate dehydration due to AGE.
Emergency Department Treatment of Viral
Gastritis Using Intravenous Ondansetron or
Dexamethasone in Children
Stork et al. Acad Emerg Med 2006
 RCT, 166 patients enrolled
 Children 6 months - 12 years with
 >3 episodes of vomiting
 mild to moderate dehydration
 failed ORT
Emergency Department Treatment of Viral
Gastritis Using Intravenous Ondansetron or
Dexamethasone in Children
Stork et al. Acad Emerg Med 2006
90
80
70
60
50
40
30
20
10
0
Ondansetron
Dexamethaso
ne
Placebo
Admitted Oral Intake
(%)
at 2 hours
(%)
Ondansetron in
conjuction with IV fluid
rehydration decreases
the hospitalization rate
and improves ability to
tolerate oral fluids when
compared to IV
rehydration alone
Roslund et al. Annals of Emerg Med 2008;
52; 22-29.
 RCT, 106 patients enrolled
 Children aged 1-10 who failed ORT in
the ED
 Single dose of ODT or placebo with ORT
reattempted in 30 minutes
Roslund et al. Annals of Emerg Med 2008;
52; 22-29
60
50
40
ODT
Placebo
30
20
10
0
Failed ORT (%)
Admitted (%)
Patients receiving ondansetron ODT were more likely to
tolerate oral hydration and less likely to require IV
hydration and hospital admission.
Use of Antiemetic Agents in Acute
Gastroenteritis:
A Systematic Review and Meta-analysis
DeCamp et al. Arch Pediatr Adolesc Med 2008
 11 studies included for quality
assessment and data extraction
 7 Antiemetic agents were evaluated







Ondansetron (n=6)
Domperidone (n=2)
Trimethobenzamide (n=2)
Pyrilamine-pentobarbital (n=2)
Metoclopromide (n=2)
Dexamethasone (n=1)
Promethazine (n=1)
Use of Antiemetic Agents in Acute
Gastroenteritis:
A Systematic Review and Meta-analysis
DeCamp et al. Arch Pediatr Adolesc Med 2008
 Ondansetron
 6 studies included 745 children
 Most recently published and achieved the
highest quality ratings
Use of Antiemetic Agents in Acute
Gastroenteritis:
A Systematic Review and Meta-analysis
DeCamp et al. Arch Pediatr Adolesc Med 2008
40
35
30
25
20
Ondansetron
Placebo
15
10
5
0
Admission
(%)
IVF use (%) Vomiting (%)
Children who received ondansetron were less likely to have
ongoing vomiting, to require IVF or to be admitted to the
hospital from the ED.
Use of Antiemetic Agents in Acute
Gastroenteritis:
A Systematic Review and Meta-analysis
DeCamp et al. Arch Pediatr Adolesc Med 2008
 Ondansetron is the only antiemetic
agent with consistent, proven efficacy in
reducing vomiting from gastroenteritis.
 “We can recommend its use in the ED
for dehydrated children at risk for ORT
failure”
Use of Antiemetic Agents in Acute
Gastroenteritis:
A Systematic Review and Meta-analysis
DeCamp et al. Arch Pediatr Adolesc Med 2008
 “Government agencies and professional
societies should strongly consider
amending current gastroenteritis
treatment guidelines to incorporate the
use of ondansetron for certain children
with gastroenteritis”
Where Do We Go From Here?
 Develop a protocol for treatment of AGE
 Parental and staff education about ORT
 Data for antiemetics is not conclusive but
favors ondansetron over other antiemetics
 Consider ondansetron use to facilitate ORT in
mild-moderate dehydration
 Reserve IVF for severe dehydration and ORT
failure
References
 Alhashimi D, Alhashim H, Fedorowicz Z. Antiemetics for reducing
vomiting related to acute gastroenteritis in children and
adolescents. Cochrane Database Syst Rev 2006; July
19;3:CD005506.
 Centers for Disease Control and Prevention. Managing Acute
Gastroenteritis Among Children. Oral Rehydration, Maitenance,
and Nutritional Therapy. MMWR 2003; 52:No.RR-16;1-13.
 DeCamp L, Byerley J, Doshi N, Steiner M. Use of Antiemetic
Agents in Acute Gastroenteritis. A Systemic Review and Metaanalysis. Arch Pediatr Adolesc Med 2008; 162(9):858-865.
 Freedman SB, Adler M, Seshadri R, Powell ED. Oral Ondansetron
for Gastroenteritis in a Pediatric Emergency Department. N Engl
J Med 2006; 354:1698-1705.
References
 Goldman R, Friedman JN, Parkin C. Validation of the Clinical
Dehydration Scale for Children with Acute Gastroenteritis.
Pediatrics 2008;122;545-549.
 Ozuah P, Avner J, Stein R. Oral Rehydration, Emergency
Physicians and Practice Parameters: A National Survey.
Pediatrics 2002;109;259-261.
 Roslund G, Hepps TS, McQuillen KK. The Role of Oral
Ondansetron in Children With Vomiting as a Result of Acute
Gastritis/Gastroenteritis Who Have Failed Oral Rehydration
Therapy: A Randomized Controlled Trial. Annals of Emerg Med
2008: 52(1); 22-29.
References
 Spandorfer PR, Alessandrini E, Joffe M, Localio R, Shaw K. Oral
Versus Intravenous Rehydration of Moderately Dehydrated
Children: A Randomized, Controlled Trial. Pediatrics 2005;
115;295-301.
 Stork CM, Brown KM, Reilly TH, Secreti L, Brown LH. Emergency
Department Treatment of Viral Gastritis Using Intravenous
Ondansetron or Dexamethasone in Children. Acad Emerg Med
2006;13(10):1027-1033.