Should Ondansetron Be Used for Acute Gastroenteritis?

Patient Presentation
A 6-year-old female came to the clinic with emesis and diarrhea. She had been well but had onset of emesis 10 hours prior to coming to clinic and 2 episodes of loose water stools without blood. The emesis was of fluid and food without blood or a bilious color. The parent had tried some oral rehydration solution (ORS) but the patient had emesis of the fluid so the mother stopped giving it to her. She also started to have diarrhea about 4 hours previously with 2 loose, watery stools without blood. Her last urination was 6 hours ago. She had no obvious ill contacts. The past medical history showed a healthy patient and the review of systems was negative for fever, chills, or cough. The pertinent physical exam showed a tired appearing female with normal vital signs except for a weight that was down 680 grams from a weight 1 month ago. She had mildly dry lips but moist mucous membranes. Her capillary refill was approximately 2 seconds. Her examination was otherwise normal. The diagnosis of acute gastroenteritis with mild dehydration was made. The parent was instructed on how to give ORS and also given 1 dose of oral ondansetron. The patient had emesis once not long after starting the rehydration but then starting feeling somewhat better. By 2-3 hours later she had taken an additional 12 ounces without emesis and had urinated. The patient was sent home with instruction about how to continue to give the ORS, how to restart a regular diet and when to call the clinic.

Discussion
Acute gastroenteritis (AGE) is a common illness worldwide and is “…defined as a decrease in the consistency of stools (loose or liquid) and/or an increase in the frequency of evacuations with or without fever or vomiting….” It is one of the most common reasons for seeking medical care and hospitalizations. In Europe, rotavirus and noroviruses are two of the most frequent viral agents causing AGE and Campylobacter and Salmonella are the most common bacterial AGE causes. For parasitic infections Giardia, and Crytosporidium are most common parasitic infections in Europe.

Recommendations for AGE treatment include oral rehydration, nasogastric rehydration and or intravenous rehydration. The European Society of Pediatric Gastroentrology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases recommends oral and nasogastric rehydration before trying intranveous rehydration. They note that “…oral rehydration is more effective and less invasive than IV rehydration and the administration of [oral rehydration solutions] should be attempted and promoted.” Additionally if IV therapy is used, patients “… should be made to switch or oral rehydration as soon as indication for parental rehydration are no longer observed.” Those indications for IV rehydration include shock, dehydration that is accompanied by a change of consciousness or severe acidosis, worsening dehydration or lack of improvement despite oral or NG rehydration, persistent emesis despite oral or NG therapy or severe abdominal distention and ileus.

According to the European guidelines, in addition to rehydration, some absorbents (i.e. Diosmectite) and antisecretory medication (i.e. Racecadotril) can be considered for AGE, but some agents are not available in all countries. Probiotics (eg. L. rhamnosus GG and S. boulardii) should be considered for use with AGE as an adjunct to rehydration therapy according to these guidelines. Drug therapy that is not recommended includes the antimotiity agent loperamide, the antisecretory agent bismuth subsalicylate, symbiotics, prebiotics, folic acid and gelatine tannate. The guidelines also note that antiinfective therapy is generally not used in the “…vast majority of healthy children with acute gastroenteritis…” and “… is not needed routinely but only for specific pathogens or in defined clinical settings.”

AGE can cause visceral stimulation of the gut causing dopamine and serotonin to be released which in turn causes the medullary vomiting center to be stimulated which thereby causes nausea and emesis. Ondansetron (Zofran®) is a setotonin antagonist (5-HT3 receptor) used to treat this effect. The site of action is not entirely known and may be in the viscera, the medulla or both. A recent retrospective multicenter cohort study from 2002-2011 of the use of ondansetron in pediatric emergency room settings found that ondansetron use increased substantially from 0.11% in 2002 to 42.2% in 2011. Unfortunately there was only a small decrease in the percentage of patients who received IV hydration (18.7% to 17.8%) and hospital admissions increased over the same study period (6.0% to 6.7%). The authors have several ideas as to why this may occur and state “Our findings highlight the need to focus efforts to administer ondansetron to children at greatest risk for oral rehydration failure.”

Learning Point
According to the European guidelines, ondansetron “…may be effective in young children with vomiting related to AGE. Before a final recommendation is made, a clearance on safety in child is however, needed.” This could be given orally or by IV. The Canadian Pediatric Society recommends a single dose be considered for children 6 months – 12 years with emesis caused by AGE plus having mild to moderate dehydration or having failed oral rehydration therapy. A known side effect of ondansetron is diarrhea, therefore it is not recommended for AGE that is primarily due to diarrhea. Patients with electrolyte abnormalities such as hypomagnesemia and hypokalemia may have increased risk of prolongation of the QT interval when receiving ondansetron.

Questions for Further Discussion
1. How has the rotavirus vaccine changed the epidemiology of gastroenteritis in industrialized nations?
2. What causes chronic diarrhea in the pediatric age group?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Gastroenteritis

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

A Cheng. Emergency department use of oral ondansetron for acute gastroenteritis-related vomiting in infants and children. Canadian Paediatric Society, Acute Care Committee.
Paediatr Child Health 2011;16(3):177-9.

Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD005506

Freedman SB, Hall M, Shah SS, Kharbanda AB, Aronson PL, Florin TA, Mistry RD, Macias CG, Neuman MI.
Impact of increasing ondansetron use on clinical outcomes in children with gastroenteritis. JAMA Pediatr. 2014 Apr;168(4):321-9.

Keren R. Ondansetron for acute gastroenteritis: a failure of knowledge translation. JAMA Pediatr. 2014 Apr;168(4):308-9.

Guarino A, Ashkenazi S, Gendrel D, Lo Vecchio A, Shamir R, Szajewska H. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014.
J Pediatr Gastroenterol Nutr. 2014 Jul;59(1):132-52.

RxList.com. Ondansetron Clinical Pharmacology.
Available from the Internet at http://www.rxlist.com/zofran-drug/clinical-pharmacology.htm (rev. 11/7/2014, cited 7/13/2015).

Flake ZA, Linn BS, Hornecker JR. Practical selection of antiemetics in the ambulatory setting. Am Fam Physician. 2015 Mar 1;91(5):293-6.

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

With An Isolated Ear Tag, Does the Baby Need to Have a Renal Ultrasound?

Patient Presentation
A 2-week-old male came to clinic for his well child check. He was breastfeeding well and gaining 21 grams/day since his 1 week examination. He was urinating and stooling well and had no jaundice concerns. His parents had normal newborn concerns. The past medical history showed a full term male born by vaginal delivery without complications. He had passed a newborn screening hearing evaluation during his hospitalization. The family history was positive for Parkinson’s disease in a paternal great-grandmother. The review of systems was negative.

The pertinent physical exam showed an alert male with weight of 3.68 kg (50%), length of 49 cm (25%) and head circumference of 35.5 cm (65%). HEENT showed a left 2 mm preauricular skin tag without a pit, and a normal shape to both ears. The rest of his examination was negative.

The diagnosis of a healthy newborn with an isolated preauricular skin tag was made. The resident seeing the patient was concerned about the skin tag and wanted to order a renal ultrasound because of potential renal abnormalities. The attending physician discussed with her that the infant had no other risk factors and therefore the risk of renal disease was basically the same as the general population. Later the attending physician was able to search the literature and find several papers that supported non-evaluation of simple isolated preauricular abnormalities.

Discussion
In 1946, Dr. Edith Potter described renal agenesis along with flattened ears (i.e. Potter’s Syndrome). Isolated preauricular tags (IPT) have an incidence of ~5-10/1000 live births. These are the most common minor external ear abnormalities and are often noted incidentally on physical examination. Renal malformations have an incidence of ~1-3/100 live births. They can be seen together in a variety of genetic diseases including:

  • BOR syndrome – brachio-oto-renal abnormalities
  • CHARGE association
  • Diabetic embryopathy
  • Epstein Syndrome
  • Miller syndrome
  • Muckle-Wells syndrome
  • Nager syndrome
  • Oculoauriculovertebral syndrome
  • Townes-Brocks syndrome

Ear and renal tissue arise embryologically at similar but different times and therefore some of these associations are best described by gene expression and not specific insults during the embrologic time period.

Learning Point
Patients with multiple congenital anomalies or syndromic external ear anomalies should be investigated for potential renal abnormalities. This is particularly true in the setting of a family history of potential genetic syndrome or known renal or hearing disease. While there have been some studies that show an increased association with ear and renal abnormalities, there have been many studies which show that patients with isolated IPTs and preauricular pits having the same risk of significant renal abnormalities as the general population and therefore IPT and pit existence alone does not warrant additional evaluation of the renal system.

Questions for Further Discussion
1. What are indications for renal ultrasonography?
2. What are indications for hearing rescreening in neonates?
3. What are indications for removal of preauricular skin tags?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Ear Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Kugelman A, Tubi A, Bader D, Chemo M, Dabbah H. Pre-auricular tags and pits in the newborn: the role of renal ultrasonography. J Pediatr. 2002 Sep;141(3):388-91.

Izzedine H, Tankere F, Launay-Vacher V, Deray G. Ear and kidney syndromes: molecular versus clinical approach. Kidney Int. 2004 Feb;65(2):369-85.

Deshpande SA, Watson H. Renal ultrasonography not required in babies with isolated minor ear anomalies. Arch Dis Child Fetal Neonatal Ed. 2006 Jan;91(1):F29-30.

Lizama M, Cavagnaro F, Arau R, Navarrete O, Fontanaz AM, Garcia CJ. Association of isolated preauricular tags and nephrourological anomalies: case-control study. Pediatr Nephrol. 2007 May;22(5):658-60.

Firat Y, Sireci S, Yakinci C, Akarçay M, Karakas HM, Firat AK, Kizilay A, Selimoglu E. Isolated preauricular pits and tags: is it necessary to investigate renal abnormalities and hearing impairment? Eur Arch Otorhinolaryngol. 2008 Sep;265(9):1057-60.

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Does a Child Need to Do To Be Ready to Go To Kindergarten?

Patient Presentation
A 5-year-old male came to clinic for his health supervision visit. He had attended a preschool for the past year three times per week and had done well. His mother reported that the teachers had no concerns about him entering kindergarten. She however was worried about him taking the bus and also needing help in the lunchroom. The past medical history showed a broken arm from falling off a bike. His immunizations were current.

The pertinent physical exam showed a well-appearing male with normal vital signs and growth parameters in the 75-90%. His physical examination was normal. The diagnosis of a healthy male was made. The pediatrician filled out the school health form and recommended that he see a dentist as he hadn’t seen one in more than 1 year. He also recommended for the parent to contact the school to see if there was a new parent orientation to learn more about the school, ask questions and meet other parents. “Even if they don’t have one, you can get your questions answered by the school personnel,” he said and then went on, “I know he knows many colors, letters and numbers, but I recommend he knows his street address and your name so if there is a problem an adult can help him.” “You can also practice the bus route with him and show him ahead of time where he will be going. Find another child who will be taking the bus and see if that child can be his “bus-buddy.” In that way he has someone else he knows will help him.” He reassured the mother by saying, “The teachers know that the kids can’t open all their containers, so they just help the kids. They also get a lot of the older kids to help the younger ones. The older ones remember having that problem too and are usually really happy to help the little ones.”

Discussion
Many parents look forward to but worry about their child starting school. These are normal concerns as the child may not have had a school experience before or has school experience but not for as long a time as a regular school day. The child often will be traveling a different route to school such as taking a bus. Kindergarteners also need to be more responsible for their own self, their belongings and often will be handling other adult items such as notes from school and money.

The most important part of kindergarten though is to instill a love of learning. It isn’t how much the children already knows or will learn, it is about them learning that school can be an enjoyable place to learn about the world.

  • What parents can/should do to help their child be successful in school
    • Relax and enjoy your child’s kindergarten time – its the small things that you will remember
    • Have your child registered and fill out all the other paperwork and forms
    • Have your child vaccinated and receive the health care and dental care they need
    • If you can, attend parent orientation or back to school nights that the school offers to learn more about the school
    • If you can, have your child attend their own orientation
  • Know school is tiring
    • Children can be very tired after school. They have been very busy learning and it takes all their energy.
    • Give them a snack (sometimes you have to pack one in the backpack or bring it for the car ride).
    • Allow them some quiet time. Remember they have been around other noisy kids all day and may need some quiet time. That may also mean that you don’t ask lots of questions right away when they get home from school.
    • Phase out naps over the summer so your child is ready to not have a nap at school. There will be rest time but usually this is not for actual sleep.
  • Parents do not have to be involved in everything but they should be involved
    • Ask your child about what they are doing in school. Sometimes they won’t say much, so ask more specific questions such as “What did you do in math today?” or “Last week you were playing soccer in gym class, are you doing the same thing?” We often ask children what they like about something, so try the opposite like “So what was bad today?” It surprises the child and then they will tell you more about what is happening in their life.
    • Clean out the homework folder every night with your child and send information back to school if needed.
    • If you can afford it, send in extra school supplies or donate items for special days
    • Write a note to the teacher with or without your child to thank them at holidays or end of year. Email or saying a special thank you with a big smile goes a long way for teachers to know that you are involved and see that they are trying to do their best for your child.
    • If you can attend or volunteer for a special event, do so. If you cannot, then don’t beat yourself up over it. Not everyone can do everything or afford everything.
  • Model learning to your child
    • Read to your child. Have an older child read to the younger one.
    • If you don’t read well, then do what you can do. Consider talking with the teachers about help for yourself.
    • You will never know all the answers. Tell your child it is okay to not know or to be wrong. Show them how to find answers and be gracious when they are wrong.
  • Communicate with the teachers and school
    • Read the notes teachers send home. Sign and send the notes back if appropriate.
    • Communicate with the school about issues in your family if it might concern the school. Family stress such as losing a job, changing homes, deaths in the family, financial worries, etc. affect the child and if the teacher is aware can be of help to the child.
      Some schools also have resource centers, social workers or guidance counselors who may be able to help you.

    • Communicate with the teacher if you have any questions or concerns. Understand that they have many more students than you do so respect their time. But they do want to hear from parents if you have concerns. Write a note, email or telephone.
    • Trust the teacher but trust yourself when things don’t seem right.
      • Teachers have worked with lots of kids and lots of parents. They probably have a good sense of how your child is doing in the very broad “normal” area. If the teacher has a concern remember that they are bringing this to your attention because they care about your child. Similarly if the teacher is not concerned about your child, but you truly think differently, talk it out with them and see their point of view. You know your child best so be their advocate but don’t be an adversary to the teacher.
      • If you cannot get the information you need from the teacher or you have a larger concern the teacher cannot address, then contact the principal. If you feel you cannot talk with the principal, then the school guidance counselor can often help or contact the central administration of the school district.
  • Find other parents
    • Find a “parent-buddy” who can also give you information about the school that your child may not bring home or be aware of. They often know the unwritten rules or ways that the school works.

    Learning Point

    Children should know (and it is a lot):

    • Self-care
      • Their own first and last name
      • Street address
      • Phone number
      • Parents/guardians first names
      • Where parents work
    • Safety
      • How to dial 911
      • Who will they go home with
      • How they will get home and by what route
      • What will they do if they get off bus, get home etc. and parent is not there
      • What will happen if school gets out early or starts late
      • What they should do in an emergency
    • Academics
      • Colors – some
      • Letters – some
      • Numbers – some
      • How to wait at least 1 minute
      • How to raise hand to be acknowledged
    • Lunch room
      • How to open food containers – but there will be lots of other personnel and students to help
      • How to pay for school meals with money or if receiving free or discounted meals
      • How to carry a tray
    • Bathroom
      • Bathroom etiquette – close door, use toilet paper, flush toilet, wash hands
    • General
      • Label everything – especially clothing and anything else they take to school
      • Keep it simple – all papers go in the homework folder – clean out the folder every night
      • What should they do if they lose something

    Questions for Further Discussion
    1. What should children know before starting middle school?
    2. What should young adults know before starting college? See case here.

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: School Health.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Peters T. 8 things I wish I’d known before my child started kindergarten. Today Parents.
    Available from the Internet at http://www.today.com/parents/8-things-i-wish-id-known-my-child-started-kindergarten-1D80005092 (rev. 8/8/14, cited 6/2/15).

    10 Things to Think About Before Your Child Starts Kindergarten. Harvard Homemaker.com.
    Available from the Internet at http://harvardhomemaker.com/10-things-to-think-about-before-your-child-starts-kindergarten/ (rev. 7/25/13, cited 6/2/15).

    Countdown to Kindergarten. Scholastic.com (Collection).
    Available from the Internet at http://www.scholastic.com/parents/resources/collection/what-to-expect-grade/count-down-to-kindergarten (cited 6/2/15).

    Starting School. American Academy of Child and Adolescent Psychiatry.
    Available from the Internet at http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/Facts_for_Families_Pages/Starting_School_82.aspx (rev. 3/11 cited 6/2/15).

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital