April 13, 2015 – This week’s blog post is also available from TREKK (Translating Emergency Knowledge for Kids).
Fever. Vomiting. Diarrhea.
These are the symptoms that characterize one of the most common pediatric illnesses – Acute Gastroenteritis (AGE). In Canada, AGE accounts for 10% of emergency department visits annually and results in the hospitalization of 1 in 25 children under the age of five, keeping primary care physicians busy as ever (1,2). Although AGE is not a serious condition in the developed world, it exerts significant economic burden. Estimates suggest Canadian AGE specific costs are $3.7 billion annually (2).
Despite the prevalence of AGE, its cost, and the ubiquity of its symptomatic presentation, there is no unified approach to its management in emergency departments (ED) institutionally, nationally, or internationally. Standardized, clinical decision tools targeting improvement of gastroenteritis care are not routinely used in Canadian EDs, which can result in variation in clinical decisions for key treatment approaches (3). In effort to bring easily accessible, up-to-date evidence for AGE treatment approaches to one place, a Cochrane overview of systematic reviews provides a cohesive summary of treatment options and their effectiveness to help clinicians in their evidence-based decision making. This overview included four systematic reviews containing 95 randomized controlled trials involving over 12,000 participants. Here is the key evidence you need to know when treating a child with AGE.
Oral Rehydration Therapy (ORT) versus Intravenous (IV) Rehydration Therapy
- ORT is less invasive than IV rehydration and therefore is considered as first line treatment for children with AGE and associated mild-to-moderate dehydration.
- There are no important clinical differences (e.g. length of hospital stay, adverse effects) between children who receive oral rehydration therapy (ORT) and those administered IV rehydration therapy.
- Oral ondansetron is the first line anti-emetic agent for children with dehydration and significant vomiting because it lowers hospital admission and IV rehydration rates.
- IV ondansetron is associated with lower hospital ED admission rates, but should only be used for children who require IV rehydration.
- Probiotics can reduce hospital duration by over 24 hours.
- There are no known interactions between probiotics and other medications.
- Existing evidence favors the use of probiotics as a safe adjunct treatment for AGE, but it is unclear which probiotic should be used, at what dose, and for what duration.
- Current evidence suggests the use of formulations containing Lactobacillus sp or boulardii, but optimal dosage and duration of therapy is unknown.
Dr. Moshe Ipp, a pediatrician and academic clinician from Toronto, shares his conclusions about this overview in this Cochrane Community podcast:
“In summary, oral rehydration therapy is considered to be the first line choice for rehydration in patients with acute gastroenteritis and mild to moderate dehydration. When there is significant vomiting, ondansetron is the recommended anti-emetic of choice. And probiotics have been shown to be safe and effective for hospitalized children.”
However, Dr. Ipp highlights that ondansetron may not be suitable for all children with AGE: “An interesting finding, and a note of caution, is that in 3 randomized controlled trials there was a higher frequency of diarrhea in the ondansetron group compared to placebo, and because of this finding it is suggested that ondansetron might not be the agent of choice when vomiting is associated with a significant amount of diarrhea.”
TRanslating Emergency Knowledge for Kids (TREKK):
- Bottom Line Recommendations: Gastroenteritis
- TREKK Talks: Gastroenteritis, Dr. Stephen Freedman
- Evidence Repository: Gastroenteritis
- Gastroenteritis Podcasts
- Gastroenteritis Cochrane Pediatric Emergency Medicine Reviews
Cochrane Community Podcast:
- Check out Dr. Ipp’s comments on the overview in this podcast
- Majowicz, S. E., McNab, W. B., Sockett, P., Henson, S., Dore, K., Edge, V. L., … & Wilson, J. B. (2006). Burden and cost of gastroenteritis in a Canadian community. Journal of Food Protection®, 69(3), 651-659.
- Alberta Provincial Pediatric Enteric Infection Team. APPETITE seminar series (PDF document). Retrieved from: Got Gastro Online Website: http://gotgastro.ca/wp-content/uploads/2015/01/APPETITE_Presentation_to_Trainees_Freedman1.pdf
- Kinlin, L. M., Bahm, A., Guttmann, A., & Freedman, S. B. (2013). A survey of emergency department resources and strategies employed in the treatment of pediatric gastroenteritis. Academic Emergency Medicine, 20(4), 361-366.
- Freedman, S. B., Ali, S., Oleszczuk, M., Gouin, S., & Hartling, L. (2013). Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries. Evidence‐Based Child Health: A Cochrane Review Journal, 8(4), 1123-1137.