Persistent Vomiting After Pediatric ED Discharge

Key Takeaways

• Persistent vomiting after discharge was reported in 8.6% of children and was concentrated in younger patients.
• The pediatric ongoing vomiting score incorporated younger age, 24 to 48 hours of symptoms, and 10 or more recent vomiting episodes, with 4 or more points identifying a higher-risk subgroup.
• Children with persistent vomiting had higher 7-day unscheduled visits, intravenous fluid use, and hospitalization, and the authors suggested the highest-risk subgroup may be most likely to benefit from home ondansetron.

Persistent vomiting after emergency department discharge affected 80 of 927 children, or 8.6%, in the first 24 hours in a JAMA Network Open analysis. The cohort included children aged 6 months to less than 18 years with acute gastroenteritis-associated vomiting who presented to emergency departments, had at least 3 vomiting episodes in the prior 24 hours and symptoms for less than 72 hours, and received ondansetron during the index visit. Investigators conducted a nonprespecified secondary analysis of a multicenter randomized clinical trial with 7 days of follow-up after the index visit. The analysis examined which children were more likely to continue vomiting after discharge.

This secondary analysis used data from a multicenter randomized clinical trial that enrolled children between September 14, 2019, and June 27, 2024. Participants were randomized to ondansetron or matching placebo every 8 hours as needed after discharge. The analysis included 977 discharged children with follow-up data; median age was 47.0 months, and 50.5% were girls. Follow-up extended for 7 days after the index emergency department visit. The primary outcome was 3 or more vomiting episodes within 24 hours of discharge, with 925 children providing complete follow-up data and 52 requiring multiple imputation.

In unadjusted analysis, age 6 months to less than 2 years was the only variable associated with ongoing vomiting after discharge, with an odds ratio of 2.17. The pediatric ongoing vomiting score assigned 6 points for age 6 months to less than 2 years, 2 points for symptom duration of 24 to 48 hours, and 2 points for 10 or more vomiting episodes before the visit. A threshold of 4 or more points corresponded to a 13.6% probability of persistent vomiting, with sensitivity of 0.50 and specificity of 0.70. Mean AUC was 0.63, and the negative predictive value at that threshold was 93.7%, indicating modest separation of a higher-risk subgroup.

During the 7 days after discharge, children with persistent vomiting had more unscheduled health care visits, intravenous fluid treatment, and hospitalization than those without persistent vomiting. Unscheduled visits occurred in 41.3% of children with persistent vomiting and 7.7% without it. Intravenous fluids were given to 11.3% versus 1.8%, and hospitalization occurred in 6.2% versus 1.1%. Across the cohort, 109 of 974 children had an unscheduled revisit, 24 received intravenous fluids, and 14 were hospitalized, making ongoing vomiting a marker of greater short-term health care use.

The subgroup most likely to have persistent vomiting included children aged 6 months to less than 2 years or those with 24 to 48 hours of symptoms plus 10 or more vomiting episodes before presentation. The authors suggested these children were most likely to benefit from ondansetron for home administration. This interpretation came from a secondary prognostic analysis within a parent trial of home ondansetron rather than external validation of the score. The pattern remained centered on younger children and those with recent, heavier vomiting before the emergency department visit.