Deciding whether to re-dose when a child vomits after taking an oral medication

Vomiting after oral administration of a medication is common in children, especially in younger children where oral solutions are more often used. Healthcare providers are often uncertain about how much of the given dose was absorbed and whether or not the dose should be repeated. As no reliable guidelines are available to support decision-making, these situations are typically managed according to the healthcare provider's experience and judgement.1A commonly followed general rule has been to re-dose if vomiting occurs within 30 minutes of taking a dose, but not to re-administer if more than 60 minutes has passed. However, in addition to time since the dose was taken, other factors such as drug type, dosage form and patient status should be considered.1 To delve more deeply into this issue, a group of pediatricians, clinical pharmacologists and clinical pharmacists at Queen Silvia Children's Hospital in Gothenburg, Sweden set out to identify factors that should be considered when a child vomits after taking an oral medication and to establish a clinical routine for these situations. The group developed a decision support tool in four steps: (1) identification of clinically relevant substances, (2) literature search and review, (3) pediatric and clinical pharmacologic discussion, and (4) internal review.1Clinically relevant substances By consulting with clinicians from various departments in the hospital, 40 substances administered orally were identified for which a decision support tool would be helpful if a child vomited. Examples of medications on the list include ondansetron, acetaminophen, clonazepam, clonidine, clopidogrel, dexamethasone, digoxin, enalapril, furosemide, ibuprofen, metoprolol, morphine, mycophenolate mofetil, nifedipine, prednisolone, propranolol, rivaroxaban, tacrolimus, valproic acid and warfarin. The list includes a variety of dosage forms, such as oral solutions/drops, tablets, capsules, granules and extended-release tablets.1,2 Considerations in re-dosingThe group identified three key areas to consider when deciding whether or not to re-dose after a child vomits. All three are considered equally important when making clinical decisions.1Consider the patient and medical condition; assess the risk–benefit of re-dosing versus underdosing. For example, is the patient receiving the medication for the first time as a single dose, as needed, or as continuous treatment? For some medications, it is important to maintain an adequate treatment effect without interruptions. One might be less inclined re-dose a narrow therapeutic index drug or one with a risk of severe adverse reactions. On the other hand, a medication where one missed dose may lead to withdrawal or rebound would increase the motivation to re-dose. The nature of the medication and the reason for treatment must also be considered. For example, an additional dose of midazolam could be potentially harmful if the child receives a double dose for sedation, but beneficial if it is being used to prevent seizures.Consider the medication, dosage form and pharmacokinetics. Some products have a rapid release and absorption and a rapid onset of action. Extended-release preparations may require several hours after a given dose to reach the maximum concentration. Check to see if the medicine is visible in the vomit in its entirety. The recommended frequency of administration can be helpful; missing one dose of a medication given multiple times daily might not affect the patient as much as missing a dose administered once daily. Narrow therapeutic index drugs have small differences between therapeutic and toxic doses; an additional dose could be hazardous for the patient.Consider timing. Gastric emptying and intestinal motility primarily determine the rate at which drugs are presented to and dispersed along the mucosal surface of the small intestine. Absorption also depends on the drug's physical and chemical properties such as solubility and design of the formulation. If the patient vomits more than 60 minutes after the medicine is given and no residues are visible in the vomit, it is likely that the medicine has passed through the stomach, reducing the risk that vomiting has affected the absorption of the medication.Considerations before next oral dose: preventing nausea and vomitingIt is important to prevent vomiting with future oral doses, where possible. Children may vomit for several reasons: the taste of the medication, fear or discomfort, pain or nausea, or anxiety about the situation in which the medication is given. Check whether the child has experienced problems earlier. For bad tasting medications, it may help to change the dosage form, or even the medication. Ask older children for their preference for dosage form. An antiemetic to prevent vomiting could also be considered.1 Clinical decision support toolThe authors created a decision support tool that summarizes the preceding key factors that should be taken into consideration when deciding whether or not to re-dose when a child vomits after taking an oral medication (see Figure 1 in the online document).1 SummaryIn addition to the commonly used time aspect between oral administration and vomiting, other important parameters need to be considered—such as the patient's current condition, medical history and drug properties—when deciding whether or not to re-dose a child who vomits after taking an oral medication.1 References:Garnemark CA, Lernfelt G, Dahlander M, et al. If a child vomits after an oral medication—should we re-dose or not? Acta Paediatr 2025. Published online May 15, 2025 ahead of print. (accessed June 3, 2025).Supplemental material. Table 1 - If a child vomits after an oral medication. (accessed June 3, 2025).

Deciding whether to re-dose when a child vomits after taking an oral medication

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