MedeliX
Start asking

Italian multidisciplinary delphi consensus on home management of nausea and vomiting in children with acute gastroenteritis (NoEmesi Project)

Italian multidisciplinary Delphi panel (NoEmesi Project) · 2026 · Italy

Source and licence

Authors
Ruggiero Francavilla, Fernanda Cristofori, Gian Luigi Marseglia et al.
Title
Italian multidisciplinary delphi consensus on home management of nausea and vomiting in children with acute gastroenteritis (NoEmesi Project)
Journal
Frontiers in Pediatrics, 2026
DOI
10.3389/fped.2026.1773341
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC13121123

Licence statement of the original publication

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Finalization of the consensus document

  • 1. Acute gastroenteritis is a fairly common illness that mainly affects children. Acute gastroenteritis is a condition involving inflammation of the lining of the stomach and intestines. The main symptoms of acute gastroenteritis are vomiting, nausea, diarrhea, dehydration and abdominal pain, with possible fever and headache% agreement (scores 4 + 5): 100%
  • 2. Vomiting is an extremely common symptom in children and is usually preceded and accompanied by a feeling of nausea. Vomiting causes distress in children and apprehension in parents. If uncontrolled, vomiting can lead to dehydration and electrolyte imbalance, making rehydration an important measure, but vomiting itself can counteract this. Vomiting can have many causes, but the most common in children is acute gastroenteritis% agreement (scores 4 + 5): 98%
  • 3. Acute gastroenteritis is one of the most common causes of hospitalization in children. Therefore, careful management of nausea and vomiting at home and prevention of dehydration are measures that can have a significant socio-economic impact% agreement (scores 4 + 5): 98%
  • 4. Acute gastroenteritis is usually a self-limiting condition that can be treated with oral rehydration at home. However, persistent and severe vomiting is unpleasant and stressful, and increases the likelihood of dehydration and electrolyte imbalances. In some cases, intravenous rehydration in hospital is necessary% agreement (scores 4 + 5): 98%
  • 5. In children with uncontrollable vomiting who cannot be rehydrated orally at home, drug therapy may be used to promote oral rehydration and prevent admission to the emergency department. There are several drugs with antiemetic properties; the most commonly used are metoclopramide, domperidone and ondansetron. However, it is essential to understand their mechanism of action and safety profile% agreement (scores 4 + 5): 86%
  • 6. Nausea and vomiting are coordinated by a complex neuroanatomical network involving peripheral vagal afferents, the area postrema, the nucleus tractus solitarius, and central pattern generators within the brainstem. Gastrointestinal inflammation activates vagal afferent fibers projecting to the nucleus tractus solitarius, while circulating emetogenic stimuli are detected by the area postrema, a circumventricular structure lacking a complete blood–brain barrier. These interconnected structures integrate dopaminergic, serotonergic, histaminergic, and cholinergic receptor-mediated signaling pathways, ultimately generating the motor and autonomic components of the emetic reflex. Pharmacological antagonism of dopamine and serotonin receptors modulates these pathways and may reduce vomiting in acute gastroenteritis% agreement (scores 4 + 5): 96%
  • 7. Metoclopramide is a drug used primarily as an antiemetic and gastroprokinetic agent, which acts by essentially blocking dopamine receptors, but also partially blocking serotonin receptors in the gut and brain% agreement (scores 4 + 5): 100%
  • 8. Metoclopramide blocks dopamine D2 receptors in the area postrema of the brain (chemoreceptor trigger zone), effectively reducing nausea and vomiting. In the gastrointestinal tract, the same D2 antagonism removes the inhibitory effects of dopamine on motility, increasing gastric contractility and facilitating emptying. Metoclopramide also has agonist activity on 5-HT4 receptors, further stimulating intestinal motility, and antagonist activity on 5-HT3 receptors, contributing to the antiemetic effect.% agreement (scores 4 + 5): 100%
  • 9 The most common side effects include drowsiness, restlessness and diarrhea. Less frequent symptoms are extrapyramidal symptoms, which are usually reversible upon discontinuation% agreement (scores 4 + 5): 92%
  • 10. The liquid formulation in drops (no longer commercially available) was previously the most frequent cause of overdose and, consequently, of adverse events. The use of the suspension formulation (syrup), which can be administered using dedicated measuring devices, reduces the risk of overdose and therefore the risk of adverse events% agreement (scores 4 + 5): 90%
  • 12. Caregivers of children receiving antiemetic therapy should be explicitly instructed to recognize early signs of adverse neurological reactions, including abnormal movements, muscle rigidity, oculogyric crisis, or acute dystonia. In the event of such symptoms, the medication must be immediately discontinued and urgent medical evaluation sought. Caregivers should not attempt home treatment of suspected extrapyramidal reactions% agreement (scores 4 + 5): 96%
  • 13. The standard pediatric dosage (ages 1–18 years) of metoclopramide is 0.1–0.15 mg/kg up to three times a day, for a maximum of 5 days. However, the maximum dose in 24 h should not exceed 0.5 mg/kg of body weight. Regulatory agencies recommend careful use in children under 5 years of age% agreement (scores 4 + 5): 100%
  • 14. Metoclopramide is available in three formulations: syrup, tablets and vials for parenteral use (in 2014, drops were withdrawn from the market). It allows for considerable adaptability of use% agreement (scores 4 + 5): 94%
  • 15. Domperidone is only indicated for individuals aged 12 years and older and weighing at least 35 kg. Among the adverse events described is the possible prolongation of the QT interval, which may predispose to ventricular cardiac arrhythmias% agreement (scores 4 + 5): 100%
  • 16. Ondansetron is indicated for chemotherapy-induced and post-operative nausea and vomiting in children. Although not formally approved for acute gastroenteritis (AGE), systematic reviews and meta-analyses, including a Cochrane review 22, demonstrate its effectiveness in reducing vomiting episodes and the need for intravenous rehydration in emergency department settings. However, robust evidence for its use in home management is lacking. Potential risks include QT prolongation, particularly relevant in children with electrolyte imbalances (hypokalemia, hypomagnesemia) due to fluid losses, and possible worsening of diarrhea. Rare cases of serotonin syndrome have been reported% agreement (scores 4 + 5): 83%
  • 17. Among the non-pharmacological remedies proposed for the home management of vomiting in children, ginger (standardized ginger extracts) represents a potential symptomatic approach. However, the available evidence of its efficacy is currently very limited% agreement (scores 4 + 5): 93%
  • 18. Early home treatment of vomiting with medication can prevent severe dehydration, facilitate oral rehydration, reduce the need for parenteral rehydration and thus prevent visits to the emergency room% agreement (scores 4 + 5): 86%
  • 19. Quick relief from nausea and vomiting reduces distress for the child and anxiety for parents% agreement (scores 4 + 5): 100%
  • 20. There is evidence in the literature that metoclopramide, even when administered orally, effectively controls vomiting% agreement (scores 4 + 5): 92%
  • 21. In children with acute gastroenteritis and uncontrollable vomiting that does not respond to standard measures, the use of metoclopramide may be considered under medical supervision, with careful assessment of the risk-benefit ratio and prior information to parents% agreement (scores 4 + 5): 88%

Clinical relevance and burden of vomiting in pediatric AGE

  • Statement 4also reached 98% agreement (mean score 4.8), confirming the panel's consensus that, although AGE is generally self-limiting and often manageable at home with ORT, persistent vomiting may necessitate escalation to intravenous rehydration.
  • Statement 19, highlighting the importance of rapid symptom control to reduce child distress and parental anxiety, achieved 100% agreement with the highest mean score (4.9). Collectively, these findings demonstrate a strong and homogeneous consensus regarding the clinical burden of vomiting and its central role in management decisions.

Metoclopramide: pharmacology, safety, and dosing

  • Statement 9reached 92% agreement (mean score 4.6), and Statement 10 achieved 90% agreement (mean score 4.4), confirming awareness of the drug's safety profile and the relevance of formulation changes, particularly the withdrawal of oral drops in favor of syrup formulations designed to reduce dosing errors. Statements 11 and 12 both reached 96% agreement (mean score 4.7), emphasizing the importance of age-related risk factors for adverse events and the critical role of caregiver education in early recognition of potential side effects.

Other antiemetic agents and non-pharmacological options

  • Statement 17, addressing ginger (standardized ginger extracts) as a possible non-pharmacological option for home management of vomiting despite limited supporting evidence, achieved 93% agreement with a mean score of 4.4.

Abstract

Introduction: Vomiting in pediatric acute gastroenteritis (AGE) is a major driver of distress, caregiver anxiety, and failure of oral rehydration, while guidance for home management and pediatric antiemetic use is limited and influenced by regulatory restrictions.

Methods: We conducted a modified Delphi consensus in three phases (statement development after literature review, anonymous online rating, and final refinement) involving a national multidisciplinary panel of 70 Italian pediatricians.

Results: Twenty-one statements addressing clinical aspects of vomiting in AGE and the pharmacology, safety, and use of commonly prescribed antiemetics (with emphasis on metoclopramide) were rated on a five-point Likert scale; consensus was predefined as ≥80% ratings of 4–5. All 21 statements met the consensus threshold (agreement 83%–100%; mean scores 4.2–4.9). The highest agreement concerned the clinical burden of vomiting in AGE, key mechanistic pathways, and practical safety considerations for metoclopramide (including dosing limits, age-related caution, and caregiver counseling). The panel agreed that, in selected children with persistent vomiting preventing oral rehydration, cautious antiemetic use, particularly metoclopramide, may support home management when safety precautions are followed, off-label requirements are respected, and parents are adequately counseled.

Discussion: This Delphi consensus provides pragmatic, expert-endorsed recommendations for home management of nausea and vomiting in pediatric AGE. Oral rehydration solutions (ORS) remain the cornerstone of care; metoclopramide may be considered in carefully selected cases to quickly resolve symptoms, facilitate rehydration and reduce dehydration risk, provided that clinicians adopt strict risk–benefit assessment and good clinical practice safeguards.

Contents of the original publication

The section headings of the original.

  • Introduction
  • Materials and methods
  • Study design
  • Steering committee and preparatory phase (round 1)
  • Panel selection and composition
  • Educational phase and delphi rounds (rounds 2 and 3)
  • Rating scale and consensus definition
  • Finalization of the consensus document
  • Ethical considerations
  • Results
  • Clinical relevance and burden of vomiting in pediatric AGE
  • Role of antiemetics in supporting home management
  • Pathophysiological rationale for antiemetic therapy
  • Metoclopramide: pharmacology, safety, and dosing
  • Other antiemetic agents and non-pharmacological options
  • Overall consensus patterns
  • Discussion
  • Generative AI statement

A question about this guideline?

Medelix answers clinical questions from guidelines and studies – every statement with its source.

Are you the rights holder and object to this reproduction? Write to contact@medelix.ai and we will take the page down promptly. Imprint