Pediatrics
Lauren Howell, PharmD
Noticing a lack of guidelines on how to determine whether to redose if vomiting occurs after a medication is given to a pediatric patient, a group of researchers in Sweden set out to establish a routine for these situations. An algorithm they developed, published May 2025 in Acta Paediatrica, could be used to educate other providers on what factors to consider when deciding whether to administer a second dose of medication after vomiting occurs.
“This represents a thoughtful transition from informal, ad hoc decisions to an evidence-informed and clinically practical framework,” said Jena Quinn, PharmD, CEO and co-founder of Perfecting Peds, who was not involved in the development of the algorithm.
Quinn explained that many clinicians will redose a pediatric patient if vomiting occurs within 30 minutes of administration.
“The findings validated that approach but added much-needed depth,” she said.
The algorithm encourages providers to consider several different factors in their decision making. Previous recommendations mainly used the factor of time between when the medication was administered and when vomiting occurred to determine whether another dose was necessary.
Factors to consider
The algorithm encourages providers to assess the risk and benefit of redosing versus underdosing a pediatric patient based on their medical condition.
According to the authors of the algorithm, more acute indications provide a greater inclination to redose compared to medications that are administered routinely. Additionally, drugs with a narrow therapeutic index or a medication that carries a high risk of adverse reactions may reduce the provider’s willingness to redose, while medications where one missed dose may lead to withdrawal or other symptoms may increase the provider’s desire to redose.
Monitoring the patient for clinical symptoms and assessing laboratory findings can also help the provider to determine if the medication was absorbed.
Pharmacokinetics of the medication should also be considered during the decision-making process. With some dosage forms, such as extended-release preparations that have a protective coating, identifying whether the medicine is visible in the vomit may be helpful in determining if any was absorbed prior to vomiting. A provider may be more likely to redose a medication that is administered once daily than a medication that is given multiple times a day.
Providers need to consider timing as well. If the patient vomits more than 60 minutes after administration and no residues are visible in the vomit, the authors suggest that the medicine has more than likely passed through the stomach and that the risk of vomiting affecting absorption is low.
Preventing nausea before next dose
The algorithm also emphasizes the importance of preventing vomiting when possible.
The taste of medicine, fear, discomfort, pain, and anxiety about the situation in which the medication is given can all influence whether vomiting occurs. Ensuring the correct technique for administration of the medication being used and considering changes in dosage forms can be helpful to prevent vomiting.
If the administration of the medication has been optimized and nausea is still present, an antiemetic may be used to prevent vomiting for future doses.
Application to clinical practice
Quinn encourages pharmacy leaders to review this framework and advocate for broader adoption of the algorithm.
“In a field where so many decisions rely on best guesses, this work brings clarity and structure to one of the most frequent yet least standardized clinical questions we face,” she said.
She believes that this work has several implications for pharmacy practice, including:
- Standardizing redosing guidance across institutions, reducing variability and risk.
- Empowering pharmacists to confidently guide families and care teams in real time.
- Improving caregiver communication, helping to explain decisions clearly and reduce unnecessary worry or overmedication.
- Paving the way for digital integration with future opportunities to embed such tools in EHRs, apps, or decision support systems. ■
Algorithm 1-2-3
This decision support tool provides advice for making informed decisions about whether to redose a medication after vomiting in pediatrics. Prior to creating the support tool, the developers conducted a literature search on PubMed to identify articles on vomiting of orally administered medications using the terms [vomiting], [pediatric], [oral], and [medication]. Additional articles on oral drug absorption, gastric emptying, and pharmacokinetics were identified. These articles were all taken into consideration by a multidisciplinary team of pediatricians, clinical pharmacologists, and clinical pharmacists at the Queen Silvia Children’s Hospital in Gothenburg, Sweden, who created the algorithm during an informal consensus discussion. Once the algorithm was created, it was internally reviewed by both pediatricians and pharmacists before being finalized for clinical use. ■