Should Gravol (dimenhydrinate) be prescribed at the beginning of refeeding before skills are taught?

Gravol (Dimenhydrinate) in Refeeding: Not Recommended Before Teaching Skills

Gravol (dimenhydrinate) should not be routinely prescribed at the beginning of refeeding before skills are taught, as there is insufficient evidence supporting this practice and it may mask important symptoms of refeeding syndrome or feeding intolerance.

Rationale for Not Using Gravol Prophylactically

Refeeding Process and Monitoring

• Refeeding should focus on careful nutritional introduction rather than symptom suppression with medications 1
• Guidelines emphasize gradual introduction of nutrition with close monitoring for complications:
  • Start with low calorie regimens and build up gradually 1
  • Monitor electrolytes (potassium, phosphate, magnesium) during refeeding 1, 2
  • Watch for signs of refeeding syndrome, which requires immediate intervention 2

Potential Issues with Prophylactic Antiemetics

• Using antiemetics like Gravol prophylactically may:
  • Mask important symptoms that indicate refeeding problems
  • Delay identification of refeeding syndrome, which can be life-threatening 3, 4
  • Create unnecessary medication exposure and potential side effects 5

Evidence-Based Approach to Refeeding

Proper Refeeding Protocol

• Begin with a starter regimen that gradually increases prescribed volume while reducing food intake 1
• For enteral nutrition:
  • Start at 10-20 mL/hour and gradually increase over 5-7 days 6
  • Monitor tolerance before increasing volume 6
• For oral refeeding:
  • A diet rich in carbohydrates and proteins but low in fats is recommended 1
  • Early refeeding decreases intestinal permeability and improves outcomes 1

Monitoring During Refeeding

• Regular assessment of:
  • Electrolytes (potassium, phosphate, magnesium) 2
  • Signs of feeding intolerance (abdominal distension, nausea, vomiting) 6
  • Vital signs and fluid balance 6

When Antiemetics May Be Appropriate

Antiemetics should be used selectively, not prophylactically:

• Appropriate use: When vomiting occurs despite proper refeeding technique and adequate hydration 1
• Guidelines state: "Ancillary treatment with antimotility, antinausea, or antiemetic agents can be considered once the patient is adequately hydrated, but their use is not a substitute for fluid and electrolyte therapy" 1
• For children >4 years and adolescents with acute gastroenteritis and vomiting, antiemetics may facilitate oral rehydration 1

Safety Considerations with Dimenhydrinate

If dimenhydrinate (Gravol) is needed for treatment (not prophylaxis):

• Ensure proper dosing based on weight and age 5
• Be aware of potential side effects including drowsiness, which may interfere with learning refeeding skills 7
• Consider that dimenhydrinate may be beneficial in adults but evidence is limited in pediatric populations 1, 7

Better Alternatives to Prophylactic Antiemetics

Instead of prophylactic Gravol, focus on:

1. Proper refeeding technique: Gradual introduction of nutrition 1, 6
2. Patient education: Teaching skills for managing the refeeding process 1
3. Close monitoring: Regular assessment for signs of refeeding syndrome 2, 4
4. Multidisciplinary support: Encouragement from the whole team is important for success 1

By prioritizing proper refeeding techniques and education over prophylactic medication, patients will develop better long-term skills for managing their nutrition while minimizing unnecessary medication exposure.