Can I give Phenergan (promethazine) to children under 10 with nausea and vomiting from food poisoning?

Promethazine (Phenergan) Should NOT Be Given to Children Under 10 Years Old with Food Poisoning

Do not administer promethazine (Phenergan) to children under 10 years of age for nausea and vomiting from food poisoning or gastroenteritis. Use ondansetron instead as the first-line antiemetic. 1

Why Promethazine is Contraindicated

• Promethazine is FDA-contraindicated in children under 2 years of age due to risk of fatal respiratory depression 1
• For children 2-10 years old, promethazine carries significant risks including:
  • Severe sedation that can mask neurological deterioration 2
  • Dystonic reactions and extrapyramidal symptoms 3
  • Agitation, hallucinations, and seizures 2
  • Possible association with apparent life-threatening events 2
• The FDA black box warning specifically prohibits use in children under 2 years 1

The Correct Antiemetic Choice: Ondansetron

Ondansetron is the recommended first-line antiemetic for pediatric gastroenteritis/food poisoning based on superior efficacy and safety profile 4, 5

Dosing for Children Under 10:

• 0.15 mg/kg per dose (maximum 16 mg) administered orally, IV, or IM 6, 4
• Can be used safely in children as young as 6 months of age 6
• May repeat every 8 hours if needed, though single-dose therapy is often sufficient 6

Evidence Supporting Ondansetron:

• The Infectious Diseases Society of America recommends ondansetron for children >4 years with acute gastroenteritis and vomiting to facilitate oral rehydration 7, 6
• Reduces recurrent vomiting, need for IV fluids, and hospital admissions 5, 8
• Significantly more effective than domperidone (87% vs 81% cessation at 6 hours; 95% vs 85% at 24 hours, p=0.01) 9
• Superior safety profile compared to older antiemetics like promethazine, metoclopramide, and prochlorperazine 3

Critical Safety Considerations for Ondansetron

While ondansetron is the preferred agent, monitor for:

• QT interval prolongation risk - obtain baseline ECG if child has known cardiac disease 4, 10
• Ensure adequate hydration before or during administration 4
• Monitor electrolytes (potassium, magnesium) as abnormalities increase QT risk 4
• Avoid concurrent use with other QT-prolonging medications 6

Clinical Algorithm for Antiemetic Use in Pediatric Food Poisoning

1. First, ensure adequate hydration - antiemetics are not a substitute for fluid/electrolyte therapy 7, 4
2. For children ≥6 months with persistent vomiting:
   • Give ondansetron 0.15 mg/kg (max 16 mg) orally or IM 6, 4
   • Reassess after 30-60 minutes
3. If vomiting persists after 8 hours, may repeat ondansetron dose 6
4. Continue oral rehydration therapy throughout 7

Common Pitfalls to Avoid

• Never use promethazine in children under 2 years - this is an FDA black box warning 1
• Avoid metoclopramide - high incidence of dystonic reactions in children, should not be used for multiple consecutive days 4, 10
• Do not use antiemetics as monotherapy - they must accompany appropriate rehydration 4
• Do not exceed 16 mg single dose maximum in pediatric patients regardless of weight 6, 4