Have you ever gone to the doctor to get some nausea medicine or given medication to your child to help with vomiting? If you are my age, you may not have given it to your children, but you almost certainly got it when you were a child. Despite all the current warnings against the use of most nausea medications, I still get parents coming into the ER asking for a prescription for Phenergan. Worse, I even see some kids whose doctors put them on this medicine. While I do not expect that parents are going to be able to keep up with all the new medical literature… I do think we should expect this of our doctors.
A Little Background
Phenergan, also called promethazine, is a medicine that has been used for years to help with nausea and vomiting. It comes in all kinds of formulations. There are pills, and liquids, and rectal suppositories – I have even heard that there is an oil-based formulation that some people like to rub on their wrists.
For many years parents and doctors alike praised the greatness of this medication for the relief of nausea and vomiting. But does it really help? Well when you understand vomiting in kids, you start to see how most of the benefit that people get from this medication is more an illusion than it is any real benefit. Remember that most vomiting in kids follows a typical and predictable time course. Normally there is lots of vomiting for the first 6 hours. This is followed by less vomiting over the next 6 hours. Then in most kids the vomiting completely resolves by 12-24 hours.
Does this sound familiar?
With this in mind, think about what happens when little Johnny has a few episodes of vomiting. Johnny probably needs to have several episodes of vomiting before you start to get alarmed. Hour #1. Then you have to call your pediatrician. The nurse says, “Sure, bring little Johnny in, we can probably work him in this afternoon. So you pack up little Johnny, get him in his car seat, and head off to see the doctor. Hour #2.
You get to your doctor’s office, check in, and sit in a room full of sick kids, most of whom are vomiting just like little Johnny. Hour #3. The nurse calls you back, checks the temp, weight, pulse, etc. and puts you in the room, where you wait another 30-45 minutes before the doctor comes in. Hour #4. The doctor listens to the lungs, pushes on the belly, and makes his diagnosis – stomach virus. Since this doctor does not keep up with the medical literature he writes out a prescription for Phenergan and tells you to give it to little Johnny rectally. The nurse comes back in and gives you some more information about vomiting, you go up front to pay, and then load little Johnny back into the car. Hour #5.
You drive down the street to Walgreen’s and drop off your prescription, which they tell you will be ready in about an hour. Hour #6. You decide to go home and have Dad pick up the medicine on his way home from work. Hour #7. Once Dad gets home, you give the suppository to little Johnny, who mind you, has only vomited once in the last hour. Hour #8.
Miracles never cease
Miraculously, little Johnny only vomits 2 more times the rest of the evening. By the next morning, except for some diarrhea, he is doing very well. Thank goodness for the Phenergan. Not sure what we would have done without that medicine. Sure glad I hauled my sick kid all over town, exposing him to lots of other sick kids, and let him vomit all over me and my car, so I could get this miracle cure for vomiting.
Smart Parents to the rescue
You see, the careful observer will note that little Johnny was already getting better by the time he got the Phenergan. Smart Parents know that most vomiting will slow down between 6-12 hours without any treatment. In most kids the vomiting will be completely resolved by 12-24 hours. It was not the medicine that helped little Johnny – he was already getting better before his parents even gave him the medicine. However, the whole process of getting and giving the medicine creates the illusion that you need the medicine to get better. Once you buy into the illusion, you will be forever convinced that every time your child vomits you must act quick to get the Phenergan.
Why Not Just Give the Medicine?
As I have mentioned countless times in the past, all medications have side-effects. Many of the side-effects are severe and some are even deadly. It just so happens that Phenergan is not the safest medicine for kids.
Black Box Warning
This is a warning issued by the drug maker because a serious and potentially fatal side-effect has been discovered with their medication. Turns out that Phenergan has a Black Box warning. I will let you read it for yourself:
Some people will say, “fatal respiratory depression is uncommon. It is a rare side-effect. It is really not a big deal.” Well, to that I say… it is not so uncommon if it happens to your kid. Maybe the side effect is not so rare if it happens to your kid. And it is big deal if it happens to your kid.
Still not convinced?
Have you ever heard of a dystonic reaction? This is when your facial muscles start contracting involuntarily. Often times your tongue starts sticking out or your cheeks pucker up. It is completely involuntary, and if you are the one having it – it is not fun. Worse if you are a parent watching it in your child, it is horrifying. Children are more likely to get it than adults and it happens in up to 2% of patients taking certain medications, like Phenergan.
If after reading that, you still think that the trip to the doctor’s office, the trip to the pharmacy, the vomit in your car, the copay, the pharmacy bill, the risk of fatal respiratory depression, and a 1:50 chance of a dystonic reaction are all worth it, even though your kid is probably going to be better by 12-24 hours…. well if you still want the Phenergan, then I am not sure there is much else I can do to convince you otherwise.
Is it safe for my 3-year old?
Absolutely not! I cannot think of any rational argument for giving a medicine to a 3-year old, that if given to his 2-year old younger brother, could result in respiratory depression and death.
Do not ask for, or accept, a prescription for Phenergan – EVER! If the day comes when your child does for some reason need a medicine for nausea or vomiting, there are much better options and very rational ways to use them. Stay tuned for more on this.
Of course at the end of the day the decision is yours. So you decide… Phenergan or no Phenergan?
This is a letter distributed by the makers of Phenergan to physicians. If your doctor is trying to give your child Phenergan, then you may want to give them a copy of this letter.
Here is a link to an article regarding the side-effects of Phenergan and the issuance of the Black Box Warning.