What is the dosage and usage of metoclopramide (metoclopramide) for pediatric patients?

Metoclopramide Dosage and Usage in Pediatric Patients

For pediatric patients, metoclopramide should be administered at 0.1 mg/kg orally every 6 hours, which provides exposure within the therapeutic range while minimizing risk of adverse effects. 1

Indications and Dosing

Gastroesophageal Reflux Disease (GERD)

• Recommended dose: 0.1 mg/kg orally every 6 hours 1
• Alternative dosing: 0.1-0.15 mg/kg orally every 6 hours (higher doses may increase risk of adverse effects) 2, 1
• Duration: Treatment should be limited and not exceed 5 days due to risk of adverse effects 3

Chemotherapy-Induced Nausea and Vomiting

• Antiemetic dosing: 1 mg/kg IV (safer dose with diphenhydramine premedication) 4, 5
• Higher doses (2 mg/kg) have shown better efficacy but significantly higher rates of adverse effects 5
• Always administer with diphenhydramine to reduce risk of extrapyramidal symptoms 4, 5

Acute Mental Health/Behavioral Emergencies

• 0.1 mg/kg PO/IM/IV when used as an adjunct for sedation 6

Special Populations

Infants

• Contraindicated in infants under 1 year of age 3
• Use with extreme caution in premature infants due to prolonged clearance and increased risk of dystonic reactions 7
• Pharmacokinetics in infants show drug accumulation with repeated dosing 2

Children Under 5 Years

• Use with caution in children under 5 years of age 3
• Higher risk of adverse effects in younger patients 5

Adverse Effects and Management

Common Adverse Effects

• Extrapyramidal symptoms (9% incidence) - most common adverse effect 3
• Sedation (6% incidence in multiple-dose studies) 3
• Diarrhea (6% incidence) 3

Serious Adverse Effects

• Acute dystonic reactions (more common in children receiving higher doses or consecutive day dosing) 4, 5
• Risk increases with doses ≥2 mg/kg (15% incidence of extrapyramidal reactions) 5
• Akathisia (33% incidence with doses ≥2 mg/kg) 5

Management of Adverse Effects

• For acute dystonic reactions: administer diphenhydramine 1-2 mg/kg or 25-50 mg/dose parenterally 8
• Premedicate with diphenhydramine when using for chemotherapy-induced nausea 4, 5

Pharmacokinetic Considerations

• Mean elimination half-life: 4.1-4.5 hours in most pediatric patients 2
• Clearance: 0.37-0.56 L/h/kg 2
• Volume of distribution: 1.93-3.0 L/kg 2
• Younger infants may have significantly longer half-life (up to 23.1 hours in neonates) 2

Important Cautions

• Metoclopramide carries a black box warning regarding its adverse effects 6
• Avoid use beyond 5 days due to increased risk of tardive dyskinesia 6, 3
• The FDA and European regulatory agencies have revised labeling to contraindicate use in children under 1 year 3
• Insufficient evidence supports routine use of prokinetic agents for GERD in infants or children 6

Clinical Decision Algorithm

1. Confirm appropriate indication (GERD unresponsive to non-pharmacological interventions)
2. Verify patient is >1 year of age (contraindicated in younger infants) 3
3. Start with 0.1 mg/kg orally every 6 hours 1
4. Monitor for extrapyramidal symptoms and other adverse effects 3
5. Limit duration to ≤5 days 6, 3
6. Have diphenhydramine available for management of acute dystonic reactions 8