Metoclopramide Dosing in Pediatric Patients
For pediatric patients, metoclopramide dosing varies significantly by indication and age: 0.1 mg/kg every 6 hours for gastroesophageal reflux, 0.1 mg/kg for small bowel intubation in children under 6 years, 2.5-5 mg for ages 6-14 years, and 1-2 mg/kg for chemotherapy-induced nausea and vomiting (CINV).
Standard Dosing by Indication
Gastroesophageal Reflux and Gastroparesis
- The recommended dose is 0.1 mg/kg every 6 hours enterally, which achieves therapeutic concentrations for gastroesophageal reflux in most pediatric patients 1
- This dosing regimen was validated in preterm infants (birth weights 790-1,040g) at 0.1 mg/kg/day divided into three doses intravenously, with excellent response and no adverse effects 2
- Simulations demonstrate that 0.1 mg/kg every 6 hours produces steady-state concentrations within the efficacy range for >75% of patients, though slightly lower exposures occur in children <2 years 1
Small Bowel Intubation
- For children under 6 years: 0.1 mg/kg metoclopramide base as a single IV dose over 1-2 minutes 3
- For children 6-14 years: 2.5-5 mg metoclopramide base as a single IV dose 3
- For children >14 years and adults: 10 mg metoclopramide base as a single IV dose 3
Chemotherapy-Induced Nausea and Vomiting
- For highly emetogenic chemotherapy (cisplatin, dacarbazine): 2 mg/kg IV over ≥15 minutes, given 30 minutes before chemotherapy, repeated every 2 hours for two doses, then every 3 hours for three doses 3
- For less emetogenic regimens: 1 mg/kg per dose may be adequate 3
- A dose-escalation study found that doses <2 mg/kg had minimal toxicity, while doses ≥2 mg/kg resulted in extrapyramidal reactions in 15% and akathisia in 33% of children 4
Critical Safety Considerations
Extrapyramidal Symptoms (EPS)
- EPS occur in approximately 9% (95% CI 5-17%) of pediatric patients receiving metoclopramide, making this the most common adverse effect 5
- Prophylactic diphenhydramine should be administered concurrently with high-dose metoclopramide (≥2 mg/kg) to reduce EPS risk 4
- If acute dystonic reactions occur, administer diphenhydramine 1-2 mg/kg or 25-50 mg parenterally 6, 3
- Children receiving two consecutive days of metoclopramide have higher EPS frequency 4
Other Common Adverse Effects
- Diarrhea occurs in 6% (95% CI 4-9%) of patients 5
- Sedation occurs in 6% (95% CI 3-12%) in multiple-dose studies 5
- These effects are reversible and of no long-term significance 5
Rare but Serious Adverse Effects
- Dysrhythmia, respiratory distress/arrest, neuroleptic malignant syndrome, and tardive dyskinesia are rarely associated with metoclopramide use in children 5
Age-Specific Dosing Considerations
Neonates and Infants (<2 years)
- Neonates are immature children with developing drug elimination pathways, requiring careful dose adjustment 7
- The 0.1 mg/kg every 6 hours regimen may result in slightly lower exposures in this age group, though still generally within therapeutic range 1
- Metoclopramide has been safely used in preterm infants as young as 26 weeks gestational age 2
Children (2-12 years)
- Children ≥2 years are essentially mature and differ from adults only in size, allowing for straightforward weight-based dosing 7
- Body weight is the primary covariate affecting metoclopramide pharmacokinetics in this population 1
Adolescents (>12 years)
- Dosing approaches adult regimens, with 10 mg as the standard dose for most indications 3
Administration Guidelines
Route and Timing
- IV administration should be given slowly over 1-2 minutes for single doses 3
- For CINV prophylaxis, infuse over ≥15 minutes 3
- Oral administration is appropriate for less severe symptoms 3
Duration of Therapy
- Limit duration to ≤5 days when possible, as regulatory agencies caution against prolonged use in children 5
- For diabetic gastroparesis, IV therapy may be required for up to 10 days before transitioning to oral administration 3