Metoclopramide vs Domperidone for Pediatric TBI
Neither metoclopramide nor domperidone are recommended as standard therapy for pediatric traumatic brain injury, as major pediatric TBI guidelines do not address these agents for this indication. 1
Evidence-Based Guideline Recommendations
The CDC and Brain Trauma Foundation guidelines for pediatric TBI management (both mild and severe) do not include recommendations for metoclopramide or domperidone. 1 The focus of evidence-based pediatric TBI management centers on:
- Symptom management with nonopioid analgesics (ibuprofen or acetaminophen) for post-traumatic headaches 2, 3
- Avoidance of opioids for headache management 2, 3
- Gradual return to activity protocols 1
- Sleep hygiene and vestibular rehabilitation for persistent symptoms 1, 2
Clinical Context and Safety Concerns
Why These Agents Are Not Standard in Pediatric TBI
Metoclopramide carries significant risks in the TBI population that make it problematic:
- Central nervous system penetration causes drowsiness and anxiety, which can obscure neurological monitoring in head trauma patients 4
- Reduced efficacy in TBI patients compared to non-TBI trauma patients, with 54% failure rate versus 35% in non-TBI patients 5
- Extrapyramidal side effects are particularly concerning when neurological assessment is critical 6, 7
Domperidone has a better safety profile due to minimal CNS penetration 6, 7, but:
- No evidence exists for its use specifically in pediatric TBI management 1
- Historical pediatric studies only addressed chronic vomiting/regurgitation, not acute trauma 7
If Antiemetic Therapy Is Absolutely Required
When nausea/vomiting must be treated in pediatric TBI (recognizing this is off-guideline):
Ondansetron would be the preferred alternative over both metoclopramide and domperidone, as it has equivalent antiemetic efficacy to metoclopramide but significantly lower rates of drowsiness and anxiety in head trauma patients 4
If choosing between metoclopramide and domperidone specifically: Domperidone is theoretically safer due to minimal CNS effects and lower extrapyramidal side effect risk 6, 7, 8, though neither has evidence supporting use in pediatric TBI
Critical Management Priorities
Focus on guideline-concordant care:
- Severe or worsening headache requires emergent neuroimaging to rule out intracranial complications, not just symptomatic treatment 2, 3
- Vomiting is a risk factor for intracranial injury (1.9% risk) and warrants clinical decision rule application for imaging 1, 9
- Close monitoring for 4-6 weeks is essential, with referral for persistent symptoms 1
Common Pitfalls
- Do not use metoclopramide routinely in pediatric TBI due to CNS side effects that interfere with neurological assessment 4, 5
- Do not assume nausea/vomiting is benign - it may indicate increased intracranial pressure or intracranial injury requiring imaging 1, 9
- Do not prescribe prokinetics without considering ondansetron first if antiemetic therapy is truly needed 4