What medications can be given to pediatric patients for dizziness?

Medications for Pediatric Dizziness

Medications should generally NOT be given to pediatric patients with dizziness, as the most common cause (BPPV) requires physical repositioning maneuvers rather than pharmacotherapy, and vestibular suppressants can interfere with natural compensation mechanisms while causing significant side effects including falls and cognitive impairment. 1, 2

Primary Treatment Approach

For BPPV (Most Common Cause in Pediatrics)

• Canalith repositioning procedures (Epley or Semont maneuvers) are the definitive first-line treatment, not medications 1, 2, 3
• BPPV accounts for approximately 20% of pediatric dizziness cases and responds dramatically to physical maneuvers with 80% success rates after 1-3 treatments 2, 3
• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends AGAINST routine use of vestibular suppressant medications for BPPV 1, 2
• Medications do not address the underlying mechanical problem of displaced otoconia and have substantially lower treatment responses (30.8% improvement) compared to repositioning maneuvers (78.6%-93.3% improvement) 2

Pediatric-Specific Considerations

• Pediatric BPPV often presents with comorbidities including concussion (38.2%) and migraine disorders (30%), which may complicate the clinical picture 3
• Average time to diagnosis in children is 178 days, suggesting significant underrecognition 3
• Multiple canals are affected in 36.4% of pediatric cases, requiring thorough assessment 3
• Children with vestibular migraine or benign paroxysmal vertigo of childhood have five times higher odds of BPPV recurrence 3

Limited Medication Indications

When Medications May Be Considered (Short-Term Only)

Severe nausea/vomiting during repositioning maneuvers:

• Meclizine may be used as prophylaxis for patients who previously experienced severe nausea during repositioning procedures 2
• Prochlorperazine 5-10 mg (oral or IV) for acute nausea management, maximum three doses per 24 hours 4
• These should be used only to facilitate the definitive repositioning treatment, not as standalone therapy 2

Acute vestibular neuritis or labyrinthitis:

• Short-term vestibular suppressants (3-5 days maximum) for severe acute symptoms only 2, 4
• Meclizine should be used as-needed (PRN) rather than scheduled to avoid interfering with vestibular compensation 2, 4

Specific Medication Dosing (When Absolutely Necessary)

Antihistamines

• Meclizine: Pediatric dosing should be weight-based; adult dosing is 25-100 mg daily in divided doses 2
• Dimenhydrinate: Has more pronounced anticholinergic side effects than meclizine; use with extreme caution in children 4, 5

Important Dosing Note for Adenosine (If SVT-Related Dizziness)

• Children require HIGHER initial doses than adults: 150-250 mcg/kg (versus adult dosing) 1
• This is relevant only if dizziness is secondary to supraventricular tachycardia, not vestibular causes 1

Critical Warnings and Contraindications

Why Medications Are Problematic in Pediatrics

Anticholinergic burden:

• Causes drowsiness, cognitive deficits, dry mouth, blurred vision, and urinary retention 2
• Interferes with school performance and daily activities 2

Fall risk:

• Vestibular suppressants are an independent risk factor for falls, particularly concerning in active children 2, 4

Interference with compensation:

• Long-term use prevents natural vestibular adaptation and central compensation mechanisms 2, 4
• This is especially problematic in developing pediatric nervous systems 4

Lack of efficacy:

• No evidence supports vestibular suppressants as effective primary treatment for BPPV 2
• Patients treated with Epley maneuver alone recover faster than those receiving concurrent vestibular suppressants 2

Clinical Algorithm for Pediatric Dizziness

1. Perform Dix-Hallpike test to diagnose posterior canal BPPV 1, 2
2. If positive: Perform Epley maneuver immediately, no medications needed 1, 2
3. If severe nausea anticipated: Consider single dose of antiemetic 30 minutes before maneuver 2
4. If Dix-Hallpike negative: Perform supine roll test for lateral canal BPPV 1
5. If all positional tests negative: Consider non-BPPV causes (vestibular neuritis, migraine-associated dizziness, orthostatic hypotension) 2, 6
6. Reassess within 1 month to document resolution or need for alternative diagnosis 1, 2

Special Populations

Pediatric Syncope (Not Vertigo)

• For vasovagal syncope: Education and lifestyle modifications are first-line 1
• Midodrine may be reasonable in children not responding to lifestyle measures (reduces recurrence from 80% to 22%) 1
• Increased salt and fluid intake may be reasonable (56% vs 39% symptom-free with oral rehydration salts) 1
• Fludrocortisone effectiveness is uncertain; one pediatric RCT showed better outcomes with placebo 1

Carbamazepine-Related Dizziness

• If child is on carbamazepine for paroxysmal kinesigenic dyskinesia, dizziness is a known side effect 1
• Medication should be taken at bedtime to minimize this adverse effect 1
• Initial pediatric dosing: 1 mg/kg, gradually titrated 1

Common Pitfalls to Avoid

• Do not order brain imaging for patients meeting BPPV diagnostic criteria without additional concerning neurological signs 1, 7
• Do not prescribe meclizine as primary BPPV treatment - this increases ED length of stay, medication side effects, and delays definitive care 7
• Do not use digoxin in infants with pre-excitation patterns, as it has been associated with sudden cardiac death and ventricular fibrillation 1
• Do not continue vestibular suppressants beyond 3-5 days for any indication 2, 4
• Do not use flecainide as first-line in children due to rare but serious adverse events 1