What is the appropriate treatment for vomiting in a 2-year-old child using domperidone (motilium)?

Domperidone Should Not Be Used for Vomiting in a 2-Year-Old Child

Domperidone is not recommended for treating vomiting in a 2-year-old child with acute gastroenteritis, as oral rehydration therapy (ORT) is the first-line treatment and recent high-quality evidence shows domperidone provides no benefit over placebo in this setting. 1, 2

Primary Treatment Approach

Oral Rehydration is First-Line Therapy

• Reduced osmolarity oral rehydration solution (ORS) is the recommended first-line therapy for mild to moderate dehydration in children with acute diarrhea and vomiting (strong recommendation, moderate evidence). 1
• Administer ORS in small, frequent volumes (e.g., 5 mL every minute initially) using a spoon or syringe to replace ongoing losses from vomiting. 3
• Replace each vomiting episode with approximately 10 mL/kg of ORS. 3
• Continue breastfeeding on demand if the infant is breast-fed, or continue full-strength formula for formula-fed children. 3

Why Domperidone Should Be Avoided

Lack of Efficacy in Recent Evidence

• A 2019 randomized, double-blind, phase 3 trial found that low-dose domperidone (0.25 mg/kg) with ORT did not significantly differ from placebo in reducing vomiting episodes in children ages 6 months to 12 years with acute gastroenteritis (32.0% vs 33.8% with no vomiting). 2
• A 2015 multicenter randomized controlled trial in Japan similarly showed no significant reduction in vomiting during the first 2 hours after treatment (20.7% vs 27.3%, P = .41). 4

Guideline Recommendations Do Not Support Domperidone

• The 2017 Infectious Diseases Society of America guidelines state that antiemetic agents can be considered once the patient is adequately hydrated, but their use is not a substitute for fluid and electrolyte therapy (weak recommendation, low evidence). 1
• Importantly, these guidelines specifically mention ondansetron as the antiemetic option for children >4 years of age, not domperidone. 1
• For children under 4 years of age (which includes your 2-year-old patient), the guidelines cannot make a recommendation for routine use of antiemetic agents. 1

Alternative Antiemetic Consideration

Ondansetron Has Better Evidence But Age Restriction Applies

• Ondansetron may be given to facilitate tolerance of oral rehydration in children >4 years of age and adolescents with acute gastroenteritis associated with vomiting (weak recommendation, moderate evidence). 1
• Since your patient is only 2 years old, ondansetron is not recommended based on current guideline evidence. 1
• Ondansetron has been shown to reduce immediate need for hospitalization or intravenous rehydration, though it may increase stool volume. 1

Clinical Algorithm for a 2-Year-Old with Vomiting

Step 1: Assess Hydration Status

• Evaluate for signs of dehydration: decreased urine output (fewer than 4 wet diapers in 24 hours), dry mucous membranes, poor skin turgor, altered mental status. 3
• Check for red flags: bilious (green) vomiting, blood in vomit or stool, abdominal distension, lethargy, or projectile vomiting pattern. 3

Step 2: Initiate Oral Rehydration

• Begin ORS in small, frequent volumes immediately—this is the definitive treatment, not an adjunct. 1
• If the child cannot tolerate oral intake due to persistent vomiting, consider nasogastric administration of ORS. 1
• Continue until clinical dehydration is corrected. 1

Step 3: Advance to Regular Diet

• Resume age-appropriate usual diet during or immediately after rehydration is completed. 1
• Do not withhold food for 24 hours—this practice is not supported by evidence. 1

Step 4: When to Escalate Care

• Administer isotonic intravenous fluids (lactated Ringer's or normal saline) if there is severe dehydration, shock, altered mental status, or failure of ORS therapy. 1
• Seek immediate medical attention if vomiting becomes projectile or bilious, or if signs of severe dehydration develop. 3

Important Caveats

Historical Use Does Not Equal Current Evidence

• While older studies from 1979-1982 suggested domperidone was effective and safe in children, these were small-scale studies that did not meet modern standards for evidence quality. 5, 6, 7
• The most recent and highest quality evidence (2019 phase 3 trial) definitively shows no benefit over placebo. 2

Avoid Non-Specific Antidiarrheal Agents

• Antimotility drugs (e.g., loperamide) should not be given to children <18 years of age with acute diarrhea (strong recommendation, moderate evidence). 1
• These agents shift focus away from appropriate fluid therapy and can cause serious side effects including ileus and deaths in young children. 1