Is 10mg of Metoclopramide (intravenous) a suitable dose for a 31kg child?

Metoclopramide 10mg IV is NOT an appropriate dose for a 31kg child

For a 31kg child, the correct metoclopramide IV dose should be 3.1mg (0.1 mg/kg), not 10mg, as 10mg represents more than triple the recommended weight-based dose and significantly increases the risk of extrapyramidal symptoms. 1

Correct Pediatric Dosing

The FDA-approved dosing for metoclopramide in pediatric patients varies by indication 1:

For Small Bowel Intubation or Radiological Examinations

• Children under 6 years: 0.1 mg/kg IV 1
• Children 6-14 years: 2.5-5 mg IV 1
• Children over 14 years and adults: 10 mg IV 1

For your 31kg patient, the appropriate dose is 3.1mg (31kg × 0.1 mg/kg), assuming they are under 14 years of age. 1

For Chemotherapy-Induced Nausea and Vomiting

• High-dose regimen: 1-2 mg/kg per dose IV 1
• For a 31kg child, this would be 31-62mg per dose 1
• However, this indication requires careful consideration due to significantly elevated risk of adverse effects 2, 3

Critical Safety Concerns with 10mg Dose

Extrapyramidal Symptom (EPS) Risk

• In pediatric studies using 2 mg/kg doses (which would be 62mg for a 31kg child), 15% of children experienced extrapyramidal reactions 2
• At doses ≥2 mg/kg, 33% experienced akathisia 2
• The 10mg dose (0.32 mg/kg) falls between standard dosing and high-dose regimens, creating unnecessary risk 2

Age-Related Vulnerability

• Younger patients have increased disposition to acute extrapyramidal reactions compared to older adults 2
• A systematic review found 9% cumulative incidence of EPS in pediatric patients receiving metoclopramide 4
• Dystonic reactions occurred most frequently in children receiving 2 mg/kg doses or consecutive day dosing 3

Clinical Algorithm for Dosing Decision

Step 1: Determine the indication

• Gastroparesis/GI motility: Use 0.1 mg/kg = 3.1mg 1
• Chemotherapy-induced nausea: Consider 1-2 mg/kg only if highly emetogenic agents used 1
• Postoperative nausea: Standard adult dose of 10mg may be considered if patient >14 years 1

Step 2: Assess patient age

• If <6 years: Maximum 0.1 mg/kg (3.1mg for 31kg) 1
• If 6-14 years: 2.5-5mg range for intubation/radiology 1
• If >14 years: Adult dosing (10mg) may be appropriate 1

Step 3: Administration technique

• Administer slowly over 1-2 minutes to reduce adverse effects 1
• For high doses (>10mg), dilute in 50mL parenteral solution and infuse over ≥15 minutes 1

Common Pitfalls to Avoid

• Do not use adult dosing (10mg) in children based solely on weight - age and indication must guide dosing 1
• Do not give consecutive days of metoclopramide without reassessing - this increases EPS risk 2, 3
• Have diphenhydramine 50mg available for immediate treatment of acute dystonic reactions 1, 3
• Reduce dose by 50% if creatinine clearance <40 mL/min as metoclopramide is renally excreted 1

Monitoring Requirements

• Observe for sedation (6% incidence), diarrhea (6% incidence), and EPS (9% incidence) during and after administration 4
• Monitor for dystonic reactions, which are rapidly reversible with diphenhydramine 3
• Rare but serious effects include dysrhythmia, respiratory distress, and neuroleptic malignant syndrome 4