What antiemetics can be given to pediatric patients?

Antiemetics for Pediatric Patients

Pediatric patients should receive 5-HT3 receptor antagonists (ondansetron or granisetron) as first-line antiemetics, with dexamethasone added for moderate-to-high emetogenic risk situations, and aprepitant for high-risk chemotherapy regimens. 1, 2

Primary Antiemetic Agents

5-HT3 Receptor Antagonists (First-Line)

Ondansetron is the most extensively studied and recommended first-line antiemetic in pediatric patients across multiple clinical contexts 1, 2:

• Standard dosing: 0.15 mg/kg per dose (maximum 16 mg per dose) IV or IM 2
• Oral dosing: 0.1 mg/kg or 5 mg/m² per dose 2
• Single dose maximum: 16 mg 2
• Age range: Safe in children as young as 6 months 2

Granisetron represents an equally effective alternative 5-HT3 antagonist with similar safety profile 1, 3:

• Available as oral tablets, liquid formulation, or transdermal patch 3
• Particularly useful when ondansetron is contraindicated due to QT prolongation concerns or allergy 3

Corticosteroids (Adjunctive Therapy)

Dexamethasone significantly enhances antiemetic efficacy when combined with 5-HT3 antagonists 1, 2:

• Should be added to ondansetron for moderate-emetic-risk chemotherapy 1
• Provides dual benefit in traumatic brain injury: reduces cerebral edema while providing antiemetic effects 3
• Dose: 2-4 mg orally in combination regimens 4

NK1 Receptor Antagonists

Aprepitant is recommended for high-emetic-risk situations 1:

• Used as part of three-drug combination with 5-HT3 antagonist and dexamethasone for high-emetic-risk chemotherapy 1
• Can substitute for dexamethasone when corticosteroids are contraindicated (combined with palonosetron) 1

Context-Specific Recommendations

Chemotherapy-Induced Nausea and Vomiting

High-emetic-risk chemotherapy (cisplatin, ifosfamide, high-dose cyclophosphamide) 1:

• Three-drug regimen: 5-HT3 antagonist + dexamethasone + aprepitant 1
• If aprepitant unavailable: 5-HT3 antagonist + dexamethasone 1
• If dexamethasone contraindicated: palonosetron + aprepitant 1

Moderate-emetic-risk chemotherapy (carboplatin, doxorubicin, standard-dose cyclophosphamide) 1:

• Two-drug regimen: 5-HT3 antagonist + dexamethasone 1
• If dexamethasone contraindicated: 5-HT3 antagonist + aprepitant 1

Low-emetic-risk chemotherapy 1:

• Monotherapy: Ondansetron or granisetron alone 1

Minimal-emetic-risk chemotherapy 1:

• No routine antiemetic prophylaxis recommended 1

Acute Gastroenteritis

Ondansetron is recommended for children >4 years with acute gastroenteritis and vomiting to facilitate oral rehydration 2, 5:

• Must be used after ensuring adequate hydration or alongside rehydration efforts 5
• Does not replace fluid and electrolyte therapy, which remains the cornerstone of treatment 2, 5
• Dosing: 0.15 mg/kg IM (maximum 16 mg) for children ≥6 months 5

Traumatic Brain Injury

Ondansetron is the first-line antiemetic for pediatric traumatic brain injury due to superior safety profile regarding neurological monitoring 5, 3:

• Dopamine antagonists (metoclopramide, prochlorperazine) cause extrapyramidal symptoms and sedation that interfere with neurological assessment 3
• Granisetron is the preferred alternative if ondansetron is contraindicated 3
• Dexamethasone may serve dual purposes: antiemetic effects plus reduction of cerebral edema 3

Postoperative Nausea and Vomiting

Ondansetron demonstrates superior prophylactic efficacy compared to droperidol, metoclopramide, prochlorperazine, and dimenhydrinate 6:

• Dosing: 0.1-0.15 mg/kg IV for procedures with high PONV risk (tonsillectomy, strabismus repair) 6
• Combination with dexamethasone or propofol-based anesthesia significantly enhances efficacy 6

Agents to Avoid or Use with Extreme Caution

Metoclopramide (Not Recommended)

Metoclopramide should NOT be used as first-line therapy in pediatric patients 2, 5:

• High incidence of dystonic reactions and extrapyramidal symptoms 5, 3
• Should not be used for multiple consecutive days 5, 3
• Significantly inferior efficacy compared to ondansetron in controlled trials 6
• Sedation interferes with neurological monitoring in TBI patients 3

Prochlorperazine (Limited Role)

Prochlorperazine causes extrapyramidal symptoms and sedation, making it problematic for neurological monitoring 3:

• Not recommended as first-line treatment 3
• Less effective than ondansetron in comparative trials 6

Critical Safety Considerations

QT Prolongation Risk

Exercise special caution in children with pre-existing cardiac disease due to potential QT interval prolongation with 5-HT3 antagonists 2, 5, 3:

• Obtain baseline ECG if patient has known cardiac disease 3
• Monitor electrolytes, particularly potassium and magnesium, as abnormalities increase QT prolongation risk 5, 3
• Ensure adequate hydration before or during ondansetron administration 5, 3

Dosing Pitfalls

Common dosing errors to avoid 2:

• Do not exceed 16 mg single dose maximum in pediatric patients 2
• Use weight-based dosing (0.15 mg/kg) rather than fixed adult doses 2, 3
• Children may require higher weight-based doses than adults due to pharmacokinetic variations 3

Hepatic Impairment

In severe hepatic impairment, do not exceed 8 mg total daily dose of ondansetron 3

Efficacy Data

Ondansetron achieves complete or major control (≤2 emetic episodes) in 6, 7, 4:

• 87-89% of pediatric patients during acute chemotherapy-induced emesis 7, 4
• 33-40% of cisplatin recipients (highly emetogenic) 6
• 48-68% of ifosfamide recipients 6
• 70-72% of patients receiving other chemotherapeutic regimens 6

The addition of dexamethasone to ondansetron significantly improves these response rates in randomized trials 6, 4