What is the recommended dose of metoclopramide (Reglan) for a pediatric patient?

Pediatric Metoclopramide Dosing

The recommended dose of metoclopramide in pediatric patients is 0.1 mg/kg per dose (maximum 10 mg) administered orally, intramuscularly, or intravenously every 6-8 hours, with use strictly limited to 5 days or less due to the high risk of extrapyramidal reactions and tardive dyskinesia. 1, 2

Standard Dosing by Indication

Nausea/Vomiting and Gastroesophageal Reflux

• 0.1 mg/kg per dose (maximum 10 mg) given PO/IM/IV every 6-8 hours 1, 2, 3
• Duration must not exceed 5 days 1, 2, 3
• Note: The American Academy of Pediatrics states there is insufficient evidence to support routine use of metoclopramide for GERD in infants or children 2, 3

Chemotherapy-Induced Nausea and Vomiting (High-Dose Regimen)

• 1-2 mg/kg per dose IV for highly emetogenic chemotherapy (cisplatin, dacarbazine) 1, 4
• 1 mg/kg per dose IV for less emetogenic regimens 4
• Administer slowly over 15 minutes, given 30 minutes before chemotherapy 1, 4
• Repeat every 2 hours for two doses, then every 3 hours for three doses 4
• Always co-administer diphenhydramine to reduce extrapyramidal reactions 5, 6

Radiological Procedures and Small Bowel Intubation

• Age <6 years: 0.1 mg/kg IV over 1-2 minutes 4
• Age 6-14 years: 2.5-5 mg IV over 1-2 minutes 4
• Age >14 years: 10 mg IV over 1-2 minutes 4

Critical Safety Warnings

Age-Based Contraindications

• Contraindicated in children <1 year of age 1
• Use with extreme caution in children <5 years of age 1, 7
• The risk of extrapyramidal symptoms is significantly higher in younger children 7, 5

Extrapyramidal Reactions (Primary Concern)

• Extrapyramidal symptoms occur in 9% (95% CI 5-17%) of pediatric patients 7
• Risk factors include: higher doses (≥2 mg/kg), consecutive day dosing, and younger age 1, 5, 6
• Acute dystonic reactions occurred in 15% of children receiving ≥2 mg/kg doses 6
• If acute dystonic reaction occurs: Immediately administer diphenhydramine 1-2 mg/kg (or 25-50 mg) parenterally 1, 2, 3, 4

Duration Limitation

• Maximum duration: 5 days due to risk of tardive dyskinesia 1, 2, 3
• This black box warning applies to all pediatric patients 3

Additional Contraindications

• Pheochromocytoma, seizure disorders, gastrointestinal bleeding, or gastrointestinal obstruction 2
• Do not combine with tramadol 1

Dosing Adjustments

Renal Impairment

• For creatinine clearance <40 mL/min: initiate at approximately one-half the recommended dosage 4
• Metoclopramide is excreted principally through the kidneys 4

Hepatic Impairment

• Metoclopramide undergoes minimal hepatic metabolism; safe use described in advanced liver disease with normal renal function 4

Common Adverse Effects Beyond Extrapyramidal Symptoms

• Diarrhea: 6% (95% CI 4-9%) 7
• Sedation: 6% (95% CI 3-12%) in multiple-dose studies 7
• Restlessness, drowsiness, and fatigue 8
• Life-threatening effects (dysrhythmia, respiratory distress/arrest, neuroleptic malignant syndrome) are rare 7

Key Clinical Pitfalls to Avoid

• Never exceed 5 days of therapy regardless of indication 1, 2, 3
• Avoid consecutive day dosing when possible, as this significantly increases extrapyramidal reaction risk 5, 6
• Do not use doses ≥2 mg/kg without prophylactic diphenhydramine in chemotherapy protocols 5, 6
• Do not use for routine GERD management in infants and children due to lack of efficacy evidence and significant adverse effect profile 2, 3