What is the use of ketamine in a 2-year-old child?

From the Guidelines

Ketamine should only be administered to a 2-year-old child in a medical setting under the direct supervision of healthcare professionals. The use of ketamine in pediatric patients, particularly those as young as 2 years old, requires careful consideration due to its potential side effects, including respiratory depression, increased intracranial pressure, and emergence reactions 1. For pediatric patients, ketamine dosing is typically 1-2 mg/kg intravenously or 4-5 mg/kg intramuscularly when used for procedural sedation, but these doses must be determined by a physician based on the child's specific weight, health status, and the procedure being performed 1. Some studies have shown that ketamine can be effective for providing procedural sedation in children, with high efficacy rates and high provider and parental satisfaction 1. However, the safety and efficacy of ketamine in young children, particularly those under the age of 3, are not well established, and its use in this population should be approached with caution 1. If a 2-year-old child needs pain management or sedation for a medical procedure, it is essential to consult with a pediatrician who can recommend appropriate and safe options specifically tailored to the child's needs 1. Some key points to consider when using ketamine in pediatric patients include:

• The importance of careful dosing and titration to minimize the risk of adverse effects
• The need for close monitoring of the child's vital signs and level of sedation
• The potential for emergence reactions and other side effects, and the need for a plan to manage these if they occur
• The importance of using ketamine in a medical setting where emergency equipment and personnel are available in case of an adverse event.

From the FDA Drug Label

1. 4 Pediatric Use Safety and effectiveness in pediatric patients below the age of 16 have not been established Published juvenile animal studies demonstrate that the administration of anesthetic and sedation drugs, such as ketamine hydrochloride injection, that either block NMDA receptors or potentiate the activity of GABA during the period of rapid brain growth or synaptogenesis, results in widespread neuronal and oligodendrocyte cell loss in the developing brain and alterations in synaptic morphology and neurogenesis. Based on comparisons across species, the window of vulnerability to these changes is believed to correlate with exposures in the third trimester of gestation through the first several months of life, but may extend out to approximately 3 years of age in humans

The use of ketamine in a 2-year-old patient is not established, and safety and effectiveness have not been proven. According to the studies, there is a potential risk of negative effects on the developing brain due to the administration of anesthetic and sedation drugs in children younger than 3 years 2. Healthcare providers should balance the benefits of appropriate anesthesia with the potential risks.

From the Research

Ketamine Use in Children

• Ketamine is a safe and effective sedative agent for use in children requiring immobilization to enable performance of a painful procedure 3
• It is a bronchodilator and maintains normal airway reflexes, permitting spontaneous respiration, making it highly suitable for children 4
• The use of intranasal ketamine in pediatric patients is a safe and effective alternative to intravenous sedatives or analgesics for procedural sedation 5

Safety and Efficacy

• Studies have shown that ketamine is well tolerated and safe for use in children, even when given repeatedly 6
• There is no evidence of needing higher doses with time to indicate tolerance, and no long-term consequences, including neurocognitive, have been reported 6
• Ketamine/midazolam is more effective at reducing observed distress than etomidate/fentanyl for pediatric orthopedic reductions, although both provide equal procedural amnesia 7

Administration and Dosage

• Ketamine can be administered intramuscularly (dose 3-4 mg/kg) or intravenously (dose 1.00-2.75 mg/kg) depending on physician preference 3
• Intranasal ketamine doses between 3 and 5 mg/kg are associated with high provider satisfaction and patient comfort 5
• The maximum number of doses per patient in one study was 42, over a maximum of 4 months, with no serious adverse events reported 6

Side Effects and Adverse Events

• Common side effects of ketamine include vomiting, rash, diplopia, salivation, and emergence reactions 3, 7
• Adverse events reported with intranasal ketamine include nausea, dizziness, and drowsiness, but were considered minor 5
• No patients required respiratory support or intubation in studies examining the use of ketamine in children 3, 5