Ketorolac Dosing for Pediatric Patients
For pediatric patients, the recommended intravenous dose of ketorolac is 0.5 mg/kg as a single bolus, followed by either 1.0 mg/kg every 6 hours or a continuous infusion of 0.17 mg/kg/hour, with a maximum daily dose of 90 mg and treatment duration not exceeding 48 hours. 1
Age and Weight Considerations
- Ketorolac is not recommended for infants under 1 year of age 1
- For children aged 4-8 years receiving a single 0.5 mg/kg IV bolus, the elimination half-life is approximately 5.8 hours, with higher volume of distribution and clearance compared to adults 2
- Older children may require somewhat lower dosages, while infants and young children may require slightly higher dosages to achieve equivalent pain relief 1
Route of Administration
- The intravenous route is strongly preferred during the immediate postoperative period until the patient can tolerate oral medication 1
- Intramuscular injections are not recommended in children unless the intravenous route is unavailable 1
- For oral administration when appropriate, the recommended dose is 0.25 mg/kg up to a maximum of 1.0 mg/kg/day, with treatment not exceeding 7 days 1
Dosing Ceiling Effect in Larger Pediatric Patients
- For pediatric patients weighing at least 60 kg, a maximum dose of 15 mg IV ketorolac provides effective analgesia comparable to 30 mg, demonstrating a ceiling effect similar to adults 3
- This lower maximum dose (15 mg versus 30 mg) resulted in effective pain control with mean pain score reductions of 5.1 versus 3.9 on a 10-point scale 3
Pharmacokinetic Differences from Adults
The pharmacokinetics of ketorolac differ significantly in pediatric patients:
- Volume of distribution is increased by up to 2-fold compared to adults 1
- Plasma clearance is higher in children, likely due to lower plasma protein binding 1
- Despite these differences, the elimination half-life remains similar between children and adults (approximately 5-6 hours) 1
- These pharmacokinetic differences necessitate higher relative dosing in children, though dosing intervals remain similar to adults 1
Maximum Dosing Limits
- Absolute maximum daily dose: 90 mg 1
- Maximum treatment duration: 48 hours for IV administration 1
- Maximum treatment duration: 7 days for oral administration 1
Clinical Efficacy
- Ketorolac demonstrates analgesic efficacy equivalent to major opioid analgesics such as morphine and superior to codeine for postoperative pain in children 1
- When combined with opioids, ketorolac exhibits marked opioid-sparing effects, allowing lower opioid doses and reducing opioid-related adverse effects including respiratory depression, nausea/vomiting, and ileus 1
Safety Considerations and Contraindications
Important caveats:
- Controversy exists regarding ketorolac use after tonsillectomy due to potential increased risk of postoperative hemorrhage 1
- For other pediatric surgeries, multiple studies confirm ketorolac is not associated with increased bleeding risk 1
- Bleeding time may be slightly increased but typically remains within normal values due to reversible antiplatelet effects 1
- Unlike opioids, ketorolac does not cause respiratory depression, sedation, nausea/vomiting, or urinary retention 1
Adult Dosing for Reference (Not Pediatric)
The adult guideline from 2002 lists 60 mg IM every 15-30 minutes with a maximum of 120 mg per day for migraine treatment, but this is not applicable to pediatric dosing 4