What is the recommended dose of tranexamic acid (TXA) in children?

Tranexamic Acid Dosing in Children

For pediatric trauma and surgery, administer tranexamic acid at 15 mg/kg as a loading dose followed by 2 mg/kg/hour infusion. 1, 2

Clinical Scenario-Specific Dosing

Trauma and Major Surgery

• Loading dose: 15 mg/kg IV followed by maintenance infusion: 2 mg/kg/hour 1, 2
• This regimen is the standard recommended by the American Society of Anesthesiologists for pediatric trauma and surgical bleeding 1
• Administer as early as possible, ideally within 3 hours of injury in trauma cases to maximize benefit 1
• Delaying administration reduces efficacy by approximately 10% for every 15 minutes 1
• Critical pitfall: Administering TXA beyond 3 hours after trauma may be harmful rather than beneficial 1

Menorrhagia in Adolescents

• Oral dosing: 30-50 mg/kg/day divided into 2-3 doses, with a maximum daily dose of 3-4 g 1, 2, 3
• For adolescents >12 years, can use adult regimen: start at 500 mg twice daily, gradually increasing up to 1000 mg 3-4 times daily as needed 3
• For severe cases requiring IV treatment (rare): 15 mg/kg loading dose followed by 2 mg/kg/hour infusion 2, 3

Hereditary Angioedema Prophylaxis

• Maximum dose: 15-25 mg/kg two to three times daily, not exceeding 3 g/day 1, 2

Hemophilia (Dental Extractions)

• 10 mg/kg IV as a single dose immediately before tooth extraction 4
• Post-extraction: 10 mg/kg IV 3-4 times daily for 2-8 days 4
• Infuse no faster than 1 mL/minute to avoid hypotension 4

Alternative Dosing Considerations

While the guideline-recommended 15 mg/kg loading dose is standard, emerging research suggests lower doses may be equally effective:

• A 2020 randomized controlled trial demonstrated that 10 mg/kg loading dose followed by 5 mg/kg/hour was non-inferior to higher doses (50 mg/kg) for craniosynostosis surgery 5
• For cardiac surgery in infants, pharmacokinetic modeling supports a "10-10-4-4 rule": 10 mg/kg bolus, 10 mg/kg/hour infusion, then 4 mg/kg into CPB prime with 4 mg/kg/hour post-CPB 6
• A 2001 study in scoliosis surgery used 10 mg/kg loading with 1 mg/kg/hour maintenance successfully 7

However, the most recent guidelines consistently recommend the 15 mg/kg loading dose with 2 mg/kg/hour maintenance for trauma and surgery, which should be followed in standard practice. 1, 2

Renal Impairment Adjustments

For moderate to severe renal impairment, dose reduction is mandatory 4:

• Serum creatinine 1.36-2.83 mg/dL: 10 mg/kg twice daily 4
• Serum creatinine 2.83-5.66 mg/dL: 10 mg/kg once daily 4
• Serum creatinine >5.66 mg/dL: 10 mg/kg every 48 hours or 5 mg/kg every 24 hours 4

Critical Safety Considerations

Contraindications

• Absolute contraindications: Active intravascular clotting, subarachnoid hemorrhage, hypersensitivity to TXA 4
• Relative contraindications: Recent thrombosis, atrial fibrillation, known thrombophilia 2, 3

Administration Safety

• TXA is for IV use only - inadvertent intrathecal administration has caused seizures and cardiac arrhythmias 4
• Avoid mixing with penicillin-containing solutions 4
• Can be mixed with electrolyte solutions, carbohydrate solutions, amino acids, and dextran; heparin may be added 4

Common Pitfall

Using fixed adult doses in pediatric patients without weight-based calculation leads to under or overdosing 1 - always calculate based on actual body weight.