What is the recommended dosing for topical 5% lidocaine (lidocaine) in pediatric patients?

Pediatric Dosing for Topical 5% Lidocaine

For topical 5% lidocaine in children over 12 years, apply to the affected area no more than 3 to 4 times daily; for children under 12 years, consult a physician before use. 1

Age-Based Dosing Guidelines

Children Over 12 Years

• Apply topical 5% lidocaine to the affected area 3 to 4 times daily maximum 1
• After application, wash hands thoroughly with soap and water 1

Children Under 12 Years

• FDA labeling explicitly states to "ask a doctor" before using topical 5% lidocaine in this age group 1
• This reflects the lack of established safety and efficacy data for routine over-the-counter use in younger children 1

Context: When Topical Lidocaine IS Used in Pediatrics

While the FDA label for 5% topical lidocaine is restrictive for children under 12, lower concentration topical lidocaine preparations (4% or less) are routinely used in pediatric emergency and procedural settings under medical supervision. 2

For Procedural Anesthesia (Under Medical Supervision)

Topical 4% liposomal lidocaine (LMX4) provides anesthesia in approximately 30 minutes and is commonly used for:

• IV line placement or venipuncture 2
• Lumbar puncture 2
• Abscess drainage 2
• Joint aspiration 2

Critical age-specific consideration: The topical anesthetic dose should be lower for patients <12 months old or weighing <10 kg. 2

For Laceration Repair (Under Medical Supervision)

Topical lidocaine-epinephrine-tetracaine (LET) combinations provide excellent wound anesthesia in 20-30 minutes for open wounds. 2

Maximum Systemic Doses When Infiltrative Lidocaine Is Used

While your question asks about topical 5% lidocaine, understanding systemic dose limits is crucial because:

For infiltrative (injected) lidocaine in children:

• Without epinephrine: 1.5-2.0 mg/kg maximum 2, 3
• With epinephrine: 3.0-4.5 mg/kg maximum 2, 3

For infants under 6 months: Reduce all amide local anesthetic doses by 30% 3, 4

Critical Safety Warnings

Contraindications for Topical Lidocaine Use

• Allergy to amide anesthetics 2
• Non-intact skin (for most preparations, though LET is specifically for open wounds) 2
• Recent sulfonamide antibiotic use (for EMLA specifically) 2

Absorption Concerns in Young Children

Younger children, particularly those under 18 months and with lower body weights, achieve higher peak plasma lidocaine levels more rapidly than older children. 5 This is why:

• The FDA restricts over-the-counter 5% topical lidocaine use in children under 12 1
• Medical supervision is essential when using topical lidocaine in younger pediatric patients 5, 6
• Plasma concentrations in children can be much higher than in adults even with the same topical dose 6

Signs of Lidocaine Toxicity to Monitor

Early signs include:

• Circumoral numbness 4
• Facial tingling 4
• Metallic taste 4
• Auditory changes 4

Severe manifestations include:

• Seizures 3, 4
• CNS depression 3, 4
• Cardiac arrhythmias 7

Common Pitfalls to Avoid

• Never use 5% topical lidocaine over-the-counter in children under 12 without physician guidance 1
• Do not apply topical lidocaine to mucous membranes or allow ingestion 2
• Avoid combining multiple lidocaine-containing products simultaneously, as this increases toxicity risk 4
• Remember that occlusive dressings significantly increase systemic absorption 8
• In infants under 6 months, always reduce doses by 30% 3, 4