Is ketorolac (Toradol) appropriate for a 10‑year‑old child, and what oral dose and precautions should be used?

Ketorolac Use in 10-Year-Old Children

Ketorolac is appropriate and effective for acute pain management in 10-year-old children, administered intravenously at 0.5 mg/kg (not to exceed 30 mg as a single dose), with oral continuation therapy contraindicated in this age group per FDA labeling. 1

FDA-Approved Dosing and Route

• The FDA explicitly states that oral ketorolac is NOT approved for children under 17 years of age. 1
• Intravenous ketorolac is the appropriate route for a 10-year-old child at 0.5 mg/kg per dose. 2
• The recommended IV dosing regimen is 0.5 mg/kg as an initial dose, followed by either bolus injections of 1.0 mg/kg every 6 hours OR a continuous infusion of 0.17 mg/kg/hour. 2
• Maximum daily dose should not exceed 90 mg, and treatment duration must be limited to 48 hours maximum in pediatric patients. 2
• Intramuscular injections should be avoided in children unless IV access is unavailable. 2

Clinical Efficacy in Pediatric Populations

• Ketorolac provides analgesic efficacy equivalent to morphine and superior to codeine for postoperative pain in children. 2
• Recent meta-analysis demonstrates a mean pain score reduction of -2.06 points with ketorolac in pediatric patients. 3
• Pain freedom at discharge was achieved in 66% of pediatric patients treated with ketorolac. 3
• Ketorolac reduces postoperative opioid requirements by 25-50% when used as part of multimodal analgesia. 4, 5

Critical Safety Considerations and Contraindications

Absolute contraindications in children include: 6

• Active or history of gastrointestinal bleeding or peptic ulcer disease
• Known hypersensitivity to aspirin or other NSAIDs
• Renal impairment or compromised kidney function
• Compromised hemostasis or bleeding disorders

Special caution is required in: 4, 7

• Children with sickle cell disease (particularly during vaso-occlusive crisis) due to elevated acute kidney injury risk 4, 7
• Children with mastocytosis (one lethal idiosyncratic reaction reported in an adult; recommend complete avoidance) 4
• Patients with marginal baseline kidney function 7
• Dehydrated or volume-depleted children 7

Monitoring Requirements

Before initiating ketorolac therapy, obtain: 8

• Baseline blood pressure
• BUN and creatinine
• Complete blood count
• Liver function tests

During therapy, monitor for: 6, 3

• Signs of gastrointestinal bleeding (the pooled rate of GI adverse events is only 1.53% in pediatric patients) 3
• Renal function deterioration
• Bleeding complications (bleeding time may be slightly increased but typically remains within normal limits) 2

Clinical Advantages Over Opioids

• Ketorolac provides opioid-level analgesia without respiratory depression, sedation, nausea/vomiting, urinary retention, or addiction potential. 5, 2
• Unlike opioids, ketorolac can be discontinued abruptly without withdrawal symptoms. 5
• Recovery of bowel function after abdominal surgery occurs sooner with ketorolac compared to opioid-treated patients. 2
• When combined with opioids, ketorolac exhibits marked opioid-sparing effects, reducing opioid-related adverse events. 2

Pharmacokinetic Considerations in Children

• Children have a 2-fold increased volume of distribution compared to adults, requiring higher weight-based dosing. 2
• Plasma clearance is higher in children due to lower plasma protein binding. 2
• Despite these differences, elimination half-life remains similar to adults, so dosing intervals remain the same (every 6 hours). 2
• Younger children and infants may require slightly higher dosages than older children to achieve equivalent pain relief. 2

Common Pitfalls to Avoid

• Do not prescribe oral ketorolac for discharge in a 10-year-old—this is off-label and not FDA-approved for children under 17 years. 1
• Do not exceed 48 hours of IV therapy in pediatric patients (unlike the 5-day limit in adults). 2
• Do not use ketorolac in children with even marginal renal impairment without careful risk-benefit assessment. 7
• Do not administer intramuscular injections as first-line in children when IV access is available. 2
• Avoid ketorolac entirely in children with mastocytosis due to reported fatal reactions. 4