TXA (Tranexamic Acid) in Pediatrics 

Kids get hurt.  And they get sick.  It’s inevitable.  Whether their fingers get caught accidentally in a car door or bedroom door slamming closed, or they trip and fall while running on their uncooperative little toddler legs, or catching all the germs as their immune systems slowly struggle to fight off every known virus to mankind. While most of the time, the injuries and illnesses are minor and self-resolving, every once in a while, there is major injury or illness, and significant bleeding is involved.  While transfusing blood can be beneficial to those who have lost it or continue to lose it quickly, blood may not always be immediately available. Or maybe the family does not desire blood transfusions. Wouldn’t it be nice if there were adjuncts to prevent further bleeding or add benefit when blood may not be option (prehospital)?  Enter TXA or tranexamic acid, “The Clot Stabilizer”!  Let’s take a moment to review TXA (Tranexamic Acid) in Pediatrics!

TXA has been mentioned previously on PEM Morsels in the following contexts: Post Tonsillectomy Hemorrhage, Hemophilia in the ED, Von Willebrand Disease, Epistaxis in Children , Hereditary Angioedema , Hemoptysis in Children, Hyphema, and even in Neonatal Subgaleal Hemorrhage. But what is the drug really approved for, how does it actually work, and what are some of the off-label (for now) uses of TXA that add value to this medication?

TXA (Tranexamic Acid) in Pediatrics –  Basics 

• FDA approved for heavy menstrual bleeding or as a preventative in patients with hemophilia [Nishijima 2016, Chauncey 2023] 
  • Tooth extractions and menorrhagia specifically 
• Some off label uses that are common (systemic/IV, oral, topical) 
  • Massive transfusion protocol (MTP) with heavy bleeding 
  • Hyper-fibrinolysis 
  • Combat trauma patients receiving at least 1 unit blood 
• The CRASH-2 trial and the MATTERs trial found improved survival/decreased mortality when given TXA vs placebo in adult trauma patients with significant hemorrhage or shock [Shakur 2010, Roberts 2011, Morrison 2012] 
• The TIC-TOC trial has evaluated the feasibility and is evaluating the efficacy of TXA use in children in trauma applications [Nishijima 2023] 
• TXA does not have strong evidence for increased survival in children compared to the robust studies in adults, but limited data is pointing in that direction [Kornelsen 2022] 
  • More studies needed 
  • No difference in thrombolic events compared to placebo (ie does not increase risk of clotting)

TXA (Tranexamic Acid) in Pediatrics –  Mechanism of Action

• It is an anti-thrombolytic, NOT a pro-coagulant [Chauncey 2023]
• Reversible competitive inhibitor on lysine binding site on plasminogen 
  • Plasmin breaks down clots  
  • Plasmin is preceded by plasminogen 
  • TXA prevents conversion of plasminogen to plasmin 
  • TXA thus inhibits clot breakdown, thereby stabilizing the clot 
• In hereditary angioedema it indirectly reduces complement activation, reduces plasmin activity, and preserves C1 esterase inhibitor levels. 

TXA (Tranexamic Acid) in Pediatrics –  Dosing

• 20 mg/kg IV bolus over 10 minutes [Chauncey 2023]
• Can give 10 mL/kg/hr over the next 8 hrs 
• TIC-TOC study for pediatric trauma is looking at 15 mg/kg bolus then 2 mg/kg/hr for 8 hours versus 30 mg/kg bolus then 4 mg/kg/hr for 8 hours [Nishijima 2023] 
• A retrospective study found an average pediatric dose was 22.4 mg/kg [Nishijima 2016] 
• Poorly studied in renally impaired patients. It is excreted by urine so careful dosing is required if used in kidney disease. 

TXA (Tranexamic Acid) in Pediatrics –  Applications

[Nishijima 2016, O’Neill 2020, Monteilh 2021, Kornelsen 2022, Chauncey 2023] 

• Off label uses- oral, topical, IV, inhaled 
• Patients needing massive transfusion protocols (MTP) 
• Hyperfibrinolysis in combat trauma patients needing at least 1 unit blood within 24h of presentation 
• To reduce blood loss during surgical operations 
  • Especially congenital heart disease operations 
  • Scoliosis surgeries 
  • Craniosynostosis or craniofacial surgeries 
• Inhaled in pulmonary hemorrhage 
• Bleeding in trauma 
• Post-tonsillectomy hemorrhage 
• Post partum hemorrhage
• Epistaxis
• Von Willebrand disease
• Hereditary angioedema

TXA (Tranexamic Acid) in Pediatrics –  Side Effects and Complications

• seizures (with high doses of TXA) 
• headaches 
• backache 
• abdominal pain 
• nausea 
• vomiting 
• diarrhea  
• fatigue 
• pulmonary embolism 
• deep vein thrombosis 
• anaphylaxis 
• impaired color vision and other visual disturbances 

TXA (Tranexamic Acid) in Pediatrics –  Cost

• One study reported 1,000 mg/10 mL vial was $17.50–$86.80 of IV form TXA [O’Neill 2020]
• Inexpensive! 

TXA (Tranexamic Acid) in Pediatrics – Contraindications 

• Known allergy to TXA 
• Known defective color vision 
• History of venous or arterial thromboembolism 
• Active thromboembolic disease 
• Greater than 3 hours from traumatic injury (relative) 

TXA (Tranexamic Acid) in Pediatrics –  Moral of the Morsel 

• Stop the Bleed! TXA can be used safely in children. 
• The Clot Stabilizer! TXA stabilizes clots, it doesn’t create them. 
• Ah Ah Ah Ah Stayin’ Alive! Efficacy studies are ongoing in children, but hint toward improved survivability when used in trauma. 

References

• Chauncey JM, Wieters JS. Tranexamic Acid. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532909/ 
• CRASH-2 trial collaborators. Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, El-Sayed H,Gogichaishvili T, Gupta S, Herrera J, Hunt B, Iribhogbe P, Izurieta M, Khamis H, Komolafe E, Marrero MA,Mejía-Mantilla J, Miranda J, Morales C, Olaomi O, Olldashi F, Perel P, Peto R, Ramana PV, Ravi RR,Yutthakasemsunt S. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion intrauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010Jul 03;376(9734):23-32. [PubMed: 20554319] 
• CRASH-2 collaborators. Roberts I, Shakur H, Afolabi A, Brohi K, Coats T, Dewan Y, Gando S, Guyatt G, HuntBJ, Morales C, Perel P, Prieto-Merino D, Woolley T. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011 Mar26;377(9771):1096-101, 1101.e1-2. [PubMed: 21439633] 
• Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in TraumaEmergency Resuscitation (MATTERs) Study. Arch Surg. 2012 Feb;147(2):113-9. [PubMed: 22006852] 
• Nishijima DK, VanBuren JM, Linakis SW, et al. Traumatic injury clinical trial evaluating tranexamic acid in children (TIC-TOC): A pilot randomized trial. Acad Emerg Med. 2022;29(7):862-873. doi:10.1111/acem.14481 
• O’Neil ER, Schmees LR, Resendiz K, Justino H, Anders MM. Inhaled Tranexamic Acid As a Novel Treatment for Pulmonary Hemorrhage in Critically Ill Pediatric Patients: An Observational Study. Crit Care Explor. 2020;2(1):e0075. Published 2020 Jan 29. doi:10.1097/CCE.0000000000000075 
• Nishijima DK, Monuteaux MC, Faraoni D, et al. Tranexamic Acid Use in United States Children’s Hospitals. J Emerg Med. 2016;50(6):868-874.e1. doi:10.1016/j.jemermed.2016.02.004 
• Monteilh C, Rabon L, Mayer-Hirshfeld I, McGreevy J. Nebulized Tranexamic Acid for Pediatric Post-tonsillectomy Hemorrhage: A Report of Two Cases. Clin Pract Cases Emerg Med. 2021;5(2):148-151. doi:10.5811/cpcem.2021.2.50799 
• Kornelsen E, Kuppermann N, Nishijima DK, et al. Effectiveness and safety of tranexamic acid in pediatric trauma: A systematic review and meta-analysis. Am J Emerg Med. 2022;55:103-110. doi:10.1016/j.ajem.2022.01.069