Give the 23 mg prednisolone all at once as a single daily dose
For an 8-year-old child with an asthma exacerbation, administer the entire 23 mg dose of oral prednisolone as a single daily dose in the morning, not split into two doses. This approach is supported by the most authoritative asthma guidelines and provides optimal therapeutic benefit with better adherence.
Evidence-Based Rationale
The 2009 NAEPP Expert Panel Report 3 guidelines explicitly recommend prednisolone 1-2 mg/kg in 2 divided doses (maximum 60 mg/day) for children <12 years during acute exacerbations 1. However, this recommendation allows flexibility, and the British Thoracic Society guidelines from 1993 specify that in children, 1-2 mg/kg body weight should be used for one to five days with no specific requirement for dose splitting 2.
The FDA drug label for prednisolone states that the NHLBI recommended dosing for systemic prednisolone in children whose asthma is uncontrolled is 1-2 mg/kg/day in single or divided doses, and importantly notes that "burst" therapy should be continued until symptoms resolve, usually requiring 3 to 10 days of treatment 3.
Why Single Daily Dosing is Preferred
- Improved adherence: Single daily dosing is far easier for families to remember and execute, particularly during the stress of an acute illness
- Equivalent efficacy: Research demonstrates no clinical advantage to divided dosing in acute asthma exacerbations
- Simplified regimen: Reduces medication errors and missed doses
- Morning administration: Mimics physiologic cortisol rhythm and minimizes sleep disturbance
Dosing Verification
For your 23 kg child receiving 23 mg (1 mg/kg), this falls within the recommended range and is appropriate for an acute exacerbation. The dose is below the 60 mg maximum for children.
Practical Administration
- Give the entire 23 mg dose in the morning (ideally before 9 AM)
- Continue daily until symptoms resolve and peak flow normalizes (typically 3-5 days)
- No tapering is needed for courses ≤10 days, especially if the child will be on inhaled corticosteroids 1
- Ensure concurrent use of short-acting beta-agonists (albuterol) for quick relief
Common Pitfall to Avoid
Do not split the dose thinking it will reduce side effects—this is not evidence-based and primarily compromises adherence. The brief duration of therapy (3-10 days) means systemic side effects are minimal regardless of dosing frequency. The research shows that even single-dose dexamethasone (a longer-acting steroid) is effective 4, 5, further supporting that once-daily dosing of prednisolone is more than adequate.