What is the recommended dose and duration of prednisolone (corticosteroid) for the treatment of croup in children?

Prednisolone Dosing for Croup in Children

For children with croup, a single oral dose of prednisolone 1 mg/kg (up to 60 mg) is recommended as an effective treatment option, though dexamethasone may be preferred due to lower re-presentation rates. 1, 2, 3

Dosing Recommendations

Initial Dose

• Prednisolone: 1 mg/kg orally (maximum 60 mg) 1, 2
• Alternative: Dexamethasone 0.6 mg/kg orally (maximum 10-12 mg) 4

Duration

• Single dose is typically sufficient for mild to moderate croup 2, 4
• For more severe cases, prednisolone can be continued for up to 3 days 5

Comparative Effectiveness

Prednisolone vs. Dexamethasone:

• Both medications effectively reduce croup symptoms 5, 2
• Dexamethasone may be superior in preventing return visits (7% vs 29% re-presentation rate) 3
• No significant differences in:
  • Duration of croup symptoms
  • Duration of nonbarky cough
  • Nights with disturbed sleep for parents 5

Clinical Decision Algorithm

1. Assess croup severity:

   • Mild: Barking cough, no stridor at rest
   • Moderate: Barking cough, audible stridor at rest, mild retractions
   • Severe: Prominent stridor, marked retractions, agitation/lethargy

2. Treatment based on severity:

   • Mild to moderate croup: Single dose of prednisolone 1 mg/kg or dexamethasone 0.6 mg/kg 2, 4
   • Severe croup: Consider nebulized epinephrine plus corticosteroids 1, 6

3. Administration considerations:

   • Oral administration is preferred when possible
   • For children unable to tolerate oral medication (vomiting or severe respiratory distress), consider alternative routes 4

Important Clinical Considerations

• Prednisolone has the advantage of being commercially available in liquid preparations, making administration easier in young children 3
• Benefits of corticosteroids in croup clearly outweigh risks 2
• Corticosteroid-induced complications in croup treatment are rare 4
• A single dose or short course of systemic corticosteroids carries minimal risk, with the only potential significant adverse effect being increased risk of severe varicella infection 2

Common Pitfalls to Avoid

• Delaying corticosteroid administration in moderate to severe croup
• Using repeated steroid courses unnecessarily
• Failing to consider dexamethasone as an alternative when available, given its potentially lower re-presentation rates 3
• Overreliance on humidified oxygen without corticosteroid therapy, as evidence for humidification alone is lacking 6

Corticosteroids have become the standard of care for croup management, with strong evidence supporting their use in reducing symptom duration, hospitalization rates, and the need for additional interventions 2, 4.