What is the preferred corticosteroid, prednisone (corticosteroid) or prednisolone (corticosteroid), for treating pediatric anaphylaxis?

Prednisolone is Preferred Over Prednisone for Pediatric Anaphylaxis

For pediatric anaphylaxis, prednisolone is preferred over prednisone as the corticosteroid of choice due to its immediate bioavailability without requiring liver conversion.

Primary Treatment Considerations

Epinephrine is the first-line treatment for anaphylaxis in children, with corticosteroids serving as adjunctive therapy only:

• Epinephrine should be administered intramuscularly into the lateral thigh at 0.01 mg/kg (maximum 0.3 mg) 1
• Epinephrine autoinjectors are recommended at 0.15 mg for children weighing 10-25 kg and 0.3 mg for children weighing >25 kg 2, 1

Corticosteroid Selection

When selecting a corticosteroid for pediatric anaphylaxis:

1. Prednisolone is preferred because:

   • It is immediately bioavailable in its active form
   • Does not require hepatic conversion (unlike prednisone which must be converted to prednisolone in the liver)
   • Provides faster onset of action in pediatric patients
   • Better suited for children who may have immature liver function

2. Dosing recommendations:

   • Oral prednisolone: 0.5-1 mg/kg/day for 2-3 days 1
   • For milder reactions, 0.5 mg/kg may be sufficient 2

Important Clinical Considerations

1. Timing of administration:

   • Corticosteroids should NEVER delay epinephrine administration 2
   • Corticosteroids have a delayed onset of action (4-6 hours) and do not treat acute symptoms 2

2. Role in treatment:

   • Corticosteroids may help prevent protracted or biphasic anaphylaxis 2
   • They may be particularly beneficial for patients with asthma or those recently treated with corticosteroids 2
   • May reduce length of hospital stay but do not reduce ED revisits 3

3. Mechanism of action:

   • Primary effects occur through genomic mechanisms (4-24 hours)
   • Some faster non-genomic effects may occur within 5-30 minutes 3

Clinical Algorithm for Corticosteroid Use in Pediatric Anaphylaxis

1. First priority: Administer epinephrine immediately for anaphylaxis
2. Second priority: Provide supportive care (positioning, oxygen if needed)
3. Third priority: Consider adjunctive therapies:
   • Administer prednisolone 0.5-1 mg/kg orally if patient can swallow
   • For patients unable to take oral medications, use IV methylprednisolone

Evidence Quality and Limitations

The evidence supporting corticosteroid use in anaphylaxis is limited:

• No randomized controlled trials exist due to the emergency nature of anaphylaxis 3, 4
• Current recommendations are based primarily on observational studies, expert opinion, and animal studies
• A 2023 study from the Cross-Canada Anaphylaxis Registry found that prehospital corticosteroid use was associated with increased need for IV fluids and hospital admission 5

Conclusion

While epinephrine remains the essential life-saving medication for anaphylaxis, when a corticosteroid is indicated as adjunctive therapy in pediatric anaphylaxis, prednisolone is preferred over prednisone due to its immediate bioavailability without requiring hepatic conversion.