Nebulized Budesonide Dosing for Pediatric Patients Based on Weight
For pediatric patients with asthma, the recommended dose of budesonide via nebulizer is 0.25-0.5 mg for low dose therapy and 0.5-1.0 mg for medium dose therapy, with up to 1.0-2.0 mg for high dose therapy, administered once or twice daily. 1
Dosing Guidelines by Age Group
Children Under 4 Years of Age
- Low dose: 0.25-0.5 mg daily
- Medium dose: 0.5-1.0 mg daily
- High dose: >1.0 mg daily (up to 2.0 mg)
Children 4-11 Years of Age
- Low dose: 0.5 mg daily
- Medium dose: 1.0 mg daily
- High dose: >1.0 mg daily (up to 2.0 mg)
Administration Considerations
- Budesonide nebulizer suspension is the only inhaled corticosteroid with FDA-approved labeling for children <4 years of age 1
- For children <4 years: Use a face mask that fits snugly over nose and mouth
- Avoid nebulizing in the eyes
- Wash face after each treatment to prevent local side effects
- The dose may be administered once or twice daily
- Use only jet nebulizers as ultrasonic nebulizers are ineffective for suspensions 1
- Budesonide suspension is compatible with albuterol, ipratropium, and levalbuterol nebulizer solutions in the same nebulizer 1
Efficacy and Safety Considerations
- For most patients, the ability to increase cortisol production in response to stress remains intact with budesonide inhalation suspension treatment at recommended doses 2
- In studies of children 6 months to 8 years of age, the highest recommended dose of budesonide inhalation suspension (1 mg total daily dose) did not show statistically significant reduced urinary cortisol excretion compared to baseline 2
- Once-daily administration of budesonide inhalation suspension has been shown to be effective and well-tolerated in children with mild persistent asthma 3
Important Clinical Considerations
- Only about 14% of the nominal dose reaches infants and toddlers, with the percentage increasing from 9% to 19% with increasing age 4
- Approximately 75% of the nominal dose remains in the nebulizer equipment 4
- Despite this, the systemic exposure is similar across age groups, suggesting that from a safety perspective, the prescribed dose need not be adjusted for age 5
Potential Adverse Effects
- Common side effects include cough, dysphonia, and oral thrush (candidiasis) 1
- In high doses, systemic effects may occur, including adrenal suppression, although studies are not conclusive 1
- In low-to-medium doses, suppression of growth velocity has been observed in children, but this effect may be transient 1
- Monitor for HPA axis effects, especially in susceptible individuals, younger children, and patients given high doses for prolonged periods 2
Practical Tips
- Use a spacer or valved holding chamber with non-breath-actuated MDIs
- Have patients rinse mouth and spit after inhalation to decrease local side effects
- For children using a face mask, clean the face after administration
- The most important determinant of appropriate dosing is the clinician's judgment of the patient's response to therapy 1
- Once control of asthma is achieved, the dose should be carefully titrated to the minimum dose required to maintain control 1
Remember that budesonide preparations are not interchangeable on a mcg or per-puff basis, and dosing should be adjusted based on clinical response.