Pediatric Systemic Steroid Dosing Guidelines
For pediatric patients requiring systemic corticosteroids, the recommended dose of prednisone or prednisolone is 1-2 mg/kg/day with a maximum of 60 mg/day for most conditions. 1, 2
General Dosing Principles
- Prednisone and prednisolone are equivalent medications and can be used interchangeably at the same dosage 1, 2
- For significantly overweight children, dosing should be based on ideal body weight to avoid unnecessary steroid exposure 1, 2
- Maximum daily dose is typically 60 mg, though in some cases up to 80 mg may be considered for specific conditions 1
- Morning administration (before 9 am) is preferred to minimize adrenocortical suppression 3
Condition-Specific Dosing
Asthma Exacerbations
- Short-course burst for children 0-4 years: 1-2 mg/kg/day, maximum 60 mg/day for 3-10 days 4
- Short-course burst for children 5-11 years: 1-2 mg/kg/day, maximum 60 mg/day for 3-10 days 4
- For mild-to-moderate asthma exacerbations, a dose of 1 mg/kg/day is recommended over 2 mg/kg/day as it provides comparable benefits with fewer behavioral side effects 5
- No tapering is needed for courses less than 7 days; for courses up to 10 days, tapering is probably not necessary, especially if patients are concurrently taking inhaled corticosteroids 4
Nephrotic Syndrome
- Initial episode: 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) as a single daily dose for 4-6 weeks, followed by 40 mg/m²/day or 1.5 mg/kg/day on alternate days for 2-5 months with tapering 1
- Infrequent relapses: 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) until remission for at least 3 days, then 40 mg/m²/day or 1.5 mg/kg/day on alternate days for at least 4 weeks 4, 1
- Frequent relapses/steroid-dependent cases: Daily prednisone until remission for 3 days, followed by alternate-day prednisone for at least 3 months at the lowest effective dose 4, 1
Administration Considerations
- Administer with food or milk to reduce gastric irritation 3
- For most conditions, administer as a single daily dose in the morning to minimize adrenocortical suppression 1, 3
- For steroid-dependent conditions where alternate-day therapy is ineffective, daily prednisone at the lowest effective dose may be used 4, 1
- During upper respiratory infections in children with frequently relapsing or steroid-dependent nephrotic syndrome, daily prednisone may be given to prevent relapse 4, 1
Tapering Recommendations
- For corticosteroid courses less than 7 days, there is no need to taper the dose 4
- For courses up to 10 days, tapering is probably not necessary, especially if patients are concurrently taking inhaled corticosteroids 4
- For longer courses, taper gradually by reducing the dose by 5 mg every week until reaching 10 mg/day, then by 2.5 mg/week until reaching maintenance dose 2
Monitoring and Precautions
- Assess for steroid-related adverse effects regularly, especially with prolonged use 1, 2
- Monitor growth in children on long-term therapy 1, 2
- Consider corticosteroid-sparing agents for children with frequent relapses or steroid dependence who develop steroid-related adverse effects 4, 1
- Behavioral side effects, particularly anxiety and aggressive behavior, are more common at higher doses (2 mg/kg/day vs. 1 mg/kg/day) 5
- Multiple "bursts" of high-dose prednisone (4 or more per year) may affect the hypothalamic-pituitary-adrenal axis, especially when combined with inhaled corticosteroids 6
Important Caveats
- Systemic corticosteroids are not recommended for routine use in bronchiolitis 7
- For asthma exacerbations, there is no known advantage for higher doses of corticosteroids, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired 4
- Single-dose dexamethasone (0.3 mg/kg) may be an effective alternative to a 3-day course of oral prednisolone (1 mg/kg/day) for mild to moderate asthma exacerbations, with potential benefits of improved compliance and less vomiting 8, 9, 10