What is the recommended dose of dexamethasone (corticosteroid) for pediatric patients?

Pediatric Dexamethasone Dosing Recommendations

The recommended dose of dexamethasone for pediatric patients varies by indication, with 0.15 mg/kg every 6 hours for 2-4 days being the standard dose for bacterial meningitis, while 0.6 mg/kg (maximum 16 mg) as a single dose is effective for asthma exacerbations. 1, 2

Dexamethasone Dosing by Indication

Bacterial Meningitis

• For infants and children with H. influenzae type b meningitis, dexamethasone should be administered at 0.15 mg/kg every 6 hours for 2-4 days 1
• Dexamethasone should be initiated 10-20 minutes prior to, or at least concomitant with, the first antimicrobial dose 1
• Adjunctive dexamethasone should not be given to infants and children who have already received antimicrobial therapy 1
• For pneumococcal meningitis in children, the use of adjunctive dexamethasone remains controversial 1
• Dexamethasone is not currently recommended for neonatal meningitis due to insufficient evidence 1

Asthma Exacerbations

• For mild to moderate asthma exacerbations, a single dose of dexamethasone at 0.6 mg/kg (maximum 16 mg) is non-inferior to multiple-day regimens 2
• Alternatively, a single dose of 0.3 mg/kg has been shown to be non-inferior to a 3-day course of prednisolone (1 mg/kg/day) 3, 4
• Single-dose dexamethasone offers advantages of improved compliance and fewer side effects compared to multi-day prednisolone regimens 5

Croup

• For croup, dexamethasone may be administered as a single dose, often in conjunction with nebulized epinephrine in severe cases 6

Bronchopulmonary Dysplasia (BPD)

• High-dose dexamethasone (0.5 mg/kg/day) is not recommended for prevention or treatment of BPD in preterm infants due to adverse neurodevelopmental outcomes 1
• Low-dose dexamethasone therapy (<0.2 mg/kg/day) may facilitate extubation with potentially fewer adverse effects 1

Acute Lymphoblastic Leukemia (ALL)

• In pediatric ALL protocols, dexamethasone dosing varies by risk stratification and treatment phase 1
• The COG uses a dexamethasone schedule of 6 mg/m² per day for 28 days in certain protocols 1
• For patients aged 10 years or older, dexamethasone carries a higher risk of osteonecrosis compared to prednisone 1

Administration Considerations

• For intravenous administration, the FDA-approved dosage is generally the same as the oral dosage 7
• In certain overwhelming, acute, life-threatening situations, higher doses may be justified 7
• When dexamethasone has not been started with the first dose of antibiotics in meningitis cases, it can still be started up to 4 hours after initiation of antibiotic treatment 1

Safety Considerations

• Dexamethasone has a longer half-life (36-72 hours) compared to prednisolone (12-36 hours), allowing for less frequent dosing 4
• Common side effects include gastric irritation, behavioral changes, weight gain, and increased appetite 8
• Dexamethasone binds only to glucocorticoid receptors, which in animal models has been shown to potentially affect hippocampal neurons differently than hydrocortisone 1
• Age may be an important factor for corticosteroid selection, with dexamethasone showing improved outcomes in patients younger than 10 years of age for certain conditions 1

Clinical Pearls

• Dexamethasone should be stopped if bacterial meningitis is ruled out or if the causative organism is not H. influenzae or S. pneumoniae 1
• For asthma exacerbations, single-dose dexamethasone offers advantages of improved compliance and fewer side effects (particularly vomiting) compared to multi-day prednisolone regimens 3, 5
• When treating bacterial meningitis, timing of dexamethasone administration is critical - it should ideally be given before or with the first antibiotic dose 1