What is the recommended steroid dosage for a 6-year-old child weighing 20 kg?

Steroid Dosing for a 6-Year-Old Child Weighing 20 kg

For most conditions requiring corticosteroid therapy in a 6-year-old weighing 20 kg, the recommended dose is 40 mg daily (calculated as 2 mg/kg/day with a maximum of 60 mg/day), or alternatively 48 mg daily using the body surface area method (60 mg/m²/day). 1, 2

Weight-Based vs. Body Surface Area Dosing

The choice between dosing methods depends on the clinical context:

• Weight-based dosing: 2 mg/kg/day = 40 mg/day for this 20 kg child 3, 2
• Body surface area dosing: 60 mg/m²/day ≈ 48 mg/day (BSA for a 6-year-old, 20 kg child is approximately 0.8 m²) 1, 2
• Simplified weight-based approximation: Using the equation [2 × W + 8], this yields 48 mg/day, which closely approximates the BSA-based dose 4

For significantly overweight children, dosing should be based on ideal body weight rather than actual weight to avoid unnecessary steroid exposure and minimize side effects. 3, 2, 5

Condition-Specific Dosing Recommendations

Acute Asthma Exacerbation

• Initial dose: 1-2 mg/kg/day (20-40 mg/day) as a single daily dose for 3-10 days 3, 5
• Lower doses (1 mg/kg/day) are preferred as they provide comparable benefits with significantly fewer behavioral side effects (anxiety, hyperactivity, aggressive behavior) compared to 2 mg/kg/day 6
• No need to taper if duration is less than 10 days 3

Nephrotic Syndrome or Autoimmune Conditions

• Initial treatment: 2 mg/kg/day or 60 mg/m²/day (maximum 60 mg/day) as a single daily dose 3, 2, 5
• For this 20 kg child: 40 mg daily (weight-based) or 48 mg daily (BSA-based)
• Continue until remission (typically 3+ days), then switch to alternate-day dosing 3
• Alternate-day maintenance: 1.5 mg/kg/dose or 40 mg/m²/dose (maximum 40 mg on alternate days) 3, 2
• For this child: 30 mg every other day (weight-based) or 32 mg every other day (BSA-based)

Perioperative Stress Dosing (Adrenal Insufficiency)

For children with known or suspected adrenal insufficiency undergoing procedures:

• Major surgery: Hydrocortisone 2 mg/kg at induction (40 mg for this child), followed by continuous infusion of 50 mg/24 hours (for 11-20 kg weight range) 3
• Minor procedures with general anesthesia: Hydrocortisone 2 mg/kg IV/IM at induction (40 mg), then double normal doses for 24 hours 3

Administration Timing and Practical Considerations

Optimal timing for single daily dosing is in the morning before 9 AM to align with the body's natural cortisol rhythm and minimize HPA axis suppression 7

However, if behavioral side effects occur (hyperactivity, emotional lability, anxiety, or aggressive behavior), consider afternoon dosing after school to minimize disruption during school hours 1, 6

Key Administration Points:

• Administer with food or milk to reduce gastric irritation 7
• For multiple daily doses, space evenly throughout the day 7
• Consider antacids between meals for high-dose or prolonged therapy 7

Tapering Guidelines

For courses longer than 2 weeks, gradual tapering is essential to prevent adrenal insufficiency:

1. Initial taper: Reduce by 25-33% at appropriate intervals once clinical response is achieved 1
2. Structured taper approach:
   • Reduce by 5 mg weekly until reaching 10 mg/day
   • Then reduce by 2.5 mg weekly until reaching maintenance dose 2
3. For courses less than 10-14 days, abrupt cessation is safe without tapering 3, 8

Critical Safety Considerations

Short-Term Use (< 2 weeks)

Short courses of oral steroids are very unlikely to cause long-term side effects in children 8

Monitoring Requirements:

• Blood pressure, weight, height, and behavioral changes should be monitored regularly 7
• Children requiring courses longer than 2 weeks warrant specialist referral and a formal weaning plan to reduce risk of adrenal suppression 8
• For long-term therapy (>18 months), consider baseline and annual bone mineral density testing 2

Common Side Effects to Anticipate:

• Behavioral effects: Anxiety, hyperactivity, aggressive behavior, emotional lability (occur in up to 50% at higher doses) 6
• Cushingoid features: Weight gain, increased appetite, moon facies (occur in 80% after 2 years of treatment) 2, 5
• Growth suppression: May occur even at low doses without laboratory evidence of HPA axis suppression 7

Important Pitfalls to Avoid:

• Do not use actual body weight for obese children—this leads to overdosing and increased side effects 3, 2, 5
• Do not abruptly stop steroids after prolonged use (>2 weeks)—this can precipitate adrenal crisis 7, 8
• Do not exceed maximum doses: 60 mg/day for daily dosing or 40 mg for alternate-day dosing, regardless of calculated dose 3, 2

Practical Dosing Summary for This 20 kg Child

Indication	Initial Daily Dose	Alternate-Day Dose	Duration
Acute asthma	20-40 mg daily	N/A	3-10 days [3,5]
Nephrotic syndrome	40 mg daily	30 mg every other day (after remission)	4-6 weeks daily, then 2-5 months alternate-day [3,2,5]
Autoimmune conditions	40 mg daily	30 mg every other day (maintenance)	Variable, individualized [1,2]

The number needed to harm for behavioral side effects at 2 mg/kg/day vs 1 mg/kg/day is 4.8 for aggressive behavior, 6.1 for anxiety, and 8.6 for hyperactivity, making lower doses preferable when clinically appropriate 6