What is the appropriate dosage and usage of oral steroids, such as prednisolone, for a 4-year-old child?

Oral Steroid Dosing for a 4-Year-Old Child

For a 4-year-old child with an asthma exacerbation, administer prednisolone or prednisone at 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days, with no need to taper if the course is less than 10 days. 1, 2

Specific Dosing Recommendations

For Asthma Exacerbations

• Dose: 1-2 mg/kg/day of prednisolone or prednisone, given as a single daily dose or divided into 2 doses 1
• Maximum daily dose: 60 mg/day (this was updated from the previous 30 mg maximum) 1
• Duration: Continue for 3-10 days, typically until symptoms resolve or peak expiratory flow reaches 70% of predicted 1, 2
• No tapering needed: For courses less than 10 days, there is no need to taper the dose, especially if the child is concurrently taking inhaled corticosteroids 1

Route of Administration

• Oral route is preferred: There is no advantage of IV or IM preparations over the oral route if gastrointestinal absorption is not impaired 1
• Oral steroids should be given early in treatment, as anti-inflammatory effects may not be apparent for 6-12 hours 3, 4

Dosing Considerations by Indication

Acute Asthma Exacerbation (Most Common)

• Start with 1 mg/kg/day rather than 2 mg/kg/day when possible, as behavioral side effects (anxiety, aggression, hyperactivity) are twice as common at the higher dose with comparable efficacy 5
• The number needed to harm is 4.8 for aggressive behavior and 6.1 for anxiety at the 2 mg/kg dose 5

Chronic Cough (Non-Specific)

• Oral steroids are NOT recommended for non-specific cough in children 1
• If asthma is suspected, use inhaled corticosteroids (400 mcg/day beclomethasone equivalent) for 2-4 weeks instead 1
• One RCT in children aged 1-5 years found oral steroids conferred no benefit for wheeze without asthma and were associated with increased hospitalizations 1

Safety Profile

Short-Course Safety (< 2 weeks)

• Short courses of oral steroids (less than 2 weeks) are very unlikely to cause long-term side effects in children 6
• Common short-term side effects include behavioral changes (anxiety, hyperactivity, aggression), increased appetite, and fluid retention 1, 5

When to Avoid or Use Caution

• Children requiring courses more than 2 weeks' duration warrant specialist referral and a weaning plan to reduce adrenal suppression 6
• Long-term use (>15 days) is associated with weight gain (21.1%), growth retardation (18.1%), Cushingoid features (19.4%), and increased infection risk 7

Critical Pitfalls to Avoid

Underuse is Dangerous

• Underuse of corticosteroids is associated with increased mortality in asthma 1, 3
• Delay in administration can be fatal—assess severity objectively and treat early 1, 3

Common Prescribing Errors

• Do not use oral steroids for non-specific cough without clear asthma features 1
• Do not exceed 60 mg/day maximum dose in this age group 1
• Do not taper doses for courses under 10 days 1, 2
• Do not use IV route unless GI absorption is compromised 1

Practical Administration Tips

Formulation Options

• Prednisolone oral solution is available and preferred for young children 2
• 5 mL of prednisolone sodium phosphate oral solution (containing 15 mg prednisolone base) can be used for dosing 2
• Ensure proper dosing by weight: for a 16 kg 4-year-old, this would be 16-32 mg daily (approximately 5-10 mL of standard solution) 2

Monitoring During Treatment

• Assess response within 24 hours of starting treatment 1
• Continue until symptoms resolve, typically 3-10 days 1, 2
• No routine follow-up labs needed for short courses 6