What is the recommended dosage of levosalbutamol (albuterol) for children?

Levosalbutamol Dosing in Children

For children with asthma, levosalbutamol should be initiated at 0.31 mg via nebulization every 4-6 hours as needed, with the option to increase to 0.63 mg for acute exacerbations or more severe disease. 1, 2

Initial Dosing Strategy

• Start with 0.31 mg for mild to moderate asthma in children aged 2-11 years, as this dose provides effective bronchodilation with the most favorable safety profile and minimal cardiovascular effects 3
• Use 0.63 mg for acute exacerbations or when initial response to 0.31 mg is inadequate 1, 2
• For acute exacerbations requiring aggressive treatment, administer 1.25 mg every 20 minutes for 3 doses, then reassess 1

Weight-Based Dosing Considerations

• The recommended weight-based dose is 0.075 mg/kg (minimum 1.25 mg) for acute asthma exacerbations 1
• Maintenance dosing should be 0.075-0.15 mg/kg every 1-4 hours as needed 1
• Levosalbutamol is administered at half the milligram dose of racemic albuterol for comparable efficacy, meaning 0.31 mg levosalbutamol equals approximately 0.625 mg of racemic albuterol 1, 4

Age-Specific Recommendations

Children 2-5 Years

• 0.31 mg three times daily is well-tolerated and effective for maintenance therapy 2
• 0.63 mg can be used for more significant symptoms or acute exacerbations 2
• Children in this age group showed significant bronchodilation with 0.31 mg compared to placebo, with improved caregiver quality of life scores 2

Children 4-11 Years

• 0.31 mg is the recommended starting dose for mild to moderate persistent asthma 3
• 0.63 mg should be considered for patients with severe disease who demonstrate a dose-response relationship 3
• This dose range (0.31-0.63 mg) provides efficacy comparable to 4-8 fold higher doses of racemic albuterol with superior safety 3

Administration Technique

• Dilute to a minimum of 3 mL with normal saline for optimal nebulizer delivery 1
• Use a standard flow rate compressor at 6-8 L/min with a Venturi nebulizer 1
• Oxygen is the preferred gas source for nebulization, particularly in acute exacerbations 5

Acute Exacerbation Protocol

For severe acute exacerbations, follow this algorithm:

1. Initial treatment: 1.25 mg every 20 minutes for 3 doses 1
2. Add ipratropium bromide 100 μg to nebulizer solution for life-threatening features, repeating every 6 hours until improvement 1
3. Monitor after each treatment: respiratory rate, work of breathing, oxygen saturation 1
4. Consider continuous nebulization in intensive care settings for very severe attacks (still under evaluation) 1

Safety Monitoring

• Watch for tachycardia, tremor, and hypokalemia, especially with frequent or high-dose administration 1
• 0.31 mg is the only dose not significantly different from placebo for changes in heart rate, QTc interval, and glucose levels 3
• Higher doses (0.63 mg and above) cause significant increases in ventricular heart rate 2
• Use with caution in patients with cardiovascular disorders, convulsive disorders, hyperthyroidism, and diabetes mellitus 1

Key Clinical Advantages

The primary advantage of levosalbutamol over racemic albuterol is the elimination of the (S)-enantiomer, which may be associated with increased airway hyperreactivity 4. This allows for lower total drug doses with equivalent or superior efficacy and a more favorable cardiovascular safety profile 3.

Common Pitfall to Avoid

Do not automatically use the same milligram dose as racemic albuterol—levosalbutamol requires half the dose for equivalent effect 1, 4. Using full racemic albuterol doses of levosalbutamol (e.g., 2.5 mg) would represent significant overdosing and increase unnecessary side effects.