What is the recommended dose of Levosalbutamol (Levalbuterol) for pediatric patients?

Levosalbutamol Dosing in Pediatric Patients

For pediatric patients with asthma, administer levosalbutamol at 0.075 mg/kg (minimum dose 1.25 mg) via nebulizer for acute exacerbations, given every 20 minutes for 3 doses initially, followed by 0.075-0.15 mg/kg (up to 5 mg) every 1-4 hours as needed for maintenance. 1, 2

Initial Treatment for Acute Exacerbations

Nebulizer dosing:

• 0.075 mg/kg (minimum 1.25 mg) every 20 minutes for 3 doses 1, 2
• Dilute to a minimum of 3 mL with normal saline for optimal delivery 1, 3
• Use a standard flow rate compressor at 6-8 L/min with oxygen as the preferred gas source 1, 3

MDI dosing (alternative for mild-to-moderate exacerbations):

• 4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours as needed 2, 3
• Always use with a valved holding chamber (spacer) for proper technique 2, 3
• MDI with proper technique is as effective as nebulized therapy for mild-to-moderate cases 2, 3

Maintenance Therapy

• 0.075-0.15 mg/kg (up to 5 mg maximum) every 1-4 hours as needed 1, 2
• The dose frequency should be based on clinical response and severity 2

Key Dosing Principle

Levosalbutamol is administered at half the milligram dose of racemic albuterol for comparable efficacy and safety. 1, 3 This means 1.25 mg of levosalbutamol provides equivalent bronchodilation to 2.5 mg of racemic albuterol, with fewer beta-mediated side effects 4, 5.

Age-Specific Considerations

Children under 4 years:

• Use levosalbutamol with caution due to limited data in this age group 2, 3
• The 0.31 mg dose (half of the standard 0.63 mg) has been studied in children aged 2-5 years and was well-tolerated 6

Children 4-11 years:

• Start with 0.31 mg (0.075 mg/kg) as the initial dose for mild-to-moderate persistent asthma 4
• Higher doses (0.63 mg or 1.25 mg) may be needed for severe disease, showing a dose-response relationship 4

Severe Exacerbations

For life-threatening asthma features:

• Add ipratropium bromide 100 μg to the nebulizer solution with levosalbutamol 1
• Repeat combination therapy every 6 hours until improvement starts 1
• Ipratropium can be mixed with levosalbutamol in the same nebulizer 2, 3

Monitoring Requirements

After each treatment, assess:

• Respiratory rate and work of breathing 1
• Oxygen saturation 1
• Heart rate (watch for tachycardia) 1, 4
• Tremor 1
• Serum potassium if giving frequent or high doses (risk of hypokalemia) 1, 4

Safety Profile Advantages

Levosalbutamol demonstrates superior safety compared to racemic albuterol:

• The 0.31 mg dose was the only treatment not different from placebo for changes in ventricular heart rate, QTc interval, and glucose 4
• Lower beta-mediated side effects (tachycardia, tremor, hypokalemia) at equipotent doses compared to racemic albuterol 4, 5
• Racemic albuterol 2.5 mg caused the greatest potassium decrease compared to all other active treatments 4

Critical Caveats

Increasing use or lack of expected effect indicates:

• Diminishing asthma control requiring immediate medical attention 2, 3
• Need for controller medication adjustment if regular use exceeds twice weekly for symptom control 2, 3

Special populations:

• Use with caution in cardiovascular disorders, convulsive disorders, hyperthyroidism, and diabetes mellitus 1
• In renal impairment, exercise caution with high doses due to 67% decline in clearance 7