What is the best oral steroid for pediatric asthma exacerbation?

Best Oral Steroid for Pediatric Asthma Exacerbation

Prednisolone and prednisone are the preferred oral corticosteroids for pediatric asthma exacerbations, with prednisolone being particularly advantageous in young children due to its liquid formulation and lack of need for hepatic conversion. 1, 2

Recommended Agents and Dosing

First-Line Options

Prednisolone or prednisone should be administered at 1-2 mg/kg/day (maximum 60 mg/day) in 1-2 divided doses until symptoms resolve or peak flow reaches 70% of predicted/personal best. 1, 2

• The National Heart, Lung, and Blood Institute guidelines specifically recommend 1-2 mg/kg/day for children with acute exacerbations 2
• Treatment duration typically ranges from 3-10 days, with most children requiring 3-10 days of therapy 1, 2
• For outpatient "burst" therapy, use 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1

Prednisolone vs. Prednisone: Key Distinction

Prednisolone is preferred over prednisone in young children because:

• Prednisolone is the active metabolite and does not require hepatic conversion 2
• Available in liquid formulation, making administration easier in pediatric patients 2
• Prednisone requires conversion to prednisolone in the liver, which may be less efficient in young children 2

Alternative: Dexamethasone

A single dose of dexamethasone (0.6 mg/kg, maximum 16 mg) represents an acceptable alternative for mild-to-moderate exacerbations, offering advantages in adherence 3:

• Longer half-life allows single-dose administration 3
• Improved compliance compared to 3-5 day courses 3
• Recent evidence suggests similar efficacy to multi-day prednisolone courses for mild-to-moderate exacerbations 3

However, the major national guidelines (NAEPP) do not specifically endorse dexamethasone as equivalent to prednisolone/prednisone, listing only these three agents in their dosing tables 1

Dosing Considerations by Severity

Mild-to-Moderate Exacerbations

• 1 mg/kg/day prednisolone in single or divided doses is effective 4
• A study comparing 0.5,1.0, and 2.0 mg/kg/day found no advantage to higher doses, suggesting 0.5 mg/kg/day may be sufficient 4
• However, guideline recommendations remain at 1-2 mg/kg/day 1, 2

Severe Exacerbations

• Use 1-2 mg/kg/day (maximum 60 mg/day) in divided doses 1, 2
• Higher doses beyond 2 mg/kg/day show no additional benefit 1

Route of Administration

Oral administration is equivalent to intravenous therapy and should be used preferentially unless gastrointestinal absorption is impaired 1, 5:

• A randomized trial found no difference in length of stay between oral prednisone (2 mg/kg twice daily) and IV methylprednisolone (1 mg/kg four times daily) 5
• Oral route is substantially more cost-effective (approximately 10-fold savings) 5
• IV administration offers no advantage when GI function is intact 1

Duration and Tapering

Treatment courses of 3-10 days do not require tapering, especially if patients are concurrently on inhaled corticosteroids 1:

• Continue until peak expiratory flow reaches 80% of personal best or symptoms resolve 2
• Most children require 3-10 days of treatment 2
• No evidence supports tapering for courses under 10 days 1

Common Pitfalls to Avoid

• Do not use higher doses than 2 mg/kg/day: No evidence of additional benefit and increases side effect risk 1
• Do not default to IV route: Oral is equally effective and far more practical 1, 5
• Do not taper short courses: Unnecessary for courses under 10 days, particularly with concurrent inhaled corticosteroids 1
• Do not delay initiation: Systemic corticosteroids should be started promptly for all but the mildest exacerbations 1

Age-Specific Considerations

For children under 5 years, prednisolone liquid formulation is particularly advantageous over prednisone tablets 2. The same dosing applies: 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1, 2.

For children 5 years and older, either prednisolone or prednisone at 1-2 mg/kg/day (maximum 60 mg/day) is appropriate 1, 2.