What is the appropriate dosage of dexamethasone (corticosteroid) for pediatric patients?

Dexamethasone Dosing in Pediatric Patients

For pediatric patients, dexamethasone dosing is indication-specific: use 0.6 mg/kg (maximum 16 mg) as a single dose for croup and asthma exacerbations, 0.15 mg/kg every 6 hours for 2-4 days for bacterial meningitis, and 6 mg/m² per day for 28 days in acute lymphoblastic leukemia protocols. 1, 2, 3

Croup Management

The American Academy of Pediatrics recommends a single dose of dexamethasone 0.6 mg/kg (maximum 16 mg) for all severities of croup. 1

• Oral administration is preferred when the child can tolerate it, as it is equally effective as intramuscular or intravenous routes and avoids injection pain. 1
• All three routes (oral, IM, IV) demonstrate equal efficacy for croup treatment. 1
• The clinical duration of action is approximately 24-72 hours, with onset as early as 30 minutes after administration. 1
• For severe cases with significant respiratory distress, adjunctive nebulized epinephrine (0.5 mL/kg of 1:1000 solution, maximum 5 mL) can be added while waiting for dexamethasone to take effect. 1
• Do not use nebulized corticosteroids from hand-held inhalers with spacers—they are ineffective for croup. 1
• The single-dose regimen does not require tapering and does not cause significant adrenal suppression. 1

Asthma Exacerbations

For mild to moderate asthma exacerbations, a single dose of dexamethasone 0.6 mg/kg (maximum 16 mg) is equally effective as a 3-5 day course of prednisolone or prednisone. 3, 4, 5

• The European Respiratory Review guidelines report consensus on oral corticosteroid dosing: dexamethasone 0.6 mg/kg for 3-5 days, prednisolone 1-2 mg/kg (maximum 40 mg) per 24 hours for 3-5 days, or prednisone 30-50 mg/day for 7 days. 3
• Single-dose dexamethasone offers improved compliance, better palatability, and eliminates the issue of multi-day adherence compared to prednisolone. 4, 6
• Meta-analysis demonstrates no difference between dexamethasone and prednisone groups in symptomatic return to baseline or unplanned physician revisits. 4
• One dose is non-inferior to two doses of dexamethasone for mild to moderate exacerbations. 5
• Some studies found additional benefits including less vomiting with dexamethasone. 4

Bacterial Meningitis

For H. influenzae type b meningitis in infants and children, the American Academy of Pediatrics recommends dexamethasone 0.15 mg/kg every 6 hours for 2-4 days. 2

• Dexamethasone must be initiated 10-20 minutes prior to, or at least concomitant with, the first antimicrobial dose. 2
• If not started with the first antibiotic dose, it can still be initiated up to 4 hours after antibiotic treatment begins. 2
• The Infectious Diseases Society of America suggests that adjunctive dexamethasone should not be given to children who have already received antimicrobial therapy. 2
• For pneumococcal meningitis in children, the use of adjunctive dexamethasone remains controversial. 2
• Stop dexamethasone if bacterial meningitis is ruled out or if the causative organism is not H. influenzae or S. pneumoniae. 2
• Dexamethasone is not currently recommended for neonatal meningitis due to insufficient evidence. 2

Acute Lymphoblastic Leukemia (ALL)

The Children's Oncology Group uses a dexamethasone schedule of 6 mg/m² per day for 28 days in certain pediatric ALL protocols. 3, 2

• Dexamethasone significantly decreases the risk of isolated CNS relapse and improves event-free survival compared with prednisone. 3
• The observed advantage is partly attributed to improved CNS penetration of dexamethasone. 3
• For patients aged 10 years or older, dexamethasone carries a higher risk of osteonecrosis compared to prednisone. 2
• Significant toxicities associated with dexamethasone include osteonecrosis and infection, especially at high doses (10 mg/m² per day). 3
• An overall survival advantage has yet to be conclusively shown, except in the subset of patients with T-ALL with prednisone good response. 3

Bronchopulmonary Dysplasia (BPD)

High-dose dexamethasone (0.5 mg/kg/day) is not recommended for prevention or treatment of BPD in preterm infants due to adverse neurodevelopmental outcomes. 2

• Low-dose dexamethasone therapy (<0.2 mg/kg/day) may facilitate extubation with potentially fewer adverse effects in preterm infants with BPD. 2

Common Side Effects and Safety

Common side effects include gastric irritation, behavioral changes, weight gain, and increased appetite. 2

• Dexamethasone binds only to glucocorticoid receptors, which in animal models has shown potential to affect hippocampal neurons differently than hydrocortisone. 2
• Age may be an important factor for corticosteroid selection, with dexamethasone showing improved outcomes in patients younger than 10 years for certain conditions. 2