Orapred (Prednisolone) Dosing for Severe Croup
For severe croup in children, prednisolone 1-2 mg/kg as a single oral dose (maximum 60 mg) is the recommended treatment, though dexamethasone 0.15-0.6 mg/kg is superior and should be used preferentially when available. 1, 2, 3
Primary Recommendation
- Prednisolone 1 mg/kg as a single oral dose is the standard dosing for croup when this agent is chosen 1, 4
- The maximum dose should not exceed 60 mg 5
- This is typically given as a one-time dose for acute croup management 4, 2
Critical Evidence Regarding Prednisolone vs. Dexamethasone
Important caveat: Prednisolone is demonstrably less effective than dexamethasone for croup:
- Children treated with prednisolone had a 29% re-presentation rate compared to only 7% with dexamethasone - a clinically significant 22% difference 2
- This represents a 4-fold higher failure rate with prednisolone 2
- Multiple high-quality studies confirm glucocorticoids reduce croup symptoms at 2,6, and 12 hours, but prednisolone specifically underperforms compared to dexamethasone 3
Preferred Alternative: Dexamethasone
If available, dexamethasone should be used instead:
- Dexamethasone 0.15 mg/kg orally (maximum 10-12 mg) is equally effective as the higher 0.6 mg/kg dose 1, 6, 3
- Dexamethasone reduces return visits by approximately 45% compared to prednisolone 3
- It reduces the need for supplemental glucocorticoid treatment by 28% 3
Dosing for Severe Croup Requiring Intubation
- For intubated children with severe croup, prednisolone 1 mg/kg every 12 hours decreases duration of intubation and need for re-intubation 1
- This represents a different dosing strategy than the single-dose approach for non-intubated children 1
Administration Considerations
- Prednisolone should be given as a single morning dose to minimize adrenocortical suppression 7
- Oral administration is preferred unless the child is vomiting or in severe respiratory distress 6
- For children unable to take oral medication, intramuscular dexamethasone should be substituted rather than attempting alternative prednisolone routes 6
Safety Profile
- Single-dose corticosteroid risks are minimal for croup treatment 1, 6
- The only potentially significant adverse effect is increased risk of severe varicella infection in exposed children 1
- Short courses have no major adverse effects and complications are rare 6
Clinical Bottom Line
While prednisolone 1 mg/kg (maximum 60 mg) as a single dose can be used for severe croup, the evidence strongly favors dexamethasone 0.15 mg/kg due to significantly lower re-presentation rates and better overall outcomes 2, 3. Prednisolone should be reserved for situations where dexamethasone is unavailable, as it represents a second-line option with inferior efficacy 2.