What is the typical dosing regimen for prednisone (corticosteroid) in children?

Prednisone Dosing for Children

For most pediatric conditions requiring corticosteroid therapy, start with prednisone 2 mg/kg/day or 60 mg/m²/day (maximum 60 mg/day) as a single morning dose. 1, 2

Initial Dosing Strategy

Standard High-Dose Therapy

• Initial dose: 2 mg/kg/day or 60 mg/m²/day (maximum 60 mg/day) given as a single morning dose 3, 1, 2
• Administer before 9 am to minimize adrenocortical suppression, as this aligns with the body's natural cortisol peak between 2 am and 8 am 4
• For significantly overweight children, dose based on ideal body weight to avoid unnecessary steroid exposure 1, 2

Weight-Based Dosing Shortcuts

If you don't have the child's height available for BSA calculation, use these validated equations 5:

• For 60 mg/m² dose: [2 × weight in kg + 8] = mg/day
• For 40 mg/m² dose: [weight in kg + 11] = mg/day
• These equations predict BSA-based dosing with >95% accuracy 5

Condition-Specific Regimens

Nephrotic Syndrome (First Episode)

• Daily phase: 60 mg/m²/day or 2 mg/kg/day (max 60 mg) for 4-6 weeks 3, 2
• Alternate-day phase: 40 mg/m²/dose or 1.5 mg/kg/dose (max 40 mg) every other day for 2-5 months with tapering 3, 2
• Total treatment duration should be at least 12 weeks to reduce relapse risk (RR 0.70 vs. 2-month therapy) 3
• Single daily dosing is as effective as divided doses, with mean response time of 9.6 days 6

Nephrotic Syndrome (Infrequent Relapses)

• 60 mg/m²/day or 2 mg/kg/day (max 60 mg) until remission for at least 3 days 3, 2
• Then 40 mg/m²/dose or 1.5 mg/kg/dose (max 40 mg) on alternate days for at least 4 weeks 3, 2

Nephrotic Syndrome (Frequent Relapses/Steroid-Dependent)

• Daily prednisone until remission for 3 days, then alternate-day dosing for at least 3 months 3, 2
• Use the lowest dose that maintains remission without major adverse effects 3
• During upper respiratory infections, give daily prednisone to prevent relapse 3, 2
• Consider steroid-sparing agents (cyclophosphamide 2 mg/kg/day for 8-12 weeks) if steroid-related adverse effects develop 3

Acute Asthma Exacerbations

• 1-2 mg/kg/day for 5 days (no taper needed for short courses) 7
• Alternative: Dexamethasone 0.6 mg/kg for 1-2 doses offers similar efficacy with better compliance and less vomiting 8

Autoimmune Hepatitis

• Initial: 1-2 mg/kg/day (max 60 mg) for 2 weeks 2
• Maintenance: Taper over 6-8 weeks to 0.1-0.2 mg/kg/day or 5 mg/day 2

Tapering Guidelines

For prolonged therapy requiring discontinuation 1:

• Reduce by 5 mg/week until reaching 10 mg/day
• Then reduce by 2.5 mg/week until reaching maintenance dose
• Never stop abruptly after long-term therapy 4

Critical Monitoring

Short-Term Therapy (<3 months)

• Monitor for infection, behavioral changes, hyperglycemia, hypertension 1, 4
• Watch for vomiting (occurs more with prednisone than dexamethasone in acute settings) 8

Long-Term Therapy (>18 months)

• Growth velocity is the most sensitive indicator of steroid toxicity in children, even without HPA axis suppression 4
• Cosmetic changes occur in 80% after 2 years of treatment 1
• Baseline and annual bone mineral density testing 1, 2
• Regular assessment for cataracts, osteoporosis, psychosocial disturbances 4

Common Pitfalls to Avoid

• Don't use divided daily doses—single morning dosing is equally effective and better tolerated 4, 6
• Don't dose obese children by actual weight—use ideal body weight to prevent overdosing 1, 2
• Don't give doses after 9 am—this increases adrenal suppression 4
• Don't continue high-dose daily therapy beyond 4-6 weeks for nephrotic syndrome—switch to alternate-day dosing to reduce side effects 3
• Don't forget that prednisone and prednisolone are equivalent and interchangeable at the same dose 3, 1, 2