Prednisone Dosing for Children
For most pediatric conditions requiring systemic corticosteroids, the recommended dose is 1-2 mg/kg/day (maximum 60 mg/day) given as a single morning dose. 1, 2
Standard Dosing Framework
Initial Dosing
- Start with 1-2 mg/kg/day of prednisone or prednisolone, with a maximum of 60 mg/day for most acute conditions requiring high-dose therapy 1, 2
- Prednisone and prednisolone are equivalent and interchangeable at the same dose 1, 2
- For significantly overweight children, calculate the dose based on ideal body weight rather than actual weight to avoid excessive steroid exposure 1, 2
- Administer as a single daily dose in the morning to minimize suppression of the adrenal axis 1
Condition-Specific Dosing
Asthma Exacerbations:
- Use 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days in children aged 0-11 years 1
- No tapering is needed for courses less than 7 days 1
- For courses up to 10 days, tapering is probably unnecessary, especially if the child is on inhaled corticosteroids 1
- Higher doses provide no additional benefit, and oral administration is as effective as intravenous when gastrointestinal absorption is intact 1
Autoimmune Hepatitis:
- Initial dose: 1-2 mg/kg/day (up to 60 mg/day) for two weeks, either alone or combined with azathioprine 1-2 mg/kg/day 3
- Taper over 6-8 weeks to a maintenance dose of 0.1-0.2 mg/kg/day or 5 mg/day 3
- Early addition of azathioprine is recommended for all children without contraindications to minimize the deleterious effects of long-term corticosteroids on growth, bone development, and physical appearance 3
Nephrotic Syndrome:
- Initial episode: 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) as a single daily dose for 4-6 weeks 1, 2
- Follow with 40 mg/m²/day or 1.5 mg/kg/day on alternate days for 2-5 months with gradual tapering 1, 2
- For relapses: 60 mg/m²/day or 2 mg/kg/day until remission for at least 3 days, then switch to alternate-day dosing 1
Tapering Guidelines
- For courses longer than 10 days, taper gradually: reduce by 5 mg every week until reaching 10 mg/day, then by 2.5 mg/week until reaching the maintenance dose 3, 2
- Courses under 7 days require no taper 1
- The maintenance regimen continues until disease resolution, treatment failure, or drug intolerance 3
Critical Monitoring Considerations
Adrenal Suppression Risk
- Children receiving more than 4 "bursts" per year (short courses of 1-2 mg/kg/day for less than 7 days) may develop hypothalamic-pituitary-adrenal axis suppression 4
- This risk increases when bursts are combined with inhaled corticosteroids, with 20% showing subnormal cortisol response to hypoglycemia 4
Long-Term Therapy Monitoring
- Assess for steroid-related adverse effects regularly, particularly with prolonged use 1, 2
- Monitor growth in children on long-term therapy 1
- For patients on long-term corticosteroids, perform baseline and annual bone mineral density testing of the lumbar spine and hip 3, 2
- Cosmetic changes occur in 80% of patients after 2 years of treatment 2
- Severe side effects are uncommon but more likely after prolonged therapy exceeding 18 months 2
Important Clinical Caveats
When to Avoid Steroids
- Do not use systemic corticosteroids for bronchiolitis in infants under 2 years of age, as systematic reviews of nearly 1200 children show insufficient evidence of benefit 5
Combination Therapy Benefits
- The combination of prednisone with azathioprine reduces corticosteroid-related side effects compared to prednisone monotherapy (10% versus 44% incidence) 3, 2
- Consider adding steroid-sparing agents for children with frequent relapses or steroid dependence who develop adverse effects 1, 2
Alternative: Dexamethasone
- A single dose of oral dexamethasone 0.3 mg/kg (maximum 12 mg) is noninferior to 3-5 days of prednisolone for asthma exacerbations 6, 7
- Dexamethasone offers improved compliance, fewer vomiting episodes, and similar efficacy 6, 7
- However, some studies show children receiving dexamethasone may require additional steroids more frequently (13.1% versus 4.2%) 6