What is the appropriate use and dosage of Decadron (dexamethasone) oral for a child?

Oral Dexamethasone for Pediatric Use

For children with acute asthma exacerbations, use oral dexamethasone 0.3 mg/kg as a single dose, which is non-inferior to a 3-5 day course of prednisolone and offers superior compliance and tolerability. 1, 2

Primary Indication: Acute Asthma Exacerbations

Dexamethasone is the preferred oral corticosteroid for pediatric asthma exacerbations based on multiple randomized controlled trials demonstrating equivalent efficacy to prednisolone with practical advantages 1, 2.

Dosing for Asthma

• Single dose: 0.3 mg/kg orally (no maximum dose specified in trials) 1, 2
• This single-dose regimen is non-inferior to prednisolone 1 mg/kg/day for 3 days based on validated respiratory assessment measures 1
• The longer half-life (36-72 hours) eliminates the need for multi-day dosing 3, 4

Advantages Over Prednisolone

• Zero vomiting rate with dexamethasone versus 11.5% with prednisolone in clinical trials 1
• 100% compliance guaranteed with single-dose administration versus potential non-adherence with 3-5 day courses 3, 2
• Better palatability compared to prednisolone's bitter taste 3, 4
• Lower cost and reduced medication burden 2

Important Caveat

• 13.1% of children receiving dexamethasone required additional systemic steroids within 14 days compared to 4.2% with prednisolone (absolute difference 8.9%) 1
• This higher retreatment rate must be weighed against the compliance and tolerability benefits
• Ensure parents understand to return if symptoms worsen or fail to improve within 48-72 hours 5

Emergency Department Dosing Guidelines

For adrenal insufficiency (life-threatening emergency):

• IV/IO: 2-3 mg/kg (maximum 100 mg) over 3-5 minutes 6
• Follow with 1-5 mg/kg every 6 hours for infants OR 12.5 mg/m² every 6 hours for older children 6
• Do not underdose in suspected adrenal crisis 6
• Strongly consider concomitant fluid bolus of 20 mL/kg of D5NS or D10NS during first hour 6

For postextubation upper airway obstruction prevention:

• Administer at least 6 hours before extubation in children at high risk 6
• Use in children with cuffed endotracheal tubes who fail air leak test 6

Conditions Where Dexamethasone is NOT Recommended

Dexamethasone provides NO benefit for:

• Pertussis-associated cough - provides no symptomatic relief 6
• Non-specific cough in children - no RCT evidence supports use 6
• Wheeze without asthma - associated with non-significant increase in hospitalizations 6

Monitoring and Follow-up

• Assess respiratory status at day 4 using validated tools (PRAM score or equivalent) 1
• Return precautions: Instruct families to seek care if symptoms worsen or fail to improve within 48-72 hours 5
• No difference in hospital admission rates or unscheduled return visits between dexamethasone and prednisolone when used appropriately 1

Clinical Pearls

• The evidence base for dexamethasone in pediatric asthma is strongest for mild to moderate exacerbations treated in the emergency department 1, 2
• More research is needed for hospitalized children with severe exacerbations 2
• Dexamethasone's longer duration of action (36-72 hours) provides sustained anti-inflammatory effect without requiring daily dosing 3, 4
• The single-dose regimen eliminates compliance issues related to prolonged treatment courses, vomiting, and bitter taste 3, 1