What is the recommended dose of albuterol (beta2-adrenergic agonist) solution for inhalation in pediatric patients?

Albuterol Solution Dosing for Pediatric Patients

For acute asthma exacerbations in children, administer 0.15 mg/kg (minimum dose 2.5 mg) of albuterol nebulizer solution every 20 minutes for 3 doses, then 0.15-0.3 mg/kg (up to 10 mg) every 1-4 hours as needed. 1

Weight-Based Dosing for Acute Exacerbations

• Initial treatment: Give 0.15 mg/kg every 20 minutes for the first 3 doses 1, 2
• Minimum dose: Always use at least 2.5 mg even if the calculated weight-based dose is lower 1, 2
• Maintenance dosing: After initial 3 doses, continue with 0.15-0.3 mg/kg (maximum 10 mg) every 1-4 hours based on clinical response 1
• Dilution requirement: Dilute to a minimum of 3 mL total volume with normal saline for optimal nebulization 1, 2

Practical Example

For a typical 10 kg child (approximately 1 year old), the calculated dose would be 1.5 mg, but you should administer the minimum dose of 2.5 mg instead 2

Routine Maintenance Dosing (Non-Acute)

• Children weighing ≥15 kg: 2.5 mg administered 3-4 times daily 3
• Children weighing <15 kg: Use 0.5% albuterol solution (not 0.083%) to allow for doses less than 2.5 mg 3
• Young children under 5 years: For routine bronchodilator therapy, 0.63 mg/3 mL via nebulizer is FDA-approved and represents the safest starting point 2

Severe Exacerbations and Continuous Nebulization

• Continuous nebulization: 0.5 mg/kg/hour (up to 10-15 mg/hour) for life-threatening cases 1, 2
• Add ipratropium bromide: 0.25-0.5 mg to the first 3 albuterol doses for moderate-to-severe exacerbations 1, 2
• The addition of ipratropium significantly reduces hospitalization rates in severe exacerbations 4

Administration Technique Essentials

• Gas source: Use oxygen as the driving gas at 6-8 L/min flow rate, particularly in hypoxic patients 1, 2, 5
• Face mask fit: Ensure the mask covers both nose and mouth snugly for children unable to use a mouthpiece 2
• Nebulizer type: Only use jet nebulizers; ultrasonic nebulizers are ineffective for albuterol solutions 2
• Large volume nebulizers: Required for continuous administration 1

Alternative: MDI with Spacer

For mild-to-moderate exacerbations, MDI with valved holding chamber (spacer) is equally effective as nebulized therapy when properly administered. 1, 2

• Dosing: 4-8 puffs (90 mcg/puff = 360-720 mcg total) every 20 minutes for 3 doses, then every 1-4 hours as needed 1
• Requirement: Must use spacer/holding chamber with face mask for children <4 years 1, 2
• This approach requires proper technique and coaching by trained personnel 1

Levalbuterol (R-Albuterol) Alternative

• Dosing: 0.075 mg/kg (minimum 1.25 mg) every 20 minutes for 3 doses, then 0.075-0.15 mg/kg (up to 5 mg) every 1-4 hours 1, 5
• Levalbuterol is administered at half the milligram dose of racemic albuterol for comparable efficacy and safety 1, 2, 5
• Has not been evaluated for continuous nebulization 1

Critical Monitoring Parameters

• Reassess after each treatment cycle: Response to treatment is a better predictor of hospitalization need than initial severity 2, 4
• Watch for adverse effects: Tachycardia, tremor, hypokalemia, and hyperglycemia, especially with frequent dosing 2, 4
• Signs of impending respiratory failure: Inability to speak, altered mental status, intercostal retractions, worsening fatigue, PaCO₂ ≥42 mmHg 1

Common Pitfalls to Avoid

• Never use oral albuterol formulations when nebulized or inhaled options are available—they are slower acting, less effective, and have more systemic side effects 5
• Don't underdose small children: Always use the minimum 2.5 mg dose even if weight-based calculation suggests less 1, 2
• Don't delay escalation: If a previously effective regimen fails to provide relief, this signals seriously worsening asthma requiring immediate reassessment 3
• Don't use ultrasonic nebulizers: They are ineffective for albuterol solution delivery 2