What is the dose of oral liquid prednisone (corticosteroid) for a child with croup on a per kilogram (kg) basis?

Prednisone Dosing for Croup in Children

Oral prednisone is NOT the preferred corticosteroid for croup—dexamethasone is superior and should be used instead at 0.15-0.6 mg/kg as a single dose. However, if you must use prednisone, the dose is 1 mg/kg every 12 hours, though this is less effective than dexamethasone. 1, 2

Why Dexamethasone is Preferred Over Prednisone

• A randomized controlled trial demonstrated that prednisolone (and by extension prednisone) is significantly less effective than dexamethasone for croup, with 29% of children treated with prednisolone re-presenting to medical care compared to only 7% treated with dexamethasone—a clinically meaningful 22% difference. 2

• The evidence clearly shows dexamethasone 0.15-0.6 mg/kg as a single oral dose is the mainstay of croup treatment, with the lower dose of 0.15 mg/kg likely having similar efficacy to the higher 0.6 mg/kg dose. 1, 3

If Prednisone Must Be Used

Dosing Regimen

• The dose is 1 mg/kg every 12 hours (not as a single daily dose like other conditions), based on evidence from severe croup requiring intubation where this regimen decreased duration of intubation. 1

• One community-based trial used 2 mg/kg/day divided over 3 days for mild-to-moderate croup, but this still showed no advantage over single-dose dexamethasone. 4

Important Caveats

• Prednisolone liquid formulations are more readily absorbed than tablets, which is relevant for children who may have difficulty swallowing or are at risk of vomiting. 5

• For significantly overweight children, calculate the dose based on ideal body weight rather than actual weight to avoid excessive steroid exposure. 6, 5

• The maximum dose should not exceed 60 mg per dose. 6

Clinical Algorithm for Corticosteroid Selection in Croup

• First-line: Oral dexamethasone 0.15 mg/kg as a single dose for all severities of croup (mild, moderate, or severe). 3

• Second-line: Nebulized budesonide 2 mg only if the child cannot tolerate oral dexamethasone (vomiting, severe distress). 1, 3

• Avoid prednisone/prednisolone unless no other corticosteroid is available, in which case use 1 mg/kg every 12 hours. 1, 2

Additional Management Considerations

• Add nebulized epinephrine (0.5 mL of 2.25% solution diluted in 2.5 mL saline) only for moderate-to-severe croup with increased work of breathing. 7, 3

• Children requiring two epinephrine treatments should be hospitalized. 7

• Short courses of corticosteroids (under 7 days) do not require tapering. 5