Ipratropium Bromide (Atrovent) Dosing for Children Under 2 Years
For children under 2 years old with acute severe asthma, nebulized ipratropium bromide should be administered at 250 mcg (0.25 mg) every 6 hours, combined with weight-based albuterol dosing of 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for the first 3 doses, then every 1-4 hours as needed. 1
Specific Dosing Recommendations
Ipratropium Bromide (Atrovent)
- Standard dose: 250 mcg nebulized every 6 hours for children of all ages, including infants under 2 years 1
- This dose applies uniformly across pediatric age groups according to British Thoracic Society guidelines 1
Albuterol (Salbutamol) Dosing for Children Under 2 Years
- Weight-based dosing: 0.15 mg/kg per dose (or 5 mg if weight-based calculation not available) 1
- Acute exacerbations: Administer every 20 minutes for the first 3 doses, then every 1-4 hours as needed 2
- Alternative for very young infants: 0.63 mg/3 mL every 4-6 hours for routine bronchospasm 3
Combination Therapy Approach
When to Combine Ipratropium with Albuterol
- Ipratropium provides maximum benefit in the first 3 hours of severe acute exacerbations and should be added to albuterol in children with severe asthma (FEV1 <50% predicted or clinical signs of severe distress) 4
- The combination is particularly beneficial in very severe cases (FEV1 ≤30% predicted), where it may reduce hospitalization rates from 83% to 27% 4
- Both medications can be mixed in the same nebulizer chamber for simultaneous administration 3
Administration Frequency
- Give ipratropium 250 mcg with each of the first 3 albuterol doses (at 0,20, and 40 minutes), then continue ipratropium every 6 hours 1, 4
- After the initial 3 doses, continue albuterol every 1-4 hours based on clinical response 2
Critical Administration Details
Nebulizer Setup
- Use oxygen as the driving gas whenever possible, especially in acute severe asthma 1
- Gas flow rate should be 6-8 L/min 2
- Minimum dilution of 3 mL total volume in the nebulizer chamber 2
Delivery Method for Infants Under 2 Years
- Use a face mask that fits snugly over the nose and mouth (not a mouthpiece, as infants cannot coordinate breathing through a mouthpiece) 5
- Ensure the mask is tight-fitting and the infant breathes with an open mouth 1
- Wash the infant's face after each treatment to prevent local side effects 5
Important Clinical Considerations
Monitoring Requirements
- Monitor heart rate, respiratory rate, and oxygen saturation closely during treatment 3
- Target oxygen saturation >92% 3
- Watch for tachycardia, tremor, hypokalemia, and hyperglycemia as potential adverse effects 3, 6
Common Pitfalls to Avoid
- Do not use ipratropium with a face mask if there is any possibility of glaucoma—use a mouthpiece instead (though this is impractical in infants under 2 years, making careful mask application essential) 1
- Ipratropium benefit is primarily in the first 3 hours; continuing beyond 24-48 hours in hospitalized patients may not provide additional benefit 3, 7
- For infants who cannot tolerate face masks, consider MDI with spacer and mask as an alternative delivery system, which may be more effective than nebulization in some cases 5
Alternative Delivery Considerations
- MDI with spacer and face mask should be assessed first for regular home treatment, as it is cheaper, more convenient, and equally effective for most situations 1, 5
- Nebulizers are reserved for infants who cannot tolerate spacers, during severe acute exacerbations, or when spacer technique has failed 5
Evidence Quality Note
The dosing recommendations come from British Thoracic Society guidelines 1, which provide uniform ipratropium dosing across all pediatric ages. Research evidence supports the efficacy of this combination therapy, particularly in severe exacerbations 4, though one study found no additional benefit when added to frequent high-dose albuterol in hospitalized children 7. The weight of evidence favors using ipratropium in the acute setting (first 3 hours) for severe presentations.