What is the recommended dosage of adrenaline (epinephrine) for nebulization in pediatric patients?

Adrenaline Nebulization Dosage in Pediatric Patients

For laryngotracheobronchitis (croup) and acute airway edema in children, administer 0.5 mL/kg of 1:1000 adrenaline solution (maximum 5 mL = 5 mg) via nebulizer, or use a standard 0.5 mL dose of racemic epinephrine (2.25% solution) in 2 mL normal saline. 1

Standard Dosing Protocols

For Croup and Laryngotracheobronchitis

• L-epinephrine (1:1000): Administer 0.5 mL/kg up to a maximum of 5 mL (5 mg) via nebulizer 1
• Racemic epinephrine (2.25% solution): Use 0.05 mL/kg (maximum 0.5 mL) diluted in 2 mL of normal saline 1
• Many institutions use a standardized 0.5 mL dose of racemic epinephrine for all patients regardless of weight 1
• If racemic epinephrine is unavailable, single-isomer L-epinephrine (1:1000) can be substituted at 0.5 mL/kg up to 5 mL 1

For Severe Asthma Exacerbation

• Subcutaneous route is preferred for severe asthma: 0.01 mg/kg of 1:1000 solution (maximum 0.3-0.5 mg) 1
• May repeat every 20 minutes up to 3 doses 1
• Critical caveat: Begin simultaneous treatment with inhaled β-agonist (albuterol) and corticosteroids—nebulized epinephrine should not be used as monotherapy 1

Safety Profile and Monitoring

Evidence-Based Safety Data

• Nebulization with 3-5 mL of adrenaline (1:1000) is safe therapy with minor side effects in children with acute inflammatory airway obstruction 2
• Expected side effects include modest heart rate increases (7-21 beats per minute) lasting up to 60 minutes post-treatment 2
• Pallor may occur in up to 48% of patients within 30 minutes of treatment 2
• No significant blood pressure changes have been documented with doses of 4-5 mL 2

Critical Safety Warning

Life-threatening cardiac arrhythmias, including unstable ventricular tachycardia, have been reported even after single doses of nebulized epinephrine. 3 While rare, these events are unpredictable and mandate:

• Continuous cardiac monitoring during and after nebulization 3
• Immediate availability of resuscitation equipment 3
• Observation period of at least 60-90 minutes post-treatment 3

Common Pitfalls to Avoid

Concentration Confusion

Do not confuse 1:1000 (for nebulization/IM) with 1:10,000 (for IV) concentrations—this is a common and potentially fatal error. 4 Always verify the concentration on the vial label before administration 4

Route Selection Error

• Nebulized epinephrine is indicated for upper airway obstruction (croup, laryngeal edema) 1
• For anaphylaxis, the IM route in the anterolateral thigh is preferred, not nebulization 4
• For severe asthma, subcutaneous epinephrine may be used but should be accompanied by inhaled β-agonists and corticosteroids 1

Repeat Dosing Guidelines

• Nebulized epinephrine effects are typically short-lived 1
• Doses can be repeated as clinically indicated based on respiratory status 1
• For croup, if multiple doses are required, consider adjunctive dexamethasone therapy 1
• Monitor for tachycardia and pallor with repeated dosing 2

When Nebulized Epinephrine Is Insufficient

If the patient fails to respond adequately to nebulized epinephrine:

• Reassess airway patency and consider alternative diagnoses 1
• For anaphylaxis misdiagnosed as croup: switch to IM epinephrine 0.01 mg/kg (1:1000, maximum 0.3-0.5 mg) in the anterolateral thigh 4
• For progressive airway obstruction: prepare for advanced airway management 1
• Consider systemic corticosteroids if not already administered 1