What is the recommended oral dose of salbutamol (albuterol) for pediatric patients?

Oral Salbutamol Dosing in Pediatric Patients

The FDA-approved oral dose of salbutamol for pediatric patients is 2.5 mg administered three to four times daily by nebulization for children weighing at least 15 kg, while children weighing less than 15 kg require individualized dosing with a lower concentration formulation (0.5% solution). 1

Important Clinical Context

Oral salbutamol is significantly inferior to inhaled formulations and should not be used when inhaled routes are available. The evidence consistently demonstrates that inhaled salbutamol (via nebulizer or MDI with spacer) provides superior bronchodilation compared to oral administration 2. The term "oral" in the FDA label 1 refers to nebulized solution administered via the oral/respiratory route, not systemic oral tablets.

Nebulized Salbutamol Dosing (Primary Route)

Acute Asthma Exacerbations

For acute asthma, administer 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses, then 0.15-0.3 mg/kg every 1-4 hours as needed. 3

Weight-based simplified dosing:

• Children < 20 kg: 2.5 mg per dose 3
• Children > 20 kg: 5 mg per dose 3
• Very young children requiring acute treatment: Use half the standard dose (2.5 mg for salbutamol) 4

Maintenance Therapy

For chronic maintenance, the FDA recommends 2.5 mg administered three to four times daily for children weighing ≥15 kg. 1 The solution should be delivered over 5-15 minutes using an oxygen-driven nebulizer at 6-8 L/min flow rate 3.

Metered-Dose Inhaler Alternative

MDI with spacer is equally effective as nebulization and should be preferred when feasible: 4-8 puffs (90 mcg/puff) every 20 minutes for 3 doses, then every 1-4 hours as needed. 3 This delivery method requires proper technique with a spacer/holding chamber 4, 3.

Severe Acute Asthma Protocol

For children not improving after initial treatment:

• Continue nebulized β-agonist every 15-30 minutes 4
• Maximum daily dose: 40 mg/day 4
• Add ipratropium 100-250 mcg to nebulizer every 6 hours 4

For life-threatening features (PEF <33% predicted, silent chest, altered consciousness):

• Consider continuous nebulization at 0.5 mg/kg/hour (maximum 10-15 mg/hour) 3
• IV salbutamol may be considered but lacks evidence for loading dose benefit in PICU settings 5

Critical Administration Details

Dilution and delivery specifications:

• Dilute salbutamol in 2-3 mL normal saline for adequate nebulization 3
• Use oxygen as the gas source at 6-8 L/min flow rate 3
• For young children who cannot tolerate a mouthpiece, use a face mask 3
• Maintain oxygen saturation >92% during treatment 4, 3

Monitoring Requirements

Monitor the following parameters during salbutamol administration:

• Heart rate (expect increase from baseline; mean increase ~20 bpm is typical) 6
• Respiratory rate and work of breathing 4
• Oxygen saturation (maintain >92%) 4
• Peak expiratory flow (if age-appropriate) 4

Reassess clinical response 15-30 minutes after each dose. 4 Tachycardia, tremors, and hypokalemia indicate potential overdosing 3.

Common Pitfalls to Avoid

Do not use systemic oral tablets for acute asthma - they are inferior to inhaled routes and have slower onset with more systemic side effects 2. The confusion arises because nebulized solution is technically administered "orally" (via mouth/respiratory tract) but is fundamentally different from swallowed tablets.

Do not exceed 40 mg/day total dose in pediatric patients during acute exacerbations 4. Higher doses increase side effects without additional bronchodilation benefit.

Levalbuterol alternative: If using levalbuterol instead of racemic salbutamol, administer half the dose listed above (e.g., 1.25 mg instead of 2.5 mg) 4, 3.