Prednisolone Dosing for a 5-Year-Old with Nighttime Cough and Allergy
For a 5-year-old child weighing 61 lb (27.7 kg) with nighttime cough and allergy symptoms suggestive of asthma exacerbation, administer prednisolone 1-2 mg/kg/day (28-56 mg/day) as a single morning dose for 1-5 days, with no tapering required for short courses. 1
Specific Dosing Calculation
The recommended dose range for this child is 28-56 mg once daily in the morning. 1
- Weight conversion: 61 lb = 27.7 kg 2
- Lower dose (1 mg/kg): 27.7 mg, rounded to 28-30 mg once daily 1
- Higher dose (2 mg/kg): 55.4 mg, rounded to 50-56 mg once daily 1
Choosing Between 1 mg/kg vs 2 mg/kg
Start with 1 mg/kg/day (approximately 28-30 mg) for moderate symptoms, as this dose provides equivalent clinical benefit with significantly fewer behavioral side effects. 3, 4
- Recent evidence demonstrates that 1 mg/kg/day is non-inferior to 2 mg/kg/day for clinical improvement in preschool children with acute moderate asthma exacerbations 4
- The 2 mg/kg dose causes twice the rate of anxiety (p<0.02) and aggressive behavior (p<0.002), with a number needed to harm of only 4.8 for aggressive behavior 3
- Vomiting occurs significantly less frequently with 1 mg/kg dosing (relative risk 0.19-0.99) 4
- Reserve 2 mg/kg dosing for severe exacerbations with sleep disturbance, morning symptoms persisting until midday, or diminishing response to bronchodilators 1
Treatment Duration and Administration
Administer for 3-5 days as a single morning dose; no tapering is necessary for short courses. 1, 2
- The British Thoracic Society guidelines explicitly state that tapering is not needed for 1-5 day courses in children 1
- Single daily morning dosing minimizes adrenocortical suppression and mimics physiologic cortisol secretion 5
- Continue until symptoms resolve, typically 3-10 days 2
Clinical Context: When to Use Prednisolone
Prednisolone is indicated when nighttime cough suggests asthma with nocturnal symptoms, particularly if associated with:
- Sleep disturbance by wheeze or cough 1
- Recurrent cough, especially at night 1
- Symptoms precipitated by viral infections, exercise, or allergen exposure 1
- Diminishing response to inhaled bronchodilators 1
Important Caveats and Pitfalls
Avoid using prednisolone for simple viral-induced wheezing without clear asthma diagnosis in preschool children. 6
- A high-quality 2009 NEJM trial demonstrated that prednisolone was not superior to placebo for mild-to-moderate viral-induced wheezing in preschool children without established asthma 6
- The key distinction: Use prednisolone for children with diagnosed asthma experiencing exacerbations, not for first-time wheezers or simple viral bronchiolitis 6
For significantly overweight children, consider dosing based on ideal body weight to avoid excessive steroid exposure. 5
Antihistamines alone have proven disappointing for asthma management and should not replace corticosteroids when indicated. 1
Monitoring and Follow-up
Monitor for common side effects including behavioral changes (anxiety, aggression, hyperactivity), increased appetite, and vomiting. 3, 4
- Behavioral effects are dose-dependent and more common at 2 mg/kg dosing 3
- Parents should be counseled about these potential effects before initiating therapy 3
Ensure the child is also receiving appropriate bronchodilator therapy and consider inhaled corticosteroids for long-term control if recurrent symptoms occur. 1