At what age can prednisolone (corticosteroid) be initiated in children?

Age for Initiating Prednisolone in Children

Prednisolone can be safely initiated in children as young as 1 month of age for specific conditions like aggressive lymphomas and leukemias, while for nephrotic syndrome the FDA-approved minimum age is 2 years. 1

FDA-Approved Age Guidelines

The FDA label for prednisolone establishes clear age thresholds based on published efficacy and safety data:

• Aggressive lymphomas and leukemias: ≥1 month of age 1
• Nephrotic syndrome: ≥2 years of age 1
• Severe asthma and wheezing: Based on adult trials with similar pathophysiology, though specific pediatric age not defined 1

Condition-Specific Age Recommendations

Duchenne Muscular Dystrophy

Glucocorticoid initiation is NOT recommended for children under 2 years of age who are still gaining motor skills. 2

• The typical age for initiating prednisolone is 4-8 years, when the child reaches a plateau phase in motor development 2
• Starting at age 6 years (±2 years) is the standard approach, with dosing at 0.75 mg/kg/day 2
• For children under 2 years showing improvement, glucocorticoid therapy should be deferred 2
• For the uncommon scenario of plateau or decline under age 2, alternative diagnoses should be considered before initiating steroids 2

Nephrotic Syndrome

For children under 12 years presenting with new nephrotic syndrome without syndromic features, glucocorticoids should be initiated without requiring a kidney biopsy first. 2

• The minimum FDA-approved age is 2 years 1
• Standard dosing is 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) for 4-6 weeks 3
• Children ≥12 years should undergo biopsy and/or genetic testing before starting steroids 2

Asthma Exacerbations

Prednisolone at 1-2 mg/kg/day (maximum 60 mg/day) can be used for acute asthma exacerbations in children, though the specific minimum age is not explicitly defined in guidelines. 4

• The FDA label indicates pediatric use for severe asthma is based on adult trials, suggesting broader applicability across pediatric ages 1
• For children under 18 months with wheezing, evidence does NOT support prednisolone use—a randomized trial of 38 children (mean age 9.8 months, range 3-17 months) showed no benefit over placebo 5
• Similarly, preschool children aged 10-60 months with virus-induced wheezing showed no benefit from prednisolone in a large trial of 687 children 6

Infantile Hemangiomas

Corticosteroids (prednisolone or prednisone at 2-3 mg per kg per day) are an alternative therapy when propranolol cannot be used, with no specific minimum age restriction mentioned. 2

• Treatment is most successful when initiated during the proliferative phase, which typically occurs by 4 weeks of age 2
• Several months of therapy are often required 2

Critical Monitoring Requirements

All pediatric patients on prednisolone require close monitoring regardless of age, with specific attention to growth velocity as the most sensitive indicator of systemic corticosteroid exposure. 1

Essential monitoring includes:

• Growth parameters: Height, weight, and growth velocity should be measured regularly, as growth suppression can occur even without laboratory evidence of HPA axis suppression 1
• Blood pressure: Monitor at each visit, using age and height-specific percentiles 2
• Ophthalmologic examination: Annual screening for cataracts 2
• Bone health: Annual DEXA scans and vitamin D monitoring for long-term use 2
• Metabolic effects: Urine glucose screening and blood glucose if positive 2

Important Precautions by Age

Infants and Very Young Children

• Complete immunization schedule before starting steroids, including varicella vaccination 2
• Infants born to mothers on corticosteroids during pregnancy should be observed for hypoadrenalism 1
• Nursing mothers should exercise caution, as prednisolone appears in breast milk and may suppress infant growth 1

All Pediatric Ages

• Titrate to the lowest effective dose to minimize growth effects 1
• For significantly overweight children, dose based on ideal body weight to avoid excessive steroid exposure 3, 7
• Courses under 10 days do not require tapering 4
• Never stop glucocorticoids abruptly—ensure gradual taper for prolonged courses 2

Common Pitfalls to Avoid

• Do NOT use prednisolone for non-specific cough in children without clear asthma features 4
• Do NOT initiate steroids in children under 2 years with Duchenne muscular dystrophy who are still making motor progress 2
• Do NOT use prednisolone for virus-induced wheezing in children under 5 years presenting to hospital—evidence shows no benefit 6
• Do NOT delay steroid administration in true asthma exacerbations, as underuse is associated with increased mortality 4