Orapred (Prednisolone) for Croup
Primary Recommendation
Prednisolone is NOT the preferred corticosteroid for croup—dexamethasone should be used instead at 0.6 mg/kg orally (maximum 10-12 mg) as a single dose. 1
If prednisolone must be used (e.g., due to dexamethasone unavailability), the dose is 1 mg/kg as a single oral dose (matched for potency to dexamethasone 0.15 mg/kg). 2 However, this is explicitly a second-line choice.
Why Dexamethasone is Superior
Prednisolone results in significantly higher re-presentation rates: 29% of children treated with prednisolone 1 mg/kg returned for unscheduled medical care versus only 7% with dexamethasone 0.15 mg/kg—a 22% absolute difference. 2
The American Academy of Pediatrics specifically recommends dexamethasone as the preferred agent based on superior outcomes, ease of administration, availability, and low cost. 1, 3
A community-based trial found no differences in outcomes between prednisolone (2 mg/kg/day for 3 days) and single-dose dexamethasone, but the prednisolone regimen required multiple doses over multiple days, making it less practical. 4
Dosing Algorithm if Prednisolone Must Be Used
Single-dose regimen:
- 1 mg/kg orally as a single dose (this matches the potency of dexamethasone 0.15 mg/kg). 2
- Maximum dose: approximately 40-60 mg based on typical pediatric weights. 5
Multi-day regimen (less preferred):
- 2 mg/kg/day for 3 days has been studied but offers no advantage over single-dose dexamethasone. 4
Severity-Based Treatment Approach
Moderate-to-severe croup:
- Use dexamethasone 0.6 mg/kg (maximum 10-12 mg) orally. 1, 3
- If the child cannot tolerate oral medication due to vomiting or severe respiratory distress, give intramuscular dexamethasone at the same dose. 3
- Add nebulized racemic epinephrine 0.05 mL/kg (maximum 0.5 mL) of 2.25% solution or L-epinephrine 0.5 mL/kg (maximum 5 mL) of 1:1000 solution for acute airway edema. 1
Mild croup:
- Lower doses of dexamethasone (0.15-0.3 mg/kg) may be sufficient, though evidence is less robust. 3
- Corticosteroids reduce hospitalizations and length of illness even in mild cases. 3
Critical Pitfalls to Avoid
Do not use prednisolone as first-line therapy: The evidence clearly demonstrates inferior outcomes compared to dexamethasone, with nearly 4 times the re-presentation rate. 2
Do not use multi-day prednisolone regimens: Single-dose dexamethasone is equally effective and far more practical than 3-day prednisolone courses. 4
Do not substitute prednisolone 1:1 for dexamethasone by weight: Prednisolone requires approximately 6.7 times the dose of dexamethasone to achieve equivalent potency (1 mg/kg prednisolone ≈ 0.15 mg/kg dexamethasone). 2
Severe varicella infection risk: While rare, this is the only significant adverse effect of short-course corticosteroids in croup. 6
Monitoring and Follow-Up
- Evaluate response within 2-4 hours of corticosteroid administration. 3
- Children receiving nebulized epinephrine should be observed for at least 2-3 hours due to potential rebound symptoms. 7
- Instruct parents to return if symptoms worsen, stridor occurs at rest, or the child develops respiratory distress. 3