What is the recommended dosing of prednisolone (corticosteroid) for pediatric patients?

Prednisolone Pediatric Dosing

For most pediatric conditions requiring systemic corticosteroids, prednisolone should be dosed at 1-2 mg/kg/day (maximum 60 mg/day) as a single morning dose, with the specific indication determining duration and tapering requirements. 1, 2, 3, 4

General Dosing Principles

Weight-based dosing (mg/kg) is simpler for clinical practice, but body surface area dosing (mg/m²) is preferred by major guidelines because it parallels prednisolone metabolism better and reduces the risk of underdosing in younger children. 3, 5

• For significantly overweight children, always use ideal body weight rather than actual weight to avoid unnecessary steroid exposure and increased side effects 1, 2, 3
• The maximum daily dose is typically 60 mg, though up to 80 mg may be considered for specific severe conditions 2
• Prednisolone and prednisone are equivalent and used interchangeably at the same dosage 1, 2

Condition-Specific Dosing

Acute Asthma Exacerbations

For acute asthma, use 1-2 mg/kg/day (maximum 60 mg/day) as a single daily dose for 3-10 days, with no tapering needed if duration is less than 10 days. 1, 3, 4

• The National Heart, Lung, and Blood Institute recommends continuing "burst" therapy until the child achieves 80% of personal best peak expiratory flow or symptoms resolve 4
• A single dose of 30 mg for children under 5 years or 60 mg for older children can reduce morbidity and hospital stay in acute presentations 6
• Research shows that 1 mg/kg/day produces comparable benefits to 2 mg/kg/day but with significantly fewer behavioral side effects (anxiety, hyperactivity, aggressive behavior) 7
• Most pediatric intensivists use higher doses (2-4 mg/kg/day of methylprednisolone equivalent) for critically ill asthmatics, though this exceeds guideline recommendations and lacks evidence-based support 8

Nephrotic Syndrome

For first episode nephrotic syndrome, use 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) as a single morning dose for 4-6 weeks, followed by 40 mg/m²/day or 1.5 mg/kg/day (maximum 40 mg) on alternate days for 2-5 months with gradual tapering. 2, 3, 4

• For infrequent relapses, give 60 mg/m²/day or 2 mg/kg/day until remission for at least 3 days, then switch to 40 mg/m²/day or 1.5 mg/kg/day on alternate days for at least 4 weeks 2
• For frequent relapses or steroid-dependent cases, use daily prednisolone until remission for 3 days, followed by alternate-day therapy for at least 3 months at the lowest effective dose 2
• During upper respiratory infections in frequently relapsing or steroid-dependent patients, daily prednisolone may prevent relapse 2
• A simplified weight-based equation can approximate BSA dosing: for 60 mg/m², use [2 × weight in kg + 8]; for 40 mg/m², use [weight in kg + 11] 5

Autoimmune Hepatitis

For autoimmune hepatitis, start with 1-2 mg/kg/day (maximum 60 mg/day) for two weeks, either alone or with azathioprine, then taper over 6-8 weeks to a maintenance dose of 0.1-0.2 mg/kg/day or 5 mg/day. 2

• Higher initial doses up to 1 mg/kg/day may achieve more rapid normalization of transaminases 1
• An alternative regimen uses 30 mg/day initially, reducing to 10 mg/day over 4 weeks when combined with azathioprine 1

Tuberculous Pericarditis

For tuberculous pericarditis in children, begin with approximately 1 mg/kg/day and taper proportionately to adult dosing: equivalent to 60 mg/day for 4 weeks, 30 mg/day for 4 weeks, 15 mg/day for 2 weeks, and 5 mg/day for the final week. 9

• This adjunctive therapy reduces mortality and need for repeated pericardiocentesis 9

Multisystem Inflammatory Syndrome in Children (MIS-C)

For MIS-C first-line therapy, use methylprednisolone 1-2 mg/kg/day IV in combination with IVIG 2 gm/kg; for refractory disease requiring intensification, escalate to methylprednisolone 10-30 mg/kg/day IV. 9

• Low-to-moderate dose glucocorticoids may be considered first-line for patients with concerning features who have not yet developed shock or organ-threatening disease 9

Dermatologic Conditions

For dermatologic conditions, dose according to severity: 0.3 mg/kg/day for moderate disease, 0.5 mg/kg/day for moderate-severe disease, and 0.75-1 mg/kg/day for severe disease. 1

Administration and Timing

Administer prednisolone as a single morning dose before 9 AM to align with physiologic cortisol rhythm and minimize hypothalamic-pituitary-adrenal axis suppression. 2, 3

• For nephrotic syndrome, the standard regimen uses three divided doses during the initial intensive phase 4
• Alternate-day dosing (40 mg/m²/day or 1.5 mg/kg/day) is preferred for maintenance therapy in nephrotic syndrome to reduce side effects 2, 3

Tapering Guidelines

For courses longer than 2 weeks, gradual tapering is essential to prevent adrenal insufficiency; reduce the dose by 25-33% at appropriate intervals once clinical response is achieved, with final reductions of 1 mg monthly. 1, 3

• For courses less than 10 days (such as asthma exacerbations), no tapering is needed 3, 4
• There is no evidence that tapering after improvement in acute asthma prevents relapse 4

Monitoring and Safety

Essential monitoring includes growth parameters, blood pressure, Cushingoid features, and consideration of calcium and vitamin D supplementation during therapy. 1, 2, 3

• Common side effects include weight gain (occurring even at low doses of 5-10 mg), increased appetite, cosmetic changes, and growth deceleration 1, 3
• Severe side effects are uncommon but more likely after prolonged therapy exceeding 18 months 3
• Consider bone mineral densitometry for patients on long-term treatment 2
• Consider corticosteroid-sparing agents if frequent relapses occur, steroid-dependent patterns develop, or significant adverse effects emerge 2, 3

Important Clinical Caveats

• The FDA label indicates that initial doses may range from 0.14 to 2 mg/kg/day (4 to 60 mg/m²/day) in three or four divided doses depending on the specific disease entity, emphasizing that dosage requirements are variable and must be individualized 4
• When switching from IV to oral therapy, 5 mL of prednisolone sodium phosphate oral solution (containing 15 mg prednisolone base) is equivalent to 12 mg methylprednisolone 4
• If long-term therapy is discontinued, withdraw gradually rather than abruptly to prevent adrenal crisis 4