Prednisolone Dosing in Pediatric Patients
For most acute pediatric conditions requiring high-dose corticosteroid therapy, start with prednisolone 1-2 mg/kg/day (maximum 60 mg/day) as a single morning dose. 1, 2
General Dosing Framework
Standard initial dosing is 1-2 mg/kg/day with a maximum of 60 mg/day for most acute conditions. 1, 2 The dose should be administered as a single daily dose in the morning to minimize adrenocortical suppression. 3, 1, 4
Critical dosing consideration: For significantly overweight children, calculate the dose based on ideal body weight rather than actual weight to avoid excessive steroid exposure. 1, 5
Condition-Specific Dosing Regimens
Asthma Exacerbations
- Acute exacerbations: 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1, 2
- No tapering needed for courses less than 7 days 1
- Lower doses (1 mg/kg/day) are non-inferior to higher doses (2 mg/kg/day) for moderate exacerbations and cause less vomiting 6
Nephrotic Syndrome
Initial episode:
- Daily phase: 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) as a single daily dose for 4-6 weeks 3, 5, 2
- Alternate-day phase: 40 mg/m²/day or 1.5 mg/kg/day (maximum 40 mg on alternate days) for 2-5 months with gradual tapering 3, 5
- Total duration: At least 12 weeks of therapy 3
Infrequent relapses:
- 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) until remission for at least 3 days 3, 5
- Then 40 mg/m²/day or 1.5 mg/kg/day on alternate days for at least 4 weeks 3, 5
Frequent relapses/steroid-dependent:
- Daily prednisolone until remission for 3 days, followed by alternate-day prednisolone for at least 3 months 3, 5
- Use the lowest dose to maintain remission without major adverse effects 3, 5
- During upper respiratory infections, give daily prednisolone to prevent relapse 3, 5
Autoimmune Hepatitis
- Initial: 1-2 mg/kg/day (maximum 60 mg/day) for two weeks, either alone or with azathioprine 1, 5
- Maintenance: Taper over 6-8 weeks to 0.1-0.2 mg/kg/day or 5 mg/day 1, 5
Duchenne Muscular Dystrophy
- Standard daily dose: 0.75 mg/kg/day 3
- Minimum effective dose: 0.3 mg/kg/day (shows some benefit but not maximum) 3
- Dose cap: Increase dose as child grows until reaching approximately 40 kg bodyweight, with maximum of 30-40 mg/day 3
- Continue even when non-ambulatory to retard scoliosis and decline in pulmonary function 3
Tapering Guidelines
For courses longer than 10 days:
- Reduce by 5 mg every week until reaching 10 mg/day 1
- Then reduce by 2.5 mg/week until reaching maintenance dose 1
- Never stop abruptly after long-term therapy 2
For short courses (≤7 days): No tapering needed 1
Critical Monitoring Requirements
- Regular assessment for steroid-related adverse effects, particularly with prolonged use 1, 5
- Growth monitoring in children on long-term therapy 1, 5
- Bone health: Baseline and annual bone mineral density testing of lumbar spine and hip for long-term corticosteroid use 1
- Calcium and vitamin D supplementation should be initiated immediately when starting steroid therapy 1
Important Clinical Caveats
Avoid these pitfalls:
- Do NOT use systemic corticosteroids for bronchiolitis in infants under 2 years—insufficient evidence of benefit 1
- Do NOT calculate doses based on actual body weight in significantly overweight children 1, 5
- Do NOT give second courses of alkylating agents in nephrotic syndrome 3
When to consider corticosteroid-sparing agents:
- Children with frequent relapses or steroid-dependent nephrotic syndrome who develop steroid-related adverse effects 3, 5
- Options include azathioprine, mycophenolate mofetil, or alkylating agents depending on the condition 3
Dose Equivalency Reference
For comparison, 15 mg prednisolone base is equivalent to:
- Prednisone: 15 mg
- Methylprednisolone: 12 mg
- Dexamethasone: 2.25 mg 2