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

Prednisolone Dosing in Pediatric Patients

The recommended prednisolone dose for most acute pediatric conditions is 1-2 mg/kg/day (maximum 60 mg/day) administered as a single morning dose, with body surface area dosing of 60 mg/m²/day preferred when height is available because it better parallels drug metabolism and reduces underdosing risk in younger children. 1, 2

General Dosing Principles

Weight-Based vs. Body Surface Area Dosing

• Body surface area (BSA) dosing (mg/m²) is preferred over simple weight-based dosing (mg/kg) because it parallels prednisolone metabolism more accurately and reduces the risk of underdosing in younger children. 1
• When height is unavailable, simplified equations can approximate BSA-based dosing using weight alone: for 60 mg/m², use [2 × weight in kg + 8]; for 40 mg/m², use [weight in kg + 11]. 3
• Weight-based dosing of 1-2 mg/kg/day remains acceptable and is simpler for clinical practice. 1, 4, 5

Maximum Dose and Weight Adjustments

• The maximum daily dose is typically 60 mg, though up to 80 mg may be considered for specific severe conditions. 1, 2
• For significantly overweight children, always calculate dose based on ideal body weight rather than actual weight to avoid unnecessary steroid exposure and increased side effects. 1, 2, 4

Timing of Administration

• Administer prednisolone as a single morning dose before 9 AM to align with physiologic cortisol rhythm and minimize hypothalamic-pituitary-adrenal (HPA) axis suppression. 1, 2, 6
• Single-dose administration results in significantly less HPA axis suppression compared to divided dosing (83% vs. 100% suppression) with equivalent efficacy. 6

Condition-Specific Dosing Regimens

Acute Asthma Exacerbations

• 1-2 mg/kg/day (maximum 60 mg/day) as a single daily dose for 3-10 days. 1, 4, 5
• No tapering is needed if duration is less than 10 days. 1
• Research demonstrates that 1 mg/kg/day is as effective as 2 mg/kg/day but with significantly fewer behavioral side effects (anxiety, hyperactivity, aggressive behavior), making the lower dose preferable. 7
• Doses as low as 0.5 mg/kg/day may be effective for mild exacerbations, with no advantage shown for higher doses. 8

Nephrotic Syndrome

First Episode:

• 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) as a single morning dose for 4-6 weeks. 1, 2, 5
• 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. 1, 2

Infrequent Relapses:

• 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) until remission for at least 3 days. 2
• Then 40 mg/m²/day or 1.5 mg/kg/day on alternate days for at least 4 weeks. 2

Frequent Relapses/Steroid-Dependent:

• Daily prednisolone until remission for 3 days, followed by alternate-day prednisolone for at least 3 months at the lowest effective dose. 2
• Consider corticosteroid-sparing agents if steroid-related adverse effects develop. 2, 4

Autoimmune Hepatitis

• Initial: 1-2 mg/kg/day (maximum 60 mg/day) for two weeks, either alone or with azathioprine. 1, 2, 4
• Maintenance: Taper over 6-8 weeks to 0.1-0.2 mg/kg/day or 5 mg/day. 1, 2

Multisystem Inflammatory Syndrome in Children (MIS-C)

• First-line: Methylprednisolone 1-2 mg/kg/day IV in combination with IVIG 2 gm/kg. 9, 1
• Intensification for refractory disease: Methylprednisolone 10-30 mg/kg/day IV. 9, 1
• Prednisolone or another steroid at equivalent dosing may be substituted for methylprednisolone. 9

Tapering Guidelines

• For courses longer than 2 weeks, gradual tapering is essential to prevent adrenal insufficiency. 1
• Reduce the dose by 25-33% at appropriate intervals once clinical response is achieved. 1
• For courses longer than 10 days, reduce by 5 mg every week until reaching 10 mg/day, then reduce by 2.5 mg/week until reaching maintenance dose. 4
• Final reductions should be 1 mg monthly. 1
• For courses less than 10 days, no tapering is needed. 1

Critical Monitoring Requirements

• Growth parameters must be monitored regularly in children on long-term therapy. 2, 4
• Blood pressure monitoring and assessment for Cushingoid features are essential. 1
• Consider calcium and vitamin D supplementation during therapy. 1
• Baseline and annual bone mineral density testing of lumbar spine and hip for long-term corticosteroid use. 4
• Common side effects include weight gain, increased appetite, cosmetic changes, and growth deceleration. 1
• Severe side effects are uncommon but more likely after prolonged therapy exceeding 18 months. 1

Important Clinical Caveats

• Prednisolone and prednisone are equivalent and used interchangeably at the same dosage. 1, 2
• Avoid systemic corticosteroids for bronchiolitis in infants under 2 years due to insufficient evidence of benefit. 4
• During upper respiratory infections in children with frequently relapsing or steroid-dependent nephrotic syndrome, daily prednisolone may be given to prevent relapse. 2
• The FDA label indicates that initial doses may range from 0.14 to 2 mg/kg/day in three or four divided doses (4 to 60 mg/m²/day), but single daily dosing is preferred when possible. 5