What is the recommended treatment approach for a 6-year-old patient with asthma, weighing 26kg, and experiencing mild shortness of breath, considering a change to prednisolone?

Prednisolone Dosing for Acute Asthma in a 6-Year-Old Child

For this 6-year-old child (26 kg) with mild shortness of breath from asthma, administer oral prednisolone 1-2 mg/kg body weight daily (26-52 mg), with a maximum dose of 40 mg, for 3-5 days. 1

Specific Dosing Recommendation

• Give prednisolone 26-40 mg orally once daily (1-2 mg/kg for this 26 kg child, capped at 40 mg maximum) 1
• Continue for 3-5 days without need for tapering after this short course 2, 3
• The FDA-approved dosing range for pediatric asthma is 0.14-2 mg/kg/day, with the National Heart, Lung, and Blood Institute specifically recommending 1-2 mg/kg/day for uncontrolled asthma 4

Assessment of Severity Before Dosing

While described as "mild shortness of breath," you must objectively assess severity before finalizing treatment:

• Acute severe asthma features in children include: respirations >50 breaths/min, pulse >140 beats/min, too breathless to talk or feed, or peak expiratory flow <50% predicted 1
• If any severe features are present: Add intravenous hydrocortisone immediately, high-flow oxygen, and nebulized salbutamol 5 mg (or half dose if very young) 1
• If truly mild (speaking normally, respiratory rate normal, no distress): Oral prednisolone alone with bronchodilators is appropriate 1, 2

Concurrent Treatment Requirements

Prednisolone should never be given in isolation:

• Add ipratropium bromide 250 mcg to nebulized albuterol if the child has not responded adequately to albuterol alone over the preceding days 2
• Continue nebulized β-agonist (salbutamol 5 mg or half dose for very young children) every 4-6 hours initially 1
• Administer oxygen if available to maintain oxygen saturation >92%, even if the child appears comfortable 2

Monitoring and Reassessment

• Reassess at 15-30 minutes after initial treatment to determine if the child is improving 1, 2
• If improving: Continue prednisolone 1-2 mg/kg daily and reduce nebulized β-agonist frequency to every 4-6 hours 1
• If NOT improving after 15-30 minutes: Increase nebulized β-agonist frequency to every 15-30 minutes and refer to hospital 1, 2

Critical Pitfalls to Avoid

• Do not delay corticosteroid administration - underuse of corticosteroids is a major factor in preventable asthma deaths 1
• Do not rely on clinical appearance alone - children with severe attacks may not appear distressed 1
• Do not taper the dose after 3-5 days - there is no evidence that tapering prevents relapse after short-course "burst" therapy 4
• Do not send the child home without objective improvement - confirm response to treatment before the provider leaves if treating at home 1, 2

Alternative Consideration: Dexamethasone

While prednisolone is the standard, a single dose of oral dexamethasone 0.3 mg/kg (7.8 mg for this child, maximum 12 mg) is noninferior to 3-5 days of prednisolone and may improve compliance 5, 6. However, one study showed a higher rate of requiring additional steroids within 14 days (13.1% vs 4.2%) with single-dose dexamethasone 6. Given this is a first presentation for treatment change, prednisolone 1-2 mg/kg daily for 3-5 days remains the preferred approach 1, 2, 4.

Disposition and Follow-Up

• Ensure 24 hours of discharge medication before stopping treatment 1
• Provide written self-management plan to parents 1, 2
• Arrange GP follow-up within 1 week and specialist follow-up within 4 weeks 1, 2
• Consider hospital admission if: treatment is given in afternoon/evening, parents unable to administer treatment appropriately, or no improvement after initial combination therapy 1, 2