What is the appropriate dose of dexamethasone (corticosteroid) for children?

Dexamethasone Dosing in Pediatric Patients

For pediatric dexamethasone dosing, use 0.6 mg/kg (maximum 16 mg) as a single dose for croup and asthma exacerbations, 0.15 mg/kg every 6 hours for 2-4 days for bacterial meningitis, and avoid high-dose therapy (0.5 mg/kg/day) in preterm infants due to neurodevelopmental harm. 1

Croup Management

The American Academy of Pediatrics recommends 0.6 mg/kg (maximum 16 mg) as a single dose for all severities of croup. 1, 2

• Oral administration is preferred when the child can tolerate it, as it is equally effective as intramuscular or intravenous routes while avoiding injection pain 1
• Clinical benefit begins as early as 30 minutes after administration, with duration of action lasting 24-72 hours 1, 3
• Research demonstrates that even lower doses (0.15 mg/kg) are effective for croup, showing statistically significant improvement by 30 minutes 4, 3
• For severe cases with significant respiratory distress, add nebulized epinephrine (0.5 mL/kg of 1:1000 solution, maximum 5 mL) while waiting for dexamethasone to take effect 1, 2

Common pitfall: Do not use nebulized corticosteroids from hand-held inhalers with spacers—they are ineffective for croup 2

Asthma Exacerbations

A single dose of 0.6 mg/kg (maximum 16 mg) is equally effective as a 3-5 day course of prednisolone for mild to moderate asthma exacerbations. 1

• Single-dose dexamethasone at 0.3 mg/kg is noninferior to prednisolone 1 mg/kg/day for 3 days, as measured by PRAM scores at day 4 5
• The higher 0.6 mg/kg dose provides additional margin of efficacy while maintaining safety 1
• Dexamethasone eliminates compliance issues associated with multi-day prednisolone courses and reduces vomiting (0% vs 11.5% with prednisolone) 5

Important caveat: More children receiving dexamethasone (13.1%) required additional systemic steroids within 14 days compared to prednisolone (4.2%), though overall outcomes remained equivalent 5

Bacterial Meningitis

For H. influenzae type b meningitis, use dexamethasone 0.15 mg/kg every 6 hours for 2-4 days. 1, 6

• Dexamethasone must be initiated 10-20 minutes prior to, or at least concomitant with, the first antimicrobial dose 1, 6
• If not started with the first antibiotic dose, it can still be initiated up to 4 hours after antibiotics begin 6
• Do not give dexamethasone to children who have already received antimicrobial therapy beyond 4 hours 1, 6
• For pneumococcal meningitis in children, adjunctive dexamethasone use remains controversial 6
• Dexamethasone is not recommended for neonatal meningitis due to insufficient evidence 6
• Stop dexamethasone if bacterial meningitis is ruled out or if the causative organism is not H. influenzae or S. pneumoniae 6

Acute Lymphoblastic Leukemia (ALL)

The Children's Oncology Group uses 6 mg/m² per day for 28 days in certain pediatric ALL protocols. 1, 6

• Dexamethasone significantly decreases isolated CNS relapse risk and improves event-free survival compared to prednisone 1
• For patients aged 10 years or older, dexamethasone carries higher osteonecrosis risk compared to prednisone 1, 6
• Age is an important factor for corticosteroid selection, with dexamethasone showing improved outcomes in patients younger than 10 years 1, 6

Bronchopulmonary Dysplasia (BPD) in Preterm Infants

High-dose dexamethasone (0.5 mg/kg/day) is contraindicated for BPD prevention or treatment due to adverse neurodevelopmental outcomes including neuromotor dysfunction and growth impairment. 7, 1, 6

• High-dose dexamethasone (0.5 mg/kg/day) is equivalent to 15-20 mg/kg/day of hydrocortisone, far exceeding safe glucocorticoid exposure 7
• Dexamethasone binds only to glucocorticoid receptors, causing hippocampal neuronal degeneration in animal models, unlike hydrocortisone which binds both mineralocorticoid and glucocorticoid receptors 7
• Dexamethasone exposure is linked to decreased hippocampal volume, altered synaptic plasticity, and impaired memory formation 7
• Low-dose dexamethasone (<0.2 mg/kg/day) may facilitate extubation with potentially fewer adverse effects, though additional RCTs are needed 7, 1, 6

Common Side Effects

• Gastric irritation, behavioral changes, weight gain, and increased appetite are common with dexamethasone therapy 1, 6
• The single-dose regimen used for croup (0.6 mg/kg once) does not carry the same neurodevelopmental risks as prolonged high-dose therapy 2