What is the recommended dose of salbutamol (albuterol) syrup for a 21-month-old child?

Salbutamol Syrup Dosing for a 21-Month-Old Child

Salbutamol syrup is NOT recommended for acute bronchospasm in a 21-month-old child; nebulized salbutamol (2.5 mg) or metered-dose inhaler with spacer and face mask is strongly preferred due to superior bronchodilation, faster onset, and fewer systemic side effects. 1

Why Inhaled Route is Preferred Over Oral Syrup

• Nebulized salbutamol or MDI with spacer/face mask provides superior bronchodilation with fewer systemic side effects compared to oral syrup formulations 1
• Oral salbutamol has slower onset of action, reduced effectiveness, and increased risk of systemic adverse effects including tachycardia, tremor, and hypokalemia 2
• For a 21-month-old child (typically <20 kg), the appropriate nebulized dose is 2.5 mg per nebulization 1, 3

Nebulized Salbutamol Dosing Protocol

For acute bronchospasm or asthma exacerbation:

• Initial treatment: 2.5 mg every 20 minutes for 3 doses 1
• Maintenance: 2.5 mg every 1-4 hours as needed based on clinical response 1
• Dilute in 2-3 mL normal saline for optimal nebulizer delivery 2
• Use oxygen as gas source at 6-8 L/min flow rate 2

For very young children with severe attacks:

• British Thoracic Society guidelines recommend half the standard adult dose (2.5 mg for salbutamol) for very young children 4, 1
• If not improving after 15-30 minutes, continue nebulized β-agonist every 15-30 minutes 1
• Maximum daily dose: 40 mg/day during acute exacerbations 1

Alternative: Metered-Dose Inhaler with Spacer

MDI with spacer is equally effective as nebulization and should be preferred when feasible:

• Dose: 4-8 puffs (90 mcg/puff) every 20 minutes for 3 doses, then every 1-4 hours as needed 1, 3
• Critical requirement: Must use spacer/valved holding chamber with face mask for children under 5 years, as drug delivery is dramatically reduced without it 2
• For a 21-month-old who will not tolerate a mouthpiece, use a face mask rather than mouthpiece 1

If Oral Syrup Must Be Used (Historical Context Only)

While not recommended for acute management, older studies from the 1970s-1980s used oral salbutamol syrup in young children:

• Historical dosing: 1-2 mg every 8 hours for children aged 2-6 years 5
• These studies predated modern inhaled delivery systems and are no longer the standard of care 6, 5

Monitoring Requirements During Treatment

• Monitor heart rate, respiratory rate, work of breathing, and oxygen saturation after each treatment 2
• Maintain oxygen saturation >92% during treatment 4, 1
• Reassess clinical response 15-30 minutes after each dose 1
• Watch for adverse effects: tachycardia, tremor, hypokalemia, hyperglycemia 2

When to Escalate Treatment

Add ipratropium bromide if:

• Life-threatening features present: add ipratropium 0.25 mg (half adult dose of 0.5 mg) to nebulizer every 6 hours 4, 1
• Inadequate response after initial 3 doses of salbutamol 1

Transfer to hospital immediately if:

• Life-threatening features present (silent chest, cyanosis, exhaustion, altered consciousness) 4
• Persistent severe features despite 3 doses of salbutamol 1
• Too breathless to feed, respiratory rate >50/min, pulse >140/min 4

Common Pitfalls to Avoid

• Never rely on oral syrup for acute bronchospasm - it is too slow and less effective 1, 2
• Never administer MDI without spacer and face mask in children under 5 years - drug delivery will be inadequate 2
• Do not underestimate severity in very young children - assessment may be difficult and objective measurements are essential 1
• Regular use exceeding twice weekly indicates poor control and need for controller medication adjustment 3