Prednisone Dosing in Children
For most acute pediatric conditions requiring high-dose corticosteroid therapy, start with prednisone 1-2 mg/kg/day (maximum 60 mg/day) as a single morning dose. 1
General Dosing Framework
The standard approach across most pediatric conditions follows these principles:
- Administer as a single daily dose in the morning to minimize adrenocortical suppression 1, 2
- Maximum daily dose is typically 60 mg, though up to 80 mg may be considered for specific conditions like severe allergic reactions or nephrotic syndrome 2, 3
- For significantly overweight children, calculate dose based on ideal body weight rather than actual weight to avoid excessive steroid exposure and increased side effects 1, 2, 3
Important Dosing Caveat for Young Children
Weight-based dosing (mg/kg) carries a risk of underdosing in younger, smaller children compared to body surface area (BSA)-based dosing 4. If you don't have the child's height available for BSA calculation, use these simplified equations that approximate BSA-based dosing using only weight 5:
- For 60 mg/m²/day equivalent: [2 × weight in kg + 8]
- For 40 mg/m²/day equivalent: [weight in kg + 11]
These equations predict BSA-based doses with average errors of only 3.4% and 2.2% respectively, and are particularly valuable for avoiding underdosing in smaller children 5.
Condition-Specific Dosing Regimens
Asthma Exacerbations
- 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1
- Typically 5 days is sufficient 6
- No tapering required for courses under 7 days 3
Allergic Reactions/Anaphylaxis
- 1 mg/kg orally as a single dose (maximum 60-80 mg) 3
- Continue daily for 2-3 days after discharge to prevent biphasic reactions 3
- Critical pitfall: Corticosteroids are adjunctive only; epinephrine remains first-line for anaphylaxis 3
- No tapering needed for short courses under 7 days 3
Nephrotic Syndrome (First Episode)
- 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) as a single daily dose for 4-6 weeks 1, 2
- Followed by 40 mg/m²/day or 1.5 mg/kg/day (maximum 40 mg) on alternate days for 2-5 months with tapering 2
- Longer initial treatment (6 months total) significantly reduces relapse rates: 50% remain relapse-free at 2 years versus only 20-27% with shorter courses 7
Nephrotic Syndrome (Relapses)
- Infrequent relapses: 60 mg/m²/day until remission for at least 3 days, then 40 mg/m²/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 therapy for at least 3 months at lowest effective dose 2
- Consider corticosteroid-sparing agents (cyclophosphamide, cyclosporine) for children developing steroid-related adverse effects 1, 2
Autoimmune Hepatitis
- Initial: 1-2 mg/kg/day (maximum 60 mg/day) for 2 weeks, either alone or with azathioprine 1, 2
- Maintenance: Taper over 6-8 weeks to 0.1-0.2 mg/kg/day or 5 mg/day 2
Duchenne Muscular Dystrophy
Tapering Guidelines
- 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 1
- For courses of 7 days or less: No tapering required 3
Critical Monitoring Requirements
For any child on corticosteroids, implement these monitoring protocols:
- Regular assessment for steroid-related adverse effects, particularly with prolonged use 1, 2
- Growth monitoring in children on long-term therapy 1, 2
- Baseline and annual bone mineral density testing of lumbar spine and hip for long-term use 1, 2
Important Clinical Caveats
- Avoid systemic corticosteroids for bronchiolitis in infants under 2 years due to insufficient evidence of benefit 1
- Prednisone and prednisolone are equivalent and used in the same dosage 2
- Oral liquid formulations are more readily absorbed than tablets, particularly relevant if the child has difficulty swallowing or is at risk of vomiting 3
- Weight-based underdosing increases the likelihood of frequent relapses in nephrotic syndrome responders, though it doesn't affect initial response rates 4