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

Prednisolone Dosing in Children

For most acute pediatric conditions requiring corticosteroid therapy, start with prednisolone 1-2 mg/kg/day (maximum 60 mg/day) as a single morning dose, with specific adjustments based on the condition being treated. 1, 2, 3

General Dosing Principles

• Body surface area dosing (mg/m²) is preferred over weight-based dosing (mg/kg) because it better parallels prednisolone metabolism and reduces the risk of underdosing in younger children, though weight-based dosing remains simpler for clinical practice 1

• Always use ideal body weight rather than actual weight in significantly overweight children to avoid unnecessary steroid exposure and increased side effects 1, 4, 2

• The maximum daily dose is typically 60 mg, though up to 80 mg may be considered for specific severe conditions 1

• Administer as a single morning dose before 9 AM to align with physiologic cortisol rhythm and minimize hypothalamic-pituitary-adrenal axis suppression 1, 2

• Prednisolone and prednisone are equivalent and interchangeable at the same dosage 5, 1, 4

Condition-Specific Dosing

Acute Asthma Exacerbations

• Dose: 1-2 mg/kg/day (maximum 60 mg/day) as a single daily dose for 3-10 days 1, 4, 2, 3

• No tapering is needed if duration is less than 10 days 1

• Research supports that even 0.5 mg/kg/day may be effective, though 1-2 mg/kg remains the guideline standard 6

• A single 30 mg dose (children under 5 years) or 60 mg dose (children 5 years and older) can reduce morbidity and hospital care in acute presentations 7

Nephrotic Syndrome (Initial Episode)

• Initial phase: 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) as a single morning dose for 4-6 weeks 5, 1, 2, 3

• Alternate-day phase: 40 mg/m²/day or 1.5 mg/kg/day (maximum 40 mg on alternate days) for 2-5 months with gradual tapering 5, 1, 2

• Total treatment duration should be at least 12 weeks to reduce relapse rates 5

• Single-dose daily administration is as effective as divided-dose regimens, with mean response time of 9.6 days for initial episodes and 11.1 days for relapses 8

Nephrotic Syndrome (Relapses)

• Infrequent relapses: 60 mg/m² or 2 mg/kg (maximum 60 mg/day) until remission for at least 3 days, then 40 mg/m² or 1.5 mg/kg on alternate days for at least 4 weeks 5

• Frequent relapses or steroid-dependent disease: Daily prednisone until remission for at least 3 days, followed by alternate-day dosing for at least 3 months 5

• For selected patients with frequent relapses, reduced doses (0.2-1.5 mg/kg/day) successfully induced remissions in 87% of episodes, providing additional steroid sparing 8

• Consider corticosteroid-sparing agents (such as cyclophosphamide or rituximab) for children developing steroid-related adverse effects 5, 2

Autoimmune Hepatitis

• Initial: 1-2 mg/kg/day (maximum 60 mg/day) for two weeks, either alone or with azathioprine 5, 1, 4, 2

• Taper over 6-8 weeks to maintenance dose of 0.1-0.2 mg/kg/day or 5 mg/day 5, 1, 4

• The combination regimen of prednisone and azathioprine is preferred over higher-dose prednisone alone (10% versus 44% corticosteroid-related side effects) 5

• Early use of azathioprine (1-2 mg/kg daily) is recommended for all children without contraindications due to significant deleterious effects of long-term corticosteroids on growth, bone development, and physical appearance 5

• Continue maintenance regimen until resolution of disease, treatment failure, or drug intolerance 5

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, 4

• When tapering from higher doses: reduce by 5 mg every week until 10 mg/day is achieved, then reduce by 2.5 mg/week down to 5 mg daily 5, 2

• Final reductions should be 1 mg monthly 1, 4

• For short courses (less than 10 days), no tapering is required 1

Critical Monitoring Requirements

• Growth parameters, blood pressure, and Cushingoid features should be monitored regularly 1, 2

• Baseline and annual bone mineral densitometry of lumbar spine and hip for patients on long-term corticosteroid treatment 5, 2

• Calcium and vitamin D supplementation should be provided during therapy 4, 2

• Common side effects include weight gain (occurring even at low doses of 5-10 mg), increased appetite, cosmetic changes, and growth deceleration 1, 4

• Severe complications (osteopenia with vertebral compression, brittle diabetes, psychosis, hypertension) are uncommon but more likely after protracted therapy exceeding 18 months 5, 1

Important Clinical Caveats

• Cosmetic changes occur in 80% of patients after 2 years of corticosteroid treatment regardless of regimen, making this the most common cause for premature drug withdrawal 5

• For children with behavioral side effects (hyperactivity, emotional lability), consider afternoon dosing after school instead of morning administration 4

• Avoid systemic corticosteroids for bronchiolitis in infants under 2 years due to insufficient evidence of benefit 2

• Children with cirrhosis have higher frequency of drug-related complications (25% versus 8%) and may have cytopenia compromising azathioprine tolerance 5