Intravenous Hydrocortisone Dosing for Severe Wheeze in Infants
For infants with severe wheeze requiring IV corticosteroids, administer hydrocortisone 4 mg/kg/dose every 6 hours intravenously, or use the fixed dose of 100 mg IV as immediate treatment. 1, 2, 3
Route Selection: When to Use IV vs Oral Corticosteroids
Intravenous hydrocortisone is specifically indicated only when the infant cannot take oral medications due to vomiting, severe illness, or inability to swallow. 3 Oral prednisolone (1-2 mg/kg, maximum 40-60 mg) is preferred when gastrointestinal transit is normal, as there is no advantage to IV administration in infants who can swallow. 2, 3
Specific IV Dosing Regimens
The British Thoracic Society guidelines for acute severe asthma in children recommend immediate administration of intravenous hydrocortisone without specifying an exact dose, but emphasize it should be given as part of immediate treatment alongside high-flow oxygen and nebulized bronchodilators. 1
Two evidence-based dosing approaches exist:
- Weight-based dosing: 4 mg/kg/dose IV every 6 hours 3
- Fixed dosing: 100 mg IV initially, which can be repeated every 6 hours 1, 2
The FDA label for hydrocortisone indicates that initial doses range from 0.56 to 8 mg/kg/day in three or four divided doses (20 to 240 mg/m² body surface area/day) for pediatric patients, with the specific dose varying depending on the disease entity being treated. 4
Complete Immediate Treatment Protocol for Severe Wheeze
Beyond corticosteroids, the complete immediate management includes:
- High-flow oxygen via face mask to maintain SaO₂ >92% 1, 2, 5
- Nebulized salbutamol 2.5 mg (for infants ≤2 years) or 5 mg via oxygen-driven nebulizer, with half doses recommended for very young children 1, 2
- Ipratropium bromide 100 mcg nebulized, added immediately for severe exacerbations and repeated every 6 hours 1, 2, 5
Subsequent Corticosteroid Management
If the infant is improving after initial treatment, continue with:
- Oral prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) once able to take oral medications 1, 2
- High-flow oxygen and nebulized β-agonist every 4-6 hours 1
If not improving after 15-30 minutes:
- Continue oxygen and steroids at the same dose 1
- Increase nebulized β-agonist frequency to every 15-30 minutes 1, 5
Critical Pitfalls to Avoid
Never delay systemic corticosteroids while giving repeated bronchodilator doses alone—this is a leading cause of preventable asthma mortality. 2, 3, 5 Underuse of corticosteroids is specifically identified as a major factor in preventable asthma deaths. 2
Do not use sedatives of any kind in acute severe wheeze, as they can depress respiratory function. 1, 5
Monitoring Requirements
- Repeat clinical assessment and oxygen saturation measurement 15-30 minutes after starting treatment 1, 2, 5
- Maintain continuous pulse oximetry with target SaO₂ >92% 1, 2, 5
- Chart response to each bronchodilator dose 1, 3
When to Escalate Care
Transfer to intensive care if:
- Deteriorating clinical status despite treatment 1, 5
- Persistent hypoxemia (SaO₂ <92% despite oxygen) 1, 5
- Exhaustion, altered consciousness, or respiratory arrest 1, 5
Context: Septic Shock Dosing (Different Clinical Scenario)
Note that in the distinct clinical scenario of septic shock with suspected adrenal insufficiency, hydrocortisone dosing ranges from 1-2 mg/kg/day for stress coverage up to 50 mg/kg/day titrated to reversal of shock. 1 This is a fundamentally different indication than acute wheeze and should not be confused with asthma exacerbation management.