What is the recommended dose of Decadron (dexamethasone) for pediatric patients?

Pediatric Dexamethasone Dosing

The recommended dose of dexamethasone in pediatric patients is 0.6 mg/kg (maximum 16 mg) as a single dose for croup and asthma exacerbations, or 0.15 mg/kg every 6 hours for 2-4 days for bacterial meningitis. 1, 2, 3

Dosing by Clinical Indication

Croup

• Administer 0.6 mg/kg as a single stat dose (maximum 16 mg) via oral, intramuscular, or intravenous route 2, 3
• All three routes are equally effective; oral administration is preferred when the child can tolerate it to avoid injection pain 2, 3
• Duration of action is 24-72 hours from a single dose, providing sustained symptom relief without requiring tapering 2, 3
• For a typical 2-year-old weighing 12-13 kg, this translates to approximately 7.2-7.8 mg as a single dose 3
• For severe croup with prominent stridor and significant retractions, add nebulized epinephrine (0.5 mL/kg of 1:1000 solution, maximum 5 mL) for immediate relief while dexamethasone takes effect 2, 3

Asthma Exacerbations

• Give 0.6 mg/kg as a single dose (maximum 16 mg) for mild to moderate exacerbations 2, 4, 5
• This single dose is equally effective as a 3-5 day course of prednisolone or prednisone 2
• One dose is non-inferior to two doses for mild to moderate asthma exacerbations 5
• Alternative regimen: 0.6 mg/kg for 3-5 days per European Respiratory Review guidelines 2

Bacterial Meningitis

• Administer 0.15 mg/kg every 6 hours for 2-4 days 1, 2
• Critical timing: Must be initiated 10-20 minutes prior to, or at least concomitant with, the first antimicrobial dose 1, 2
• Dexamethasone is ineffective if given after antimicrobial therapy has already begun 1, 2
• This dosing applies specifically to H. influenzae type b meningitis in infants and children 2

Chemotherapy-Related Indications

• For antiemetic prophylaxis with moderate-emetic-risk chemotherapy: 8 mg oral or IV on day 1, combined with a 5-HT3 receptor antagonist 6
• For acute lymphoblastic leukemia protocols: 6 mg/m² per day for 28 days per Children's Oncology Group protocols 2
• Dexamethasone decreases isolated CNS relapse risk and improves event-free survival compared to prednisone in ALL 2
• Caution: In patients ≥10 years old with ALL, dexamethasone carries higher osteonecrosis risk compared to prednisone 2

Other Indications

• Adrenal insufficiency: 2-3 mg/kg IV/IO (maximum 100 mg) over 3-5 minutes, followed by 1-5 mg/kg every 6 hours for infants or 12.5 mg/m² every 6 hours for older children 6
• Strongly consider concomitant fluid bolus of 20 mL/kg of D5NS or D10NS during the first hour 6
• Immune thrombocytopenia (ITP): 0.6 mg/kg per day (maximum 40 mg per day) for 4 days 6
• However, the American Society of Hematology suggests prednisone (2-4 mg/kg per day; maximum 120 mg daily for 5-7 days) rather than dexamethasone for children with newly diagnosed ITP due to concerns about higher corticosteroid exposure with repeated dexamethasone courses 6

Age-Specific Dosing Adjustments

Neonates and Preterm Infants

• High-dose dexamethasone (≥0.5 mg/kg/day) is contraindicated in neonates and preterm infants 1, 2
• Risk of gastrointestinal perforation, hypertension, hyperglycemia, impaired growth, and neurodevelopmental impairment 1, 2
• High-dose dexamethasone (0.5 mg/kg/day) causes hippocampal neuronal degeneration, decreased hippocampal volume, altered synaptic plasticity, and impaired memory formation 2
• For bronchopulmonary dysplasia, high-dose dexamethasone is not recommended; low-dose therapy (<0.2 mg/kg/day) may facilitate extubation with fewer adverse effects 2

Age-Related Dose Modifications for Post-Extubation Stridor Prevention

• 0-2 weeks: Reduce dose by 60% compared to standard 2-6 year old dosing 7
• 2-4 weeks: Reduce dose by 40% 7
• 1-3 months: Reduce dose by 20% 7
• 3 months to 6 years: Use standard dosing 7
• 6-12 years: Reduce dose by 20% 7
• 12-18 years: Reduce dose by 40% 7
• These adjustments reflect age-related variation in CYP3A4 activity and drug disposition 7

Critical Safety Considerations

Absolute Contraindications

• Do not use high-dose dexamethasone (≥0.5 mg/kg/day) in preterm infants for bronchopulmonary dysplasia prevention or treatment 1, 2
• Do not use dexamethasone for streptococcal pharyngitis; use acetaminophen or NSAIDs instead 1

Common Side Effects

• Gastric irritation, behavioral changes, weight gain, and increased appetite 2
• Transient hyperglycemia and hypertension 8
• Increased risk of bacteremia or clinical sepsis with prolonged use 8
• Vomiting occurs in approximately 3-9% of patients receiving single-dose therapy 5

Important Clinical Pitfalls to Avoid

• Do not use nebulized corticosteroids from hand-held inhalers with spacers for croup—they are ineffective 3
• Do not assume repeat dosing is necessary for croup; the single dose provides 24-72 hours of coverage 3
• Do not delay dexamethasone in severe croup waiting to determine if oral route is tolerated—use IM or IV routes immediately 3
• Do not give dexamethasone for bacterial meningitis after antimicrobial therapy has begun—it is ineffective 1, 2
• A single short course (2-4 days) does not cause clinically significant adrenal suppression 1