Oral Prednisone Dosing in Children
For most acute pediatric conditions requiring oral corticosteroids, administer prednisone 1-2 mg/kg/day (maximum 60 mg/day) as a single morning dose. 1, 2
General Dosing Framework
The standard approach for pediatric prednisone dosing depends on the clinical indication:
- Standard acute dosing: 1-2 mg/kg/day with a maximum of 60 mg/day, given as a single morning dose before 9 am 1, 2, 3
- Weight-based calculation: For significantly overweight children, calculate the dose using ideal body weight rather than actual weight to avoid excessive steroid exposure 1, 4
- Alternative BSA-based dosing: 60 mg/m²/day can be approximated using the equation [2 × weight in kg + 8] when height is unavailable 5
Condition-Specific Dosing
Asthma Exacerbations
- Recommended dose: 1 mg/kg/day (maximum 60 mg/day) for 3-10 days 1, 2
- Evidence supporting lower dosing: Research demonstrates that 1 mg/kg/day provides equivalent clinical benefit to 2 mg/kg/day, with significantly fewer behavioral side effects including anxiety (number needed to harm = 6.1) and aggressive behavior (number needed to harm = 4.8) 6
- Even lower doses may suffice: A study comparing 0.5 mg/kg, 1 mg/kg, and 2 mg/kg found no significant differences in recovery patterns, suggesting 0.5 mg/kg/day may be appropriate for acute exacerbations 7
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, followed by 40 mg/m²/day or 1.5 mg/kg/day (maximum 40 mg) on alternate days for 2-5 months with tapering 1, 4
- Relapses: 60 mg/m²/day or 2 mg/kg/day until remission for at least 3 days, then 40 mg/m²/day on alternate days for at least 4 weeks 4
- Critical caveat: Weight-based dosing (2 mg/kg/day) results in relative underdosing compared to BSA-based dosing (60 mg/m²/day), particularly in younger children, which increases the risk of frequent relapses 8
Autoimmune Hepatitis
- Initial treatment: 1-2 mg/kg/day (maximum 60 mg/day) for two weeks, either alone or with azathioprine 2, 4
- Maintenance: Taper over 6-8 weeks to 0.1-0.2 mg/kg/day or 5 mg/day 4
Duchenne Muscular Dystrophy
Administration Timing and Technique
- Morning dosing preferred: Administer as a single dose before 9 am to minimize adrenocortical suppression and mimic physiologic cortisol secretion patterns 1, 2, 3
- Exception for behavioral side effects: Consider afternoon dosing after school if hyperactivity or emotional lability occurs with morning administration 1
- With food: Give before, during, or immediately after meals to reduce gastric irritation 3
Tapering Guidelines
- For courses >10 days: Reduce by 5 mg every week until reaching 10 mg/day, then reduce by 2.5 mg/week until reaching maintenance dose 2
- General principle: Reduce by 25-33% at appropriate intervals once clinical response is achieved 1
- Avoid abrupt withdrawal: Always taper gradually after long-term therapy 3
Critical Monitoring Requirements
- Regular assessment: Monitor for steroid-related adverse effects including Cushingoid features, growth deceleration, weight gain, hypertension, and gastric irritation, especially with prolonged use 1, 4
- Growth monitoring: Essential for children on long-term therapy 2, 4
- Bone health: Consider baseline and annual bone mineral density testing for long-term use; provide calcium and vitamin D supplementation during therapy 1, 2
Important Clinical Caveats
- Avoid in bronchiolitis: Do not use systemic corticosteroids for bronchiolitis in infants under 2 years due to insufficient evidence of benefit 2
- Consider steroid-sparing agents: For children with frequent relapses or steroid dependence who develop adverse effects 2, 4
- Behavioral side effects: Higher doses (2 mg/kg/day) cause twice the rate of anxiety and aggressive behavior compared to 1 mg/kg/day, with no additional clinical benefit in asthma 6