Initial Treatment for Nephrotic Syndrome in a 10 kg Child
Begin oral prednisone at 60 mg/m²/day (or 2 mg/kg/day) as a single morning dose for 6 weeks, followed by 40 mg/m² on alternate days for another 6 weeks, then taper over 4 weeks for a total duration of 16 weeks. 1, 2
Calculating the Dose for a 10 kg Child
For a 10 kg child, the weight-based calculation yields:
- 2 mg/kg/day = 20 mg daily (maximum 60 mg/day) 1, 2
- This dose should be given as a single morning dose to minimize adrenal suppression 3
- Administer with food to reduce gastric irritation 3
Important caveat: The body surface area (BSA) method (60 mg/m²/day) and weight-based method (2 mg/kg/day) are not equivalent in children weighing less than 30 kg, with weight-based dosing typically yielding 15-20% lower doses 4. However, both methods are acceptable per guidelines, and the weight-based approach may reduce cumulative steroid exposure while maintaining efficacy 5, 6.
Complete Treatment Protocol
Phase 1: Daily Dosing (6 weeks)
- Prednisone 20 mg once daily every morning for the full 6 weeks, regardless of when remission occurs 1, 2
- Continue daily dosing even after achieving remission (defined as urine protein <1+ on dipstick for 3 consecutive days) 1, 2
Phase 2: Alternate-Day Dosing (6 weeks)
- After 6 weeks of daily therapy, switch to 40 mg/m² (approximately 13-14 mg for a 10 kg child) on alternate days as a single morning dose 7
- Continue this for 6 weeks 7
Phase 3: Tapering (4 weeks)
- Taper at the rate of 10 mg/m² per week (approximately 3 mg per week for a 10 kg child) until reaching 5 mg on alternate days 7
- Total treatment duration: 16 weeks 1, 2
Critical Considerations Before Starting Treatment
Age-specific evaluation is essential:
- Children younger than 1 year are more likely to have genetic causes and should be managed differently—do not use the standard regimen without further evaluation 2
- This 10 kg child is likely between 1-3 years old (typical weight range), making standard treatment appropriate 2
Monitoring for Response
- Remission definition: Urine protein <1+ on dipstick for 3 consecutive days or urine protein-to-creatinine ratio <200 mg/g 1, 2
- If no remission by 6 weeks of daily prednisone, suspect steroid-resistant nephrotic syndrome (SRNS) and consider kidney biopsy 1
- Approximately 80% of children will achieve remission, but 50% will experience frequent relapses or become steroid-dependent 2
Common Pitfalls to Avoid
Do not use shorter treatment courses: The older 8-week regimen (4 weeks daily + 4 weeks alternate-day) significantly increases relapse risk compared to the 12-16 week protocol 1, 2. Longer initial courses reduce relapses without increasing adverse effects 1.
Do not discontinue steroids abruptly: Even after completing the full course, avoid sudden cessation as this increases relapse risk 2.
Do not exceed 60 mg/day maximum: Even if calculations suggest higher doses, cap the daily dose at 60 mg 1, 2, 3.
Monitor for steroid side effects: Watch for increased appetite, irritability, mood changes, sleep disturbances, growth suppression, and signs of infection 3, 8.
Management of Future Relapses
If this child relapses (defined as ≥3+ protein on dipstick for 3 consecutive days):
- Treat with prednisone 60 mg/m²/day (20 mg for 10 kg child) until remission for at least 3 consecutive days 1, 2
- Then switch to alternate-day prednisone 40 mg/m² for 4 weeks 1, 2
- For frequent relapses (≥2 relapses in 6 months) or steroid-dependent disease, consider steroid-sparing agents with levamisole as first-line (if available), followed by cyclophosphamide 7, 1