Prednisolone Dosing in Children
For most pediatric conditions requiring corticosteroid therapy, prednisolone should be dosed at 1-2 mg/kg/day (maximum 60 mg/day) as a single morning dose, with the specific regimen tailored to the underlying condition. 1, 2
General Dosing Principles
Use body surface area dosing (mg/m²) when possible rather than weight-based dosing, as it better parallels prednisolone metabolism and reduces the risk of underdosing in younger children. 1
For overweight children, always calculate the dose based on ideal body weight rather than actual weight to avoid excessive steroid exposure and increased side effects. 1, 2, 3
The maximum daily dose is typically 60 mg, though up to 80 mg may be considered for specific severe conditions. 1, 3, 4
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 used interchangeably at the same dosage. 1, 3
Condition-Specific Dosing Algorithms
Acute Asthma Exacerbations
Dose: 1-2 mg/kg/day (maximum 60 mg/day) as a single daily dose for 3-10 days. 1, 2, 4
No tapering is needed if duration is less than 10 days. 1
Lower doses (1 mg/kg/day) are equally effective as higher doses (2 mg/kg/day) and cause significantly fewer behavioral side effects, particularly anxiety and aggressive behavior. 5, 6
Research shows that 0.5 mg/kg/day may be sufficient for acute exacerbations in hospitalized children, though guidelines recommend 1-2 mg/kg/day. 7
Nephrotic Syndrome
Initial 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 gradual tapering. 8, 1, 3
Total duration of therapy should be at least 12-16 weeks to account for tapering. 8
Infrequent Relapses:
- 60 mg/m²/day (maximum 60 mg/day) daily until remission (trace/negative proteinuria for at least 3 consecutive days), then 40 mg/m²/day on alternate days for at least 4 weeks. 8, 3
Frequent Relapses or Steroid-Dependent Cases:
Daily prednisolone until remission for 3 days, followed by alternate-day prednisolone for at least 3 months at the lowest effective dose. 8, 3
Consider corticosteroid-sparing agents (levamisole first-line, then cyclophosphamide) if steroid-related adverse effects develop. 8, 3
Multisystem Inflammatory Syndrome in Children (MIS-C)
First-Line Treatment:
Intensification for Refractory Disease:
Escalate to methylprednisolone 10-30 mg/kg/day IV or high-dose anakinra. 8, 1
Refractory disease is defined as persistent fevers and/or ongoing significant end-organ involvement. 8
Autoimmune Hepatitis
Initial: 1-2 mg/kg/day (maximum 60 mg/day) for two weeks, either alone or with azathioprine. 1, 3
Maintenance: Taper over 6-8 weeks to 0.1-0.2 mg/kg/day or 5 mg/day. 1, 3
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, with final reductions of 1 mg monthly. 1
For courses less than 10 days, no tapering is needed. 1
Critical Monitoring Requirements
Monitor growth parameters, blood pressure, and Cushingoid features regularly, especially with prolonged use. 1, 2, 3
Consider calcium and vitamin D supplementation during therapy. 1
Baseline and annual bone mineral density testing of lumbar spine and hip for long-term corticosteroid use. 2
Common Pitfalls and Caveats
Avoid using actual body weight in overweight children, as this leads to unnecessary steroid exposure and increased side effects. 1, 2, 3
Higher doses (2 mg/kg/day) in asthma cause significantly more behavioral side effects (anxiety, hyperactivity, aggressive behavior) without additional clinical benefit compared to 1 mg/kg/day. 5, 6
Vomiting is significantly more common with higher doses (2 mg/kg/day vs 1 mg/kg/day) in preschool children with asthma. 6
Severe side effects are uncommon but more likely after prolonged therapy exceeding 18 months. 1
Do not use systemic corticosteroids for bronchiolitis in infants under 2 years due to insufficient evidence of benefit. 2