Recommended Syrups for Pediatric Asthma Exacerbations
For pediatric asthma exacerbations, prescribe oral prednisolone syrup 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days, starting immediately after initial bronchodilator treatment in yellow or red zone episodes. 1, 2, 3
Critical Point: Avoid Oral Albuterol Syrup
Never prescribe oral albuterol syrup for asthma exacerbations—it has lower potency, longer onset of action, and more side effects compared to inhaled albuterol. 2 The FDA-approved oral albuterol dosing (2-4 mg three to four times daily) is intended only for maintenance therapy in specific circumstances, not acute exacerbations. 4
Prednisolone Syrup Dosing by Zone
Yellow Zone (Worsening Symptoms)
- Start prednisolone syrup 1-2 mg/kg daily (maximum 60 mg/day) after giving 3 doses of inhaled albuterol (4-8 puffs every 20 minutes). 1, 2
- Continue for 3-10 days total. 1, 3
- No tapering needed for courses under 10 days, especially if the child is on inhaled corticosteroids. 1
Red Zone (Severe Exacerbation)
- Give prednisolone syrup 1-2 mg/kg (maximum 60 mg) immediately while calling 911. 2
- Continue the same dose daily for the full 3-10 day course after emergency department discharge. 2, 3
Specific Formulation Details
The prednisolone sodium phosphate oral solution contains 15 mg prednisolone base per 5 mL. 3 For a 20 kg child requiring 1 mg/kg:
- Dose = 20 mg prednisolone
- Volume = approximately 6.7 mL of the 15 mg/5 mL solution 3
Prednisolone, prednisone, and methylprednisolone are equally effective and interchangeable for asthma exacerbations. 1 The choice depends on local availability and palatability.
Why Oral Corticosteroid Syrup is Essential
Systemic corticosteroids address the underlying airway inflammation that worsens during exacerbations, which bronchodilators alone cannot treat. 1 Inhaled corticosteroids alone are never sufficient for acute exacerbations—oral prednisolone is significantly more effective and prevents hospitalizations. 2
The National Heart, Lung, and Blood Institute specifically recommends 1-2 mg/kg/day in children with uncontrolled asthma requiring systemic therapy, continued until peak expiratory flow reaches 80% of personal best or symptoms resolve, typically requiring 3-10 days. 3
Common Pitfall to Avoid
Do not double the child's maintenance inhaled corticosteroid dose instead of giving oral prednisolone during exacerbations—evidence shows this strategy is ineffective in adherent patients. 1, 2 The 2020 NAEPP guidelines specifically recommend against increasing ICS doses for worsening symptoms in patients 4 years and older who are adherent to daily ICS treatment. 1