Prednisolone for URTI in Pediatric Patients: Evidence-Based Dosing
Prednisolone should NOT be routinely given to otherwise healthy children with uncomplicated upper respiratory tract infections, as there is no evidence of benefit for typical viral URTIs. 1
Critical Context: When Prednisolone IS Indicated for URTI
The evidence for prednisolone use during URTIs applies only to specific high-risk populations, not general pediatric URTIs:
Children with Nephrotic Syndrome (Specific Indication)
For children with frequently relapsing or steroid-dependent nephrotic syndrome already on low-dose alternate-day prednisolone:
- Dosing: 0.5 mg/kg/day (low-dose) daily for 3 extra doses at URTI onset can be considered 1
- Patient selection criteria: Only those with documented history of repeated infection-associated relapses OR significant prednisolone-related morbidity 1
- Important limitation: The most recent high-quality evidence (PREDNOS 2 trial, 2020) showed no benefit from this approach in UK children, leading KDIGO 2025 to recommend against routine use 1
Key nuance: Older studies from developing nations (2008-2017) showed benefit with this approach 2, 3, but the definitive PREDNOS 2 trial in 365 UK children found no difference between prednisolone and placebo (42.7% vs 44.3% relapse rate, p=0.70) 4. This led to the 2025 KDIGO guideline reversal recommending against routine daily glucocorticoids during URTIs for nephrotic syndrome patients 1.
Children with Croup (Different Indication)
For viral croup with stridor:
- Dosing: 1 mg/kg as a single oral dose (though dexamethasone is preferred) 5
- Maximum: No specific maximum for single-dose therapy 5
- Duration: Single dose only; no tapering required 5
- Evidence: Reduces croup scores, shortens hospital stays, and reduces return visits 5
Children with Asthma Exacerbations (Different Indication)
For acute asthma exacerbations uncontrolled by inhaled corticosteroids:
- Dosing: 1-2 mg/kg/day (maximum 60 mg/day) 6, 7
- Duration: 3-10 days until peak expiratory flow reaches 80% of personal best 7
- Tapering: Not required for courses <7 days 6, 5
What NOT to Do
Prednisolone should NOT be used for:
- Uncomplicated viral URTIs in healthy children: No evidence of benefit 8
- Bronchiolitis in infants <2 years: Systematic reviews show insufficient evidence 6
- Mild viral wheezing in preschool children (10 months-5 years): A high-quality RCT of 687 children showed no difference between prednisolone (10-20 mg daily for 5 days) and placebo for hospitalization duration or symptom scores 8
General Pediatric Dosing Framework (When Indicated)
For conditions requiring high-dose corticosteroid therapy:
- Standard dose: 1-2 mg/kg/day (maximum 60 mg/day) as single morning dose 6, 9, 7
- Weight adjustment: Use ideal body weight for significantly overweight children to avoid excessive exposure 1, 6, 9
- Body surface area dosing: 60 mg/m²/day for nephrotic syndrome and similar conditions 1, 9
Critical Safety Considerations
Monitoring requirements:
- Short courses (<7-10 days): No tapering needed; minimal monitoring required 6, 5, 7
- Longer courses (>10-14 days): Structured taper required (reduce by 5 mg weekly until 10 mg/day, then 2.5 mg weekly) 6, 9
- Long-term therapy (>30 days at ≥30 mg daily): Baseline and annual bone density testing recommended 6, 9
Common pitfall: The methylprednisolone dose pack (84 mg total over 6 days) is inadequate for most conditions requiring therapeutic dosing 6.
Bottom Line for URTIs
For a typical pediatric URTI without underlying conditions: Prednisolone is not indicated and should not be prescribed. The evidence supporting corticosteroids during URTIs is limited to very specific populations (nephrotic syndrome patients already on steroids), and even in that population, the most recent evidence shows no benefit 1, 4.