What is the recommended dosage of albuterol (salbutamol) inhalation treatment for pediatric patients?

Albuterol Inhalation Treatment Dosing for Pediatric Patients

For acute asthma exacerbations in children, administer 0.15 mg/kg (minimum dose 2.5 mg) of albuterol nebulizer solution every 20 minutes for 3 doses, then 0.15-0.3 mg/kg (up to 10 mg) every 1-4 hours as needed based on severity and clinical response. 1

Nebulizer Solution Dosing by Clinical Scenario

Acute Exacerbations (Emergency Department/Hospital)

• Initial treatment: 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses 1
• Maintenance after initial 3 doses: 0.15-0.3 mg/kg every 1-4 hours as needed, up to maximum 10 mg per dose 1
• Severe/life-threatening exacerbations: Consider continuous nebulization at 0.5 mg/kg/hour (up to 10-15 mg/hour) 1, 2
• Always dilute to minimum 3 mL total volume and deliver at 6-8 L/min gas flow 1

Maintenance/Outpatient Dosing

• Children weighing ≥15 kg: 2.5 mg (one full vial of 0.083% solution) three to four times daily 3
• Children weighing <15 kg: Use 0.5% concentration to allow doses less than 2.5 mg 3
• For children under 5 years with mild bronchospasm: 0.63 mg every 4-6 hours as needed 2

Metered-Dose Inhaler (MDI) Dosing

Acute Exacerbations

• Initial treatment: 4-8 puffs (90 mcg/puff) every 20 minutes for 3 doses 1
• Maintenance: 4-8 puffs every 1-4 hours as needed 1
• Must use valved holding chamber (spacer) with face mask for children <4 years 2

Maintenance/Outpatient

• 1-2 puffs every 4-6 hours as needed for children under 5 years 2
• 2 puffs every 4-6 hours as needed for children 5-11 years 2

Critical Adjunctive Therapy Considerations

Add ipratropium bromide 0.25-0.5 mg to albuterol nebulization for moderate-to-severe exacerbations or when patients fail to improve after 15-30 minutes of initial beta-agonist therapy. 1, 2 This combination should be given every 20 minutes for the first 3 doses, then every 6 hours until improvement begins 2. The medications can be mixed in the same nebulizer solution 2.

Age-Specific Nuances

Infants and Children <2 Years

• Albuterol HFA 180-360 mcg via MDI with spacer and face mask is safe and effective 4
• Cumulative dosing improved symptoms by approximately 48% without significant safety concerns 4
• Nebulizer solution dosing follows same weight-based guidelines (0.15 mg/kg minimum 2.5 mg) 1

Children 6-12 Years

• Both 0.62 mg and 1.25 mg doses are effective for maintenance therapy 5
• Lower dose (0.62 mg) more effective in children ≤10 years or those ≤40 kg with less severe asthma 5
• Higher dose (1.25 mg) more effective in children 11-12 years weighing >40 kg or with more severe asthma 5

Continuous Nebulization Protocol

For severe status asthmaticus requiring PICU admission:

• Standard dose: 0.5 mg/kg/hour (up to 10-15 mg/hour) 1, 2
• High-dose protocols: Some centers use 75-150 mg/hour (approximately 2.4-5.8 mg/kg/hour) with acceptable safety profile 6
• Dilute in 25-30 mL saline for 1 hour of nebulization 2
• No optimal weight-based dose has been definitively established; lower doses may be as efficacious as higher doses 7

Evidence Strength and Practical Considerations

The National Asthma Education and Prevention Program (NAEPP) guidelines provide the foundational dosing framework 1, which has been reinforced by multiple pediatric societies 2. The weight-based approach (0.15 mg/kg) ensures adequate dosing across age ranges while the minimum dose of 2.5 mg prevents underdosing in smaller children 1.

Higher doses (0.30 mg/kg) administered hourly resulted in significantly greater FEV1 improvement compared to standard dosing (0.15 mg/kg) without increased side effects 8, suggesting that escalation to the upper end of the recommended range (0.3 mg/kg) is appropriate for patients with inadequate response.

Common Pitfalls to Avoid

• Never underdose based on weight alone: Always use minimum 2.5 mg even if weight-based calculation yields lower dose 1, 2
• Don't delay ipratropium addition: Add at presentation for moderate-severe exacerbations, not after prolonged failed beta-agonist therapy 2
• Oxygen as driving gas: Use oxygen-driven nebulizers when possible, especially in acute exacerbations 2
• Reassess after initial 3 doses: Response at 60-90 minutes predicts hospitalization need better than initial severity 1
• Don't continue ipratropium beyond initial stabilization: Once hospitalized and improving, ipratropium provides no additional benefit 9

Monitoring Requirements

• Assess clinical response (respiratory rate, work of breathing, oxygen saturation) after each treatment 2
• Monitor for tachycardia, tremor, and hypokalemia with frequent or high-dose administration 2
• Increasing albuterol requirement or lack of expected effect indicates worsening asthma control requiring reassessment 2, 3