What is the appropriate dose of albuterol for pediatric patients of different ages?

Albuterol Dosing by Age in Pediatric Patients

For children under 5 years, use 0.63 mg (or 1-2 puffs of MDI with spacer/mask) every 4-6 hours for routine bronchospasm, and for acute exacerbations use 0.075 mg/kg (minimum 1.25 mg) every 20 minutes for 3 doses; for children 5-11 years, use 2 puffs MDI or 2.5 mg nebulized every 4-6 hours routinely, and 0.075 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses in acute settings. 1, 2

Age-Specific Dosing Guidelines

Children Under 5 Years

Routine/Maintenance Dosing:

• Nebulizer: 0.63 mg/3 mL every 4-6 hours as needed 1
• MDI with spacer/face mask: 1-2 puffs (90 mcg/puff) every 4-6 hours 1
• A spacer with face mask is mandatory for children under 4 years—failure to use one dramatically reduces drug delivery 1

Acute Exacerbations:

• Initial treatment: 0.075 mg/kg (minimum dose 1.25 mg) every 20 minutes for 3 doses 1, 2
• Maintenance after initial 3 doses: 0.075-0.15 mg/kg every 1-4 hours as needed 1
• MDI alternative: 4-8 puffs every 15-20 minutes for 3 doses, then every 1-4 hours 1, 2
• Critical point: Always use the minimum 1.25 mg dose even if weight-based calculation yields lower—at 12 months of age, weight-based dosing may fall below effective threshold 1

Children 5-11 Years

Routine/Maintenance Dosing:

• MDI with spacer: 2 puffs every 4-6 hours as needed 1
• Nebulizer: 2.5 mg every 4-6 hours 2, 3

Acute Exacerbations:

• Weight-based: 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses 2
• Fixed dosing alternative: 2.5 mg for children <20 kg, 5 mg for children >20 kg 2
• Maintenance: 0.15-0.3 mg/kg every 1-4 hours as needed 2
• MDI alternative: 4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours 2

Children 12 Years and Older

Standard adult dosing applies:

• Nebulizer: 2.5 mg three to four times daily, with higher doses for acute exacerbations 3
• Patients weighing ≥15 kg should use the standard 2.5 mg dose 3

Severe Exacerbations and Escalation

When to escalate beyond standard dosing:

• If inadequate response after initial 3 doses, consider doubling the dose 1
• Add ipratropium bromide 0.25-0.5 mg to albuterol for severe exacerbations—mix in same nebulizer, give every 20 minutes for 3 doses, then every 6 hours 1, 2
• Continuous nebulization: 0.5 mg/kg/hour (maximum 10-15 mg/hour) for severe status asthmaticus, diluted in 25-30 mL saline 1, 2

Levalbuterol (Levosalbutamol) Conversion

Use exactly half the milligram dose of racemic albuterol for equivalent effect: 4

• Children <5 years: 0.31 mg/3 mL (vs 0.63 mg albuterol) 1, 4
• Acute dosing: 0.075 mg/kg minimum 1.25 mg (vs 0.15 mg/kg minimum 2.5 mg albuterol) 4
• MDI: 45 mcg/puff (vs 90 mcg/puff albuterol) 4

Administration Techniques

Critical technical points:

• Oxygen is the preferred gas source at 6-8 L/min flow rate 1, 2
• Dilute in 2-3 mL saline for adequate nebulization (5-15 minute delivery time) 2, 3
• For children under 2 years who won't tolerate mouthpiece, use face mask 2
• Puffs from MDI can be taken at 10-15 second intervals 1

Monitoring and Safety

Monitor after each dose:

• Respiratory rate, work of breathing, oxygen saturation (maintain >92%) 2
• Heart rate (watch for symptomatic tachycardia) 1, 2
• Potassium levels with frequent dosing (risk of hypokalemia) 1

Common pitfall: Never use oral albuterol syrup for acute bronchospasm—inhaled delivery provides superior bronchodilation with fewer systemic side effects 2, 4

When to Transfer/Escalate Care

Immediate hospital transfer if: 2

• Life-threatening features present
• Peak flow remains <50% predicted after initial treatment
• Persistent severe features despite 3 doses of albuterol
• Consider IV albuterol (15 mcg/kg over 10 minutes) for severe deterioration 2