Prednisolone Liquid Dosing Frequency in Children
Prednisolone liquid for children should be given as a single daily dose in the morning, not divided into twice-daily dosing. This recommendation applies to most pediatric conditions requiring corticosteroid therapy, including asthma exacerbations and nephrotic syndrome.
Standard Dosing Approach
The American Academy of Pediatrics and multiple international guidelines consistently recommend administering prednisolone as a single morning dose before 9 AM to align with physiologic cortisol rhythm and minimize hypothalamic-pituitary-adrenal (HPA) axis suppression 1, 2, 3. This single-dose approach is supported by:
- FDA labeling acknowledges divided dosing (3-4 times daily) as an option for initial pediatric dosing 4, but this conflicts with current best practice guidelines that favor single daily dosing
- The KDIGO guidelines specifically recommend single daily dosing for nephrotic syndrome management 5
- Single morning dosing has been proven equally effective as divided dosing for inducing remission in nephrotic syndrome 6, 7
Evidence Supporting Single Daily Dosing
The superiority of single-dose administration is well-established:
- Single morning dosing causes significantly less HPA axis suppression compared to divided dosing (83% vs 100% suppression rates) 7
- Children receiving single-dose prednisolone had a longer time to first relapse (median 131 days) compared to divided dosing (median 28 days) in nephrotic syndrome 7
- Single-dose therapy achieves remission in comparable timeframes to divided-dose regimens (mean 9.6-11.1 days) 6
Condition-Specific Applications
For acute asthma exacerbations: 1-2 mg/kg/day (maximum 60 mg/day) as a single daily dose for 3-10 days 1, 2
For nephrotic syndrome (initial episode): 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) as a single morning dose for 4-6 weeks, followed by alternate-day dosing 5, 1, 2
For nephrotic syndrome relapses: 60 mg/m² or 2 mg/kg (maximum 60 mg/day) as a single dose until remission for at least 3 days 5, 2
Important Clinical Caveat
One recent study found that split-dose prednisolone (2/3 morning, 1/3 evening) achieved remission faster in nephrotic syndrome relapses (8.02 days vs 9.74 days) compared to single dosing 8. However, this conflicts with the broader evidence showing single dosing causes less HPA suppression and longer time to relapse 7. Given the priority of minimizing long-term morbidity from HPA axis suppression, single morning dosing remains the preferred approach unless rapid remission is critically needed in a specific clinical scenario.
Practical Implementation
- Administer the entire daily dose before 9 AM to preserve circadian cortisol patterns 1, 2
- Calculate dose based on body surface area (mg/m²) rather than weight (mg/kg) when possible, as this better parallels prednisolone metabolism 1, 2
- Use ideal body weight rather than actual weight in overweight children to avoid excessive steroid exposure 1, 2, 3
- Maximum daily dose is typically 60 mg, though up to 80 mg may be considered for severe conditions 1, 2