What is the recommended dose of epinephrine (adrenaline) nebulisation and intravenous (IV) dexamethasone for a neonate with stridor?

Epinephrine and Dexamethasone Dosing for Neonatal Stridor

Nebulized Epinephrine Dosing

For neonates with stridor (laryngotracheobronchitis/croup), administer 0.5 mL/kg of 1:1000 epinephrine solution (maximum 5 mL) via nebulizer. 1

Preparation and Administration Details

• Use L-epinephrine 1:1000 concentration (1 mg/mL) 1
• Dose calculation: 0.5 mL/kg of body weight 1
• Maximum single dose: 5 mL (5 mg) 1
• If racemic epinephrine (2.25% solution) is available, use 0.05 mL/kg (maximum 0.5 mL) diluted in 2 mL normal saline 1
• Many institutions use a standard 0.5 mL dose of racemic epinephrine for all patients regardless of weight 1

Clinical Response and Timing

• Onset of action: Clinical improvement typically occurs within 10-30 minutes 2
• Duration of effect: Short-lived, lasting 1-2 hours 1
• Repeat dosing: May be repeated every 20 minutes up to 3 doses if needed 2, 3
• Patients should be observed for at least 3 hours after treatment before considering discharge 3

Critical Safety Considerations

• Do not use for outpatient management or in children who will be discharged shortly, as the effect is transient 1
• Nebulized epinephrine should be used to stabilize children prior to transfer to intensive care or to avoid intubation 1
• The effect wears off after 1-2 hours, requiring extended observation 1

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Intravenous Dexamethasone Dosing

The evidence does not support a specific IV dexamethasone dose for neonatal stridor. The available guidelines address dexamethasone for other indications but not specifically for croup/stridor in neonates.

Available Dosing Information from Guidelines

• For acute allergic disorders in children: Initial dose of 4-8 mg intramuscularly on day 1, followed by oral taper 4
• For cerebral edema: 10 mg IV initially, followed by 4 mg every 6 hours IM 4
• General pediatric dosing range: 0.5 to 9 mg/day depending on disease severity 4

Pediatric Stridor Evidence (Not Neonatal-Specific)

• For prevention of post-extubation stridor in children: 0.15 mg/kg/dose given 6-12 hours prior to extubation, repeated every 6 hours for 6 doses 5
• For croup in older children: 0.6 mg/kg oral dexamethasone has been studied in combination with nebulized epinephrine 3
• The 0.15 mg/kg dose did not show significant benefit over placebo in one pediatric study 5

Critical Gaps in Evidence

• No neonatal-specific dosing guidelines exist for IV dexamethasone in stridor/croup 1, 4
• The FDA label states that "solutions used for intravenous administration should be preservative-free when used in the neonate, especially the premature infant" 4
• Dosing must be individualized based on disease severity, with initial doses ranging from 0.5-9 mg/day 4

Practical Approach for Neonatal Stridor

Given the lack of neonatal-specific evidence, extrapolating from pediatric data suggests considering 0.15 mg/kg IV dexamethasone 5, though this dose showed limited efficacy in preventing post-extubation stridor. For acute croup in neonates, oral or IV dexamethasone at 0.15-0.6 mg/kg may be reasonable based on pediatric studies 6, 3, but this represents extrapolation from older children rather than evidence-based neonatal dosing.

Important Caveats

• Dexamethasone effect is not immediate: Clinical improvement may take hours, unlike the rapid effect of nebulized epinephrine 2, 3
• Use preservative-free preparations in neonates 4
• Monitor for hyperglycemia, hypertension, and other steroid-related adverse effects 4
• If stridor persists or recurs despite treatment, consider alternative diagnoses such as mediastinal masses, vascular rings, or other structural abnormalities 6