Recommended Prednisolone Doses in Children
For most pediatric conditions requiring corticosteroids, prednisolone dosing ranges from 1-2 mg/kg/day (maximum 60 mg/day) or 60 mg/m²/day as a single morning dose, with specific protocols varying by indication. 1, 2
Condition-Specific Dosing
Acute Asthma Exacerbations
- 1-2 mg/kg/day in single or divided doses for 3-10 days until the child achieves 80% of personal best peak expiratory flow or symptoms resolve 2
- No evidence supports tapering after improvement to prevent relapse 2
- Short "burst" therapy courses are appropriate without gradual taper 2
Croup
- While not explicitly detailed in the provided evidence, dexamethasone 0.3 mg/kg as a single dose is commonly used and may be preferable to multi-day prednisolone courses 3
Nephrotic Syndrome (Initial Episode)
Body surface area-based dosing is superior to weight-based dosing, particularly in children under 30 kg, as weight-based calculations result in significant underdosing. 4, 5
Initial Treatment Protocol
- 60 mg/m²/day (or 2 mg/kg/day, maximum 60 mg) as single morning dose for 4-6 weeks 6, 7, 2
- Followed by 40 mg/m² on alternate days for 2-5 months with gradual tapering 6, 7, 8
- Total treatment duration should be at least 12 weeks, ideally 16 weeks to reduce relapse rates 6, 7, 8
Practical Dosing Equations
For clinicians without height measurements, use these validated weight-based equations that approximate BSA dosing 9:
- For 60 mg/m² dose: [2 × weight in kg + 8]
- For 40 mg/m² dose: [weight in kg + 11]
These equations prevent the 15-30% underdosing that occurs with standard 2 mg/kg calculations in children under 30 kg 4, 5
Relapse Treatment
- Infrequent relapses: 60 mg/m²/day until remission (3 consecutive days with urine protein <1+), then 40 mg/m² on alternate days for 4 weeks 6, 7, 8
- Frequent relapses or steroid-dependent disease: 60 mg/m²/day until remission, then 40 mg/m² on alternate days for at least 3 months 6, 8
Severe Inflammatory Diseases and Allergic Reactions
- Initial dose: 1-2 mg/kg/day or 60 mg/m²/day (maximum 60 mg) as single morning dose 1, 2
- Adjust based on disease severity and response 2
Critical Administration Principles
Timing and Food
- Always administer as single morning dose to minimize adrenal suppression 7, 1
- Give with food to reduce gastric irritation 7, 1
Monitoring During Treatment
- Daily urine dipstick during nephrotic syndrome treatment 8
- Blood pressure and potassium levels 8
- Watch for signs of relapse (≥2+ proteinuria for 3 consecutive days) 8
Tapering Considerations
- Short courses (2-10 days) for asthma require no taper 2
- Longer courses require gradual tapering by 5-10 mg/m² per week 1, 8
- Never abruptly discontinue after prolonged therapy 2
Common Pitfalls to Avoid
Underdosing in Young Children
The most critical error is using 2 mg/kg dosing in children under 30 kg or weighing less than the dose threshold for 60 mg/day. 4, 5 Research demonstrates that weight-based dosing results in a median underdosing of 15% compared to BSA-based dosing, with the discrepancy most pronounced in younger children 5. This underdosing significantly increases the risk of frequent relapses in nephrotic syndrome (16.6% relative underdosing in frequent relapsers vs 8.7% in infrequent relapsers) 4.
Divided Dosing
- Single daily dosing is equally effective as divided dosing and reduces adrenal suppression 10
- Historical recommendations for divided doses are not evidence-based 10
Age-Specific Cautions
- Children under 1 year with nephrotic syndrome likely have genetic causes and should not receive standard protocols without kidney biopsy 7, 8
- Children over 12 years should consider biopsy before treatment as secondary causes become more common 8
Treatment Duration in Nephrotic Syndrome
Shorter initial courses (2 months) result in 81% relapse rates versus 59% with longer courses (6 months). 8 The evidence strongly supports completing the full 12-16 week protocol even after achieving remission 6, 7, 8.