What is the appropriate nebulized albuterol dose for a 6‑week‑old infant?

Nebulized Albuterol Dosing for a 6-Week-Old Infant

For a 6-week-old infant with acute bronchospasm or wheezing, administer nebulized albuterol at 0.15 mg/kg per dose (minimum 2.5 mg), given every 20 minutes for 3 doses initially, then every 1-4 hours as needed. 1

Weight-Based Calculation

• Calculate the dose as 0.15 mg/kg of the infant's weight 1, 2, 3
• Even if the calculated dose falls below 2.5 mg, always administer the minimum dose of 2.5 mg 1
• For example, a 4 kg infant would calculate to 0.6 mg, but you must give the 2.5 mg minimum 1

Initial Treatment Protocol for Acute Exacerbations

• Administer 2.5 mg every 20 minutes for the first 3 doses (first hour of treatment) 1, 4
• Dilute the albuterol solution to a minimum of 3 mL total volume with normal saline for optimal nebulizer delivery 1
• Use a gas flow rate of 6-8 L/min for nebulization 1

Maintenance Dosing After Initial Treatment

• Continue with 2.5 mg every 1-4 hours as needed based on clinical response 1
• Reassess respiratory status, oxygen saturation, and work of breathing after each treatment 1

Evidence Supporting Use in Young Infants

• A randomized controlled trial in infants 6 weeks to 24 months with bronchiolitis demonstrated that albuterol 0.15 mg/kg per dose significantly improved accessory muscle use, respiratory rate, and oxygen saturation compared to placebo 3
• Another trial in children under 2 years with acute asthma showed greater improvement in clinical status with the same 0.15 mg/kg dosing 2
• The response to therapy was similar in infants younger than 6 months compared to older infants 3

Monitoring and Safety Considerations

• Monitor for tachycardia, tremor, and hypokalemia, especially with frequent dosing 1
• Watch for mild increases in heart rate (expected physiologic response) 3
• Assess for signs of worsening respiratory distress: inability to feed, altered mental status, intercostal retractions, and increasing work of breathing 4
• No significant oxygen desaturation should occur with appropriate dosing 2

Adjunctive Therapy to Consider

• Add systemic corticosteroids early for moderate to severe exacerbations (prednisone 1-2 mg/kg/day, maximum 60 mg/day) 4
• For moderate to severe cases, consider adding ipratropium bromide to the nebulizer solution, though this is more commonly done in older children 1, 4

Critical Pitfall to Avoid

• Do not underdose by using less than 2.5 mg even when weight-based calculations suggest a lower amount—the minimum effective dose is 2.5 mg 1
• Increasing frequency of albuterol use beyond twice weekly for maintenance indicates poor disease control and requires initiation or escalation of controller therapy (inhaled corticosteroids), not simply more albuterol 1