What are the recommended pediatric dosing and administration guidelines for budesonide (inhaled aerosol/dry‑powder inhaler, nasal spray, and oral suspension) in children with asthma or chronic obstructive airway disease, allergic rhinitis, and inflammatory bowel disease?

Budesonide Prescribing Guidelines for Children

Inhaled Budesonide for Asthma (Nebulizer Suspension)

Budesonide inhalation suspension is the only FDA-approved inhaled corticosteroid for children under 4 years of age and should be administered twice daily via jet nebulizer with a face mask that fits snugly over the nose and mouth. 1

Age-Specific Dosing for Asthma

Children 0-4 years:

• Low dose: 0.25-0.5 mg total daily (0.125-0.25 mg twice daily) 1
• Medium dose: 0.5-1.0 mg total daily (0.25-0.5 mg twice daily) 1
• High dose: >1.0-2.0 mg total daily (>0.5-1.0 mg twice daily) 1

Children 5-11 years:

• Low dose: 0.5 mg total daily (0.25 mg twice daily) 1
• Medium dose: 1.0 mg total daily (0.5 mg twice daily) 1
• High dose: 2.0 mg total daily (1.0 mg twice daily) 1

Administration Technique for Nebulizer

• Use a jet nebulizer with standard flow rate compressor at 6 L/min 1
• Apply face mask snugly over nose and mouth for children under 4 years 1
• Wash the child's face after each treatment to prevent oral candidiasis 1
• Avoid nebulizing directly into the eyes 1
• Use oxygen as the driving gas when possible, especially in acute severe asthma 1

Intermittent Therapy for Viral-Induced Wheeze

For children with recurrent wheezing triggered by respiratory infections (≥3 lifetime episodes or 2 episodes in past year), prescribe 1 mg twice daily for 7 days at the first sign of respiratory infection symptoms rather than continuous maintenance therapy. 2 This approach is conditionally recommended with high certainty of evidence 2.

Safety Monitoring

• Reassess response after 2-3 weeks of therapy 1
• If no benefit within 4-6 weeks with proper technique and adherence, stop treatment and consider alternative diagnoses 1
• Monitor for adverse effects including cough, dysphonia, and oral thrush 1
• Small, nonprogressive reduction in growth velocity may occur at low-to-medium doses but is transient and outweighed by benefits 1, 2
• Do not exceed 400 μg/day equivalent dose as trial therapy for chronic nonspecific cough 1

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Budesonide Nasal Spray for Allergic Rhinitis

For children 6-16 years with perennial allergic rhinitis, prescribe budesonide aqueous nasal spray 128 μg (64 μg per nostril) once daily, with onset of action within 12 hours. 3

Administration Technique for Nasal Spray

• Direct spray away from the nasal septum to prevent septal perforation 4
• Periodically examine nasal septum for mucosal erosions 4
• No evidence of nasal mucosal atrophy with 1-5 years of use 4

Safety Considerations

• At recommended doses, no growth suppression detected in children (except toddlers at twice recommended doses) 4
• Short-term use (200 μg/day) shows no suppression of plasma osteocalcin levels 4
• Common side effects: nasal irritation, blood-tinged secretions (usually minimal) 4

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Oral Budesonide for Eosinophilic Esophagitis

For children with eosinophilic esophagitis, prescribe oral viscous budesonide in age-appropriate formulations: 1 mg/day for children <150 cm height or 2 mg/day for children ≥150 cm height. 4

Dosing Regimen

• Induction therapy: 2 mg twice daily for 12 weeks 4
• Maintenance therapy: Tailor dosage according to individual response (1-2 mg once or twice daily) 4
• Maintenance treatment is strongly recommended as relapse rates are high after withdrawal 4

Administration Instructions

• Use viscous formulations appropriate for age and volume 4
• Administer as swallowed topical therapy, not systemic 4
• For adolescents, orodispersible budesonide may be beneficial but requires local authority approval 4

Expected Outcomes

• Sustained histological remission (<6 eosinophils/hpf) in 49% of patients on maintenance therapy 4
• Median time to relapse >350 days with maintenance vs. 87 days with placebo 4
• Minor adverse effect: Candida albicans infection in up to 22% (does not require discontinuation) 4

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Critical Pitfalls to Avoid

• Never use metered-dose inhalers or dry powder inhalers in children under 4 years—they cannot generate sufficient inspiratory flow 1
• Never administer systemic corticosteroids routinely for eosinophilic esophagitis—topical therapy is preferred due to fewer adverse effects 4
• Never actuate multiple puffs into spacer before inhalation—this reduces drug delivery 1
• Never discontinue budesonide abruptly—taper carefully to minimum dose required for control 1
• Once asthma control is sustained for ≥3 months, attempt step-down therapy as children have high spontaneous remission rates 1

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Special Clinical Situations

Acute croup: Single dose of 500 μg (0.5 mg) may reduce symptoms within first 2 hours 1, 2

Post-viral rhinosinusitis in children: Budesonide nasal spray 50 μg per nostril twice daily for 3 weeks combined with antibiotics shows significantly better cure rates than antibiotics alone 4