What is the recommended pediatric dose of prednisolone syrup in mg per kilogram per day?

Prednisolone Syrup Dosing in Pediatrics

The recommended pediatric dose of prednisolone syrup is 1-2 mg/kg/day (maximum 60 mg/day) given as a single morning dose, with body surface area dosing of 60 mg/m²/day preferred for younger children to avoid underdosing. 1, 2, 3

Dosing Method Selection

Use body surface area (BSA) dosing over weight-based dosing whenever possible, particularly in children under 30 kg or younger than 5-6 years, as weight-based dosing systematically underdoses smaller children by 15-20% and increases the risk of frequent relapses. 1, 2, 3, 4, 5

Weight-Based Dosing

• Standard dose: 1-2 mg/kg/day (maximum 60 mg/day) 1, 2, 6
• Minimum effective dose: 0.3 mg/kg/day for maintenance therapy in conditions like Duchenne muscular dystrophy 7
• Calculate using ideal body weight in overweight children, not actual weight, to prevent excessive steroid exposure and side effects 1, 2, 3

Body Surface Area Dosing (Preferred)

• Standard dose: 60 mg/m²/day (maximum 60-80 mg/day) 1, 2, 3, 6
• BSA dosing better parallels prednisolone metabolism and reduces underdosing risk in younger children 1, 2, 3
• Research demonstrates that 2 mg/kg dosing yields only 85% of the 60 mg/m² dose in children under 30 kg, with a proportional error up to average daily doses of 60 mg 4, 5

Administration Timing

Give prednisolone as a single morning dose before 9 AM to align with physiologic cortisol rhythm and minimize hypothalamic-pituitary-adrenal axis suppression. 1, 2, 3

• For children with behavioral side effects (hyperactivity, emotional lability), consider afternoon dosing after school instead 7
• Single daily dosing is equally effective as divided doses, with mean response times of 9.6-11.1 days 8

Condition-Specific Dosing

Acute Asthma Exacerbations

• 1-2 mg/kg/day (maximum 60 mg/day) as a single daily dose for 3-10 days 1, 2, 3, 6
• No tapering needed if duration is less than 10 days 2

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 1, 2, 3, 6, 8
• Followed by 40 mg/m²/day or 1.5 mg/kg/day (maximum 40 mg) on alternate days for 2-5 months with gradual tapering 1, 2
• Response typically occurs within 9.6 days for initial episodes 8
• Critical caveat: Weight-based dosing significantly increases the risk of frequent relapses compared to BSA dosing, with underdosing percentages of 16.6% in frequent relapsers versus 8.7% in infrequent relapsers 4

Multisystem Inflammatory Syndrome in Children (MIS-C)

• First-line: Methylprednisolone 1-2 mg/kg/day IV in combination with IVIG 2 gm/kg 7, 1, 2
• Intensification for refractory disease: Methylprednisolone 10-30 mg/kg/day IV 7, 2

Autoimmune Hepatitis

• Initial: 1-2 mg/kg/day (maximum 60 mg/day) for two weeks, alone or with azathioprine 1, 2, 3
• Taper over 6-8 weeks to maintenance dose of 0.1-0.2 mg/kg/day or 5 mg/day 1, 2

Duchenne Muscular Dystrophy

• Daily prednisone: 0.75 mg/kg/day is the preferred regimen over alternate-day or intermittent schedules 7
• Increase dose incrementally as child grows up to maximum weight of 40 kg (prednisone cap of 30-40 mg/day) 7
• Minimum effective daily dose is approximately 0.3 mg/kg/day 7

Tapering Guidelines

For courses longer than 2 weeks, gradual tapering is essential to prevent adrenal insufficiency. 1, 2, 3

• Reduce dose by 25-33% at appropriate intervals once clinical response is achieved 1, 2, 3
• When tapering from higher doses: reduce by 5 mg weekly until 10 mg/day, then reduce by 2.5 mg/week down to 5 mg daily 3
• Final reductions of 1 mg monthly 2
• No tapering needed for short courses under 10 days 2

Critical Monitoring Requirements

• Growth parameters, blood pressure, and Cushingoid features should be monitored regularly 1, 2, 3
• Provide calcium and vitamin D supplementation during therapy 1, 2, 3
• Consider baseline and annual bone mineral density testing of lumbar spine and hip for long-term use 1, 3
• Severe side effects are uncommon but more likely after prolonged therapy exceeding 18 months 1, 2
• Cosmetic changes occur in 80% of patients after 2 years of treatment regardless of regimen 3

Common Pitfalls to Avoid

• Never use actual body weight in overweight children—this leads to excessive steroid exposure and increased side effects 1, 2, 3
• Do not assume 2 mg/kg equals 60 mg/m²—they are not equivalent in children under 30 kg, with weight-based dosing providing only 85% of the BSA dose 4, 5
• Avoid systemic corticosteroids for bronchiolitis in infants under 2 years due to insufficient evidence of benefit 1, 3
• Do not abruptly discontinue after prolonged use—always taper to prevent adrenal crisis 1, 2, 3