Prednisolone Dosing for Croup
For a child with acute viral croup, give prednisolone 1 mg/kg as a single oral dose (maximum 60 mg), though dexamethasone is the preferred corticosteroid for this condition. 1
Recommended Dosing
- Prednisolone: 1 mg/kg as a single oral dose 1, 2
- Maximum dose: 60 mg 1
- No tapering required for single-dose therapy 1
- Use liquid formulation when available, as it is more readily absorbed than tablets, particularly important if the child has difficulty swallowing or is at risk of vomiting 1
Critical Clinical Context: Dexamethasone is Superior
Dexamethasone is the preferred corticosteroid for croup, not prednisolone. The evidence clearly demonstrates that prednisolone is less effective:
- A randomized controlled trial found that prednisolone 1 mg/kg resulted in 29% re-presentation to medical care versus only 7% with dexamethasone 0.15 mg/kg 3
- This 22% difference in re-presentation rates (confidence interval 8-35%) fell outside the equivalence range, establishing prednisolone as inferior 3
- Dexamethasone 0.15 mg/kg orally is the evidence-based first choice 4, 5
Weight-Based Dosing Examples
For prednisolone 1 mg/kg (if dexamethasone unavailable):
- 10 kg child: 10 mg
- 14 kg child: 14 mg 1
- 20 kg child: 20 mg
- 30 kg child: 30 mg
For significantly overweight children, calculate dose based on ideal body weight rather than actual weight to avoid excessive steroid exposure 6
Alternative Corticosteroid Options
If oral administration is not possible:
- Nebulized budesonide 2 mg can be given as an alternative 2, 5
- Budesonide appears equivalent in efficacy to oral dexamethasone 2
Severity-Based Treatment Algorithm
Mild to moderate croup:
- Single dose of oral dexamethasone 0.15 mg/kg (preferred) 4, 5
- OR prednisolone 1 mg/kg if dexamethasone unavailable 1, 2
Moderate to severe croup with respiratory distress:
- Oral dexamethasone 0.15-0.6 mg/kg PLUS nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) 1, 5
- Monitor for at least 2 hours after epinephrine administration for rebound airway obstruction 7
Severe croup requiring intubation:
- Oral prednisolone 1 mg/kg every 12 hours decreases duration of intubation and need for re-intubation 2
Common Pitfalls to Avoid
- Do not use lower doses of corticosteroids - doses below the recommended range have proven ineffective 7
- Do not prescribe multi-day courses - single-dose therapy is sufficient and eliminates compliance issues 1
- Do not choose prednisolone over dexamethasone when both are available - the evidence clearly favors dexamethasone 3
- Dexamethasone onset of action is approximately 6 hours, so nebulized epinephrine may be needed as a bridge in severe cases 7