At what age can prednisolone be initiated in infants?

Prednisolone Initiation in Infants: Age-Specific Guidelines

Prednisolone can be initiated in infants from birth onward for specific indications, with no absolute minimum age restriction, though the indication, dose, and monitoring requirements vary significantly by condition and infant age. 1, 2

Condition-Specific Age Thresholds

Acute Conditions (No Minimum Age)

For acute asthma exacerbations, prednisolone may be started at any pediatric age at 1-2 mg/kg/day (maximum 60 mg/day for children ≥5 years; maximum 30 mg/day for children 0-4 years) for 3-10 days. 1

For infantile hemangiomas, prednisolone (2-3 mg/kg/day as a single morning dose) serves as alternative therapy when propranolol cannot be used, with no specific minimum age restriction mentioned. 3 Treatment is most successful when initiated during the proliferative phase, and several months of therapy are often required. 3

Bronchopulmonary Dysplasia in Premature Infants

For premature infants with evolving or established BPD, systemic corticosteroids (including prednisolone) may be initiated during the neonatal period, though optimal timing remains controversial. 1

• Initiate between 7-14 days of postnatal age for ventilator-dependent preterm infants with severe respiratory failure to balance mortality reduction against neurodevelopmental risks. 4
• Prednisolone has been studied in infants initiated at a mean postmenstrual age of 41.7 weeks at doses of 1.7 mg/kg/day, showing sustained decreases in pulmonary severity scores. 5
• Important caveat: Long-term prednisolone (≥30 days) may impair linear growth despite modest respiratory improvements. 6

Nephrotic Syndrome

For children under 12 years presenting with new nephrotic syndrome, glucocorticoids should be initiated without requiring kidney biopsy first. 1 Standard dosing is 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) for 4-6 weeks. 3, 1

• Children older than 1 year are the primary target population, as those younger than 1 year are more likely to have genetic causes requiring different management. 3

Critical Safety Considerations by Age

Neonatal and Young Infant Period

Premature infants are at highest risk for systemic absorption and HPA axis suppression due to their high body surface-area-to-volume ratio. 7 The FDA label notes that hypertrophic cardiomyopathy has been reported in premature infants receiving corticosteroids. 2

Complete the immunization schedule, including varicella vaccination, before starting steroids whenever possible in infants and very young children. 1

Monitoring Requirements (All Ages)

All pediatric patients on prednisolone require close monitoring regardless of age: 1

• Growth velocity is the most sensitive indicator of systemic corticosteroid exposure and should be monitored at every visit. 1, 2
• Blood pressure at each visit using age- and height-specific percentiles. 1
• For courses >3 months: annual ophthalmologic examination for cataracts, annual DEXA scans, vitamin D monitoring, and urine/blood glucose screening. 1

Dosing Adjustments

Titrate to the lowest effective dose to minimize growth effects. 1 For significantly overweight children, dose based on ideal body weight to avoid excessive steroid exposure. 1

Courses under 10 days do not require tapering; never stop glucocorticoids abruptly for prolonged courses—ensure gradual taper. 1

Key Pitfalls to Avoid

Do NOT use prednisolone for: 1

• Non-specific cough in children without clear asthma features
• Virus-induced wheezing in children under 5 years presenting to hospital
• Duchenne muscular dystrophy in children under 2 years who are still making motor progress (defer until age 4-8 years, typically 6±2 years) 1

Do NOT delay steroid administration in true asthma exacerbations, as underuse is associated with increased mortality. 1

Avoid concomitant use of prednisolone with indomethacin in neonates due to markedly increased risk of isolated intestinal perforation. 4