What is the safe oral corticosteroid dose for an otherwise healthy 8‑year‑old child requiring a short course for asthma exacerbation or croup?

Safe Oral Corticosteroid Dose for an 8-Year-Old Child

For an otherwise healthy 8-year-old child with asthma exacerbation or croup, prescribe oral prednisolone 1–2 mg/kg per day (maximum 60 mg daily) divided into two doses for 3–10 days without tapering. 1, 2, 3

Weight-Based Dosing Calculation

• An average 8-year-old weighs approximately 25–30 kg, yielding a dose range of 25–60 mg per day when using the 1–2 mg/kg formula. 1
• The maximum daily dose is capped at 60 mg regardless of the child's weight; for significantly overweight children, calculate the dose using ideal body weight (approximately 25–30 kg for this age) rather than actual weight to avoid excessive steroid exposure and associated adverse effects such as behavioral changes, weight gain, and growth suppression. 1
• Divide the total daily dose into two administrations (morning and afternoon/evening) for optimal anti-inflammatory effect. 1, 2, 3

Duration and Tapering

• Continue treatment for 3–10 days until peak expiratory flow reaches ≥70% of predicted or the child's personal best, or until symptoms resolve. 1, 2, 3
• No tapering is required for courses lasting less than 7–10 days, especially when the child is concurrently using inhaled corticosteroids; tapering short courses is unnecessary and may lead to under-dosing during the critical recovery period. 1, 2

Route of Administration

• Oral administration is strongly preferred and provides equivalent efficacy to intravenous therapy when gastrointestinal absorption is intact. 1, 2
• Reserve intravenous hydrocortisone (4–7 mg/kg every 8 hours or 200 mg every 6 hours for severe cases) only for children who are actively vomiting, severely ill, or unable to tolerate oral intake. 1, 2

Alternative Single-Dose Option for Mild-to-Moderate Exacerbations

• For mild-to-moderate asthma exacerbations, a single dose of oral dexamethasone 0.3 mg/kg (approximately 7.5–9 mg for a 25–30 kg child) is noninferior to a 3-day course of prednisolone and offers superior compliance, no vomiting of medication, and easier administration. 4, 5
• However, children receiving dexamethasone have a slightly higher rate of requiring additional systemic steroids within 14 days (13.1% vs. 4.2%), so prednisolone remains the standard first-line choice for most exacerbations. 4

Concurrent Essential Therapies

• Administer high-dose inhaled β₂-agonist (salbutamol 5 mg or 2.5 mg if weight <15 kg) via oxygen-driven nebulizer or 4–8 puffs via metered-dose inhaler with spacer, every 20 minutes for three doses, then every 1–4 hours as needed. 2, 1
• Provide supplemental oxygen to maintain SpO₂ >92%. 2, 6
• For severe exacerbations, add ipratropium bromide 0.25–0.5 mg to nebulized salbutamol to reduce hospitalization risk. 2, 1
• Initiate or increase the inhaled corticosteroid dose at discharge to address underlying poor control. 1

Critical Timing Considerations

• Administer systemic corticosteroids immediately upon recognizing a moderate-to-severe exacerbation, rather than after repeated trials of bronchodilators alone, because the anti-inflammatory effect requires 6–12 hours to become clinically apparent. 2, 1
• Delaying corticosteroid therapy while delivering repeated bronchodilator doses is a common and dangerous pitfall; under-use of systemic corticosteroids is a documented preventable cause of asthma-related deaths. 2, 1

Monitoring and Follow-Up

• Measure peak expiratory flow 15–30 minutes after starting treatment and continue monitoring to assess therapeutic response. 2, 6
• Reassess the child within 48 hours by checking symptoms and ideally measuring peak expiratory flow if available. 1
• Schedule primary-care follow-up within 1 week and a respiratory specialist appointment within 4 weeks after discharge. 1, 6

Important Clinical Pitfalls to Avoid

• Never postpone systemic corticosteroids while delivering repeated bronchodilator doses alone; this delay can be fatal. 2, 1
• Never use sedatives in a child with acute asthma; they are contraindicated and may be fatal. 1
• Do not rely solely on subjective clinical impression; objective measurement of peak expiratory flow or FEV₁ is required to assess severity. 1, 6
• Do not discharge the patient unless they have been stable on discharge medications for at least 24 hours, possess a written asthma action plan, have verified inhaler technique, and have PEF >75% of predicted with diurnal variability <25%. 6, 1
• Do not use unnecessarily high doses (>2 mg/kg/day), as higher doses have not shown additional benefit in severe exacerbations but increase adverse effects. 2, 1

Croup-Specific Dosing

• For croup, either oral dexamethasone 0.15 mg/kg as a single dose or nebulized budesonide 2 mg are effective for mild-to-moderate cases; dexamethasone is preferred for ease of administration and compliance. 7
• For severe croup requiring intubation, oral prednisolone 1 mg/kg every 12 hours decreases the duration of intubation and need for re-intubation. 7