What is the recommended weight‑based prednisolone dose for children for common conditions such as acute asthma exacerbation, nephrotic syndrome, croup, and allergic reactions?

Prednisolone Dosing in Pediatric Patients

For most acute pediatric conditions requiring corticosteroid therapy, prednisolone should be dosed at 1-2 mg/kg/day (maximum 60 mg/day) as a single morning dose, with specific adjustments based on the underlying condition. 1, 2, 3

General Dosing Framework

• Standard high-dose therapy: Start with 1-2 mg/kg/day or 60 mg/m²/day, with an absolute maximum of 60 mg/day regardless of weight 4, 1
• Timing: Administer as a single morning dose before 9 AM to minimize adrenocortical suppression and mimic physiologic cortisol patterns 1, 3
• Weight considerations: For significantly overweight children, calculate the dose based on ideal body weight rather than actual weight to avoid excessive steroid exposure 1, 2, 3

Important caveat: Weight-based dosing (mg/kg) systematically underdoses children weighing <30 kg compared to BSA-based dosing (mg/m²), which can increase relapse rates in conditions like nephrotic syndrome 5, 6, 7. The underdosing is most pronounced in younger, smaller children and can result in 15-20% lower doses than intended 5, 6.

Condition-Specific Dosing

Acute Asthma Exacerbation

• Dose: 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1, 3
• Duration: Short courses of 5-7 days are typically sufficient 1
• Tapering: No taper needed for courses ≤7-10 days; can stop abruptly 1

Nephrotic Syndrome

Initial episode (first presentation):

• Induction phase: 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) as a single daily dose for 4-6 weeks 4, 1
• Alternate-day phase: Switch to 40 mg/m²/dose or 1.5 mg/kg/dose (maximum 40 mg on alternate days) for 2-5 months with gradual tapering 4, 2
• Total duration: At least 12 weeks of therapy recommended 4

Infrequent relapses:

• Daily phase: 60 mg/m² or 2 mg/kg (maximum 60 mg/day) until remission for at least 3 days 4
• Alternate-day phase: 40 mg/m²/dose or 1.5 mg/kg/dose (maximum 40 mg on alternate days) for at least 4 weeks 4

Frequent relapses or steroid-dependent disease:

• Treat relapses with daily dosing until remission for 3 days, then alternate-day dosing for at least 3 months 4
• Consider steroid-sparing agents (levamisole, calcineurin inhibitors, or mycophenolate) if adverse effects develop 4

Croup (Viral Laryngotracheobronchitis)

• Dose: 1-2 mg/kg/day (maximum 60 mg/day) as a single dose 1
• Duration: Typically 1-2 days is sufficient for mild-to-moderate croup 1

Allergic Reactions

• Moderate severity: 0.3 mg/kg/day 1
• Moderate-severe: 0.5 mg/kg/day 1
• Severe reactions: 0.75-1 mg/kg/day 1
• Duration: 3-5 days typically adequate for acute allergic reactions 1

Multisystem Inflammatory Syndrome in Children (MIS-C)

• First-line (with IVIG): Methylprednisolone 1-2 mg/kg/day IV 4
• Intensification therapy: Methylprednisolone 10-30 mg/kg/day IV for refractory disease (persistent fevers or ongoing organ involvement) 4

Autoimmune Hepatitis

• Induction: 1-2 mg/kg/day (maximum 60 mg/day) for 2 weeks 1, 3
• Tapering: Reduce gradually over 6-8 weeks to maintenance of 0.1-0.2 mg/kg/day 1
• Adjunctive therapy: Add azathioprine 1-2 mg/kg/day to allow earlier steroid tapering 1

Tapering Protocols

For courses >10-14 days:

• Reduce by 5 mg every week until reaching 10 mg/day 1, 2, 3
• Then reduce by 2.5 mg/week until reaching maintenance dose 1, 2
• Finally reduce by 1 mg monthly to reach minimum effective dose 1

For courses <7-10 days:

• No tapering required; can stop abruptly without increased relapse risk 1

Critical Monitoring and Prevention

Bone health:

• Initiate calcium and vitamin D supplementation immediately when starting therapy 1
• For therapy >2-3 weeks at doses >7.5 mg/day (or equivalent), implement osteoporosis prevention measures 1, 3
• Consider baseline and annual bone mineral density testing for long-term therapy 2, 3

Growth monitoring:

• Regular height and weight measurements essential for children on long-term therapy 3
• Growth deceleration is a common adverse effect requiring monitoring 1

Common adverse effects to monitor:

• Cushingoid features (occur in 80% after 2 years of treatment) 2
• Weight gain and increased appetite 1
• Hypertension (monitor blood pressure throughout treatment) 1, 7
• Adrenal suppression (risk with >5 mg/day prednisone equivalent) 4

Key Clinical Pitfalls

Dosing errors in young children:

• Weight-based dosing (2 mg/kg) consistently underdoses children <30 kg by 10-20% compared to BSA-based dosing (60 mg/m²) 5, 6, 7
• This underdosing significantly increases the risk of frequent relapses in nephrotic syndrome (relative underdosing of 16.6% in frequent relapsers vs. 8.7% in infrequent relapsers) 5
• For nephrotic syndrome specifically, BSA-based dosing is preferable to reduce relapse risk and total steroid exposure 7

Simplified BSA approximation:

• If height is unavailable, use the equation [2 × weight in kg + 8] to approximate a 60 mg/m² dose 8
• For 40 mg/m² dose, use [weight in kg + 11] 8

Abrupt discontinuation:

• Never abruptly stop steroids after >10-14 days of therapy or in patients on chronic therapy (>5 mg/day) due to risk of adrenal crisis 4, 1
• Consider stress-dose steroids during intercurrent illness in patients with potential HPA axis suppression 4