Pediatric Dexamethasone Dosing
For croup, administer a single dose of 0.6 mg/kg (maximum 16 mg) orally, intramuscularly, or intravenously, though lower doses of 0.15 mg/kg are equally effective and may reduce side effects. 1
Croup (Laryngotracheobronchitis)
Standard Dosing
- Single dose: 0.6 mg/kg (maximum 16 mg) via oral, IM, or IV route 1
- Lower dose alternative: 0.15 mg/kg is equally effective for symptom relief and hospitalization duration 2, 3
- Oral administration is preferred when tolerated—equally effective as IM/IV but avoids injection pain 1
Onset and Duration
- Clinical benefit evident as early as 30 minutes after 0.15 mg/kg dose, with statistical significance by 30 minutes 4
- Duration of action: 24-72 hours 1
- No tapering required for single-dose regimen; does not cause significant adrenal suppression 1
Severe Croup Management
- For moderate-to-severe cases with significant respiratory distress: add nebulized epinephrine 0.5 mL/kg of 1:1000 solution (maximum 5 mL) while waiting for dexamethasone effect 1, 5
- Repeat dexamethasone dose plus nebulized epinephrine for severe croup with prominent stridor, significant retractions, and agitation 1
Critical Pitfalls
- Do NOT use dexamethasone for non-specific cough, chronic cough, or pertussis-associated cough—provides no benefit 1
- Prednisolone is less effective than dexamethasone (29% vs 7% re-presentation rate) 1
- Nebulized corticosteroids from hand-held inhalers with spacers are ineffective for croup 1
Postextubation Upper Airway Obstruction (UAO) Prevention
High-Risk Patients
- Administer dexamethasone at least 6 hours before extubation in children at high risk for postextubation UAO 6, 1
- Early administration (>12 hours before extubation) is most effective; high or low doses are similarly effective when started early 6
Dosing Strategy
- When administered ≥6 hours before extubation: standard doses (0.5 mg/kg/dose) are effective 6
- When administered **<6 hours before extubation**: higher doses (>0.5 mg/kg/dose) may provide benefit, while lower doses have minimal impact 6
Clinical Considerations
- Do not delay extubation to administer dexamethasone, particularly in standard-risk children 6
- Dexamethasone reduces UAO incidence (OR 0.40) but unclear benefit in preventing extubation failure itself 6
Perioperative Use (Tonsillectomy)
Standard Recommendation
- Administer single intraoperative dose of IV dexamethasone to all children undergoing tonsillectomy 6
- Dose range: 0.15-1.0 mg/kg, with most studies using 0.5 mg/kg; lower doses may be equally effective 6
- Maximum dose range in studies: 8-25 mg 6
Benefits
- Decreased postoperative nausea/vomiting up to 24 hours 6
- Reduced throat pain and faster return to oral intake 6
- Longer time to first analgesic requirement 6
Exclusions
- Avoid in patients with endocrine disorders already receiving exogenous steroids 6
- Avoid in diabetics or those with impaired glucose-insulin regulation 6
Adrenal Insufficiency (Acute Crisis)
Emergency Dosing
- IV/IO: 2-3 mg/kg (maximum 100 mg) over 3-5 minutes 6
- Maintenance: 1-5 mg/kg every 6 hours for infants OR 12.5 mg/m² every 6 hours for older children 6
- Do not underdose—strongly consider concomitant fluid bolus of 20 mL/kg D5NS or D10NS during first hour 6
Tuberculous Meningitis with Communicating Hydrocephalus
Dosing Algorithm by Weight
Duration and Tapering
- Initial dose for 3 weeks, then taper gradually over following 3 weeks (total 6 weeks) 7
- Start immediately with anti-TB therapy; do not delay for diagnostic confirmation if clinical suspicion high 7
Evidence and Pitfalls
- Greatest mortality benefit in Stage II disease (15% vs 40% mortality with vs without dexamethasone) 7
- Do NOT use bacterial meningitis dosing (10 mg every 6 hours for 4 days)—inadequate duration 7
- Do NOT stop prematurely if paradoxical reactions occur; may require continuation or resumption 7
Special Populations
Obesity
- Weight-based dosing (0.5-1 mg/kg) in children with obesity achieves comparable exposures to adults 8
- No dose adjustment specifically required, though pharmacokinetic modeling suggests potential for individualization 9