In a child with cough and wheezing suggestive of an acute asthma exacerbation, which oral glucocorticoid—prednisone, prednisolone, or methylprednisolone—is appropriate and what is the recommended dose and duration?

Oral Corticosteroid Selection and Dosing for Pediatric Cough and Wheezing

For children with cough and wheezing from acute asthma exacerbations, use oral prednisolone or prednisone at 1–2 mg/kg/day (maximum 60 mg/day) divided into two doses for 3–10 days without tapering; all three agents (prednisolone, prednisone, methylprednisolone) are equally effective at equivalent doses, but prednisolone and prednisone are preferred due to wider availability and established safety profiles. 1, 2, 3

Agent Selection: Prednisolone, Prednisone, or Methylprednisolone

• All three oral corticosteroids are equally effective when given at equivalent doses for pediatric asthma exacerbations, according to the National Asthma Education and Prevention Program. 1, 2

• Prednisolone and prednisone are the preferred first-line agents because they have the most extensive evidence base in pediatric asthma and are explicitly recommended by major guidelines. 1, 2, 3

• Methylprednisolone is an acceptable alternative at 0.25–2 mg/kg/day for children, but offers no clinical advantage over prednisolone or prednisone for oral administration. 1, 2

• The choice between prednisolone and prednisone is clinically insignificant—prednisone is converted to prednisolone in the liver, making them functionally equivalent. 3

Recommended Dosing Algorithm

Standard Pediatric Dosing

• Administer prednisolone or prednisone 1–2 mg/kg/day in 2 divided doses (maximum 60 mg/day) until peak expiratory flow reaches 70% of predicted or personal best, typically for 3–10 days. 1, 2, 4, 3

• The maximum daily dose is 60 mg regardless of the child's weight—do not exceed this ceiling even in heavier children. 1, 2, 3

• For overweight children, calculate the dose using ideal body weight (approximately 25–30 kg for an 8-year-old) rather than actual weight to avoid excessive steroid exposure and behavioral side effects. 2, 5

Dose Selection Within the 1–2 mg/kg Range

• Start with 1 mg/kg/day for mild-to-moderate exacerbations (child able to speak in sentences, SpO₂ >92% on room air, peak flow >50% predicted). 1, 5

• Use 2 mg/kg/day (maximum 60 mg) for severe exacerbations (difficulty speaking, SpO₂ <92%, peak flow <50% predicted, poor response to initial bronchodilators). 1, 2, 4

• Evidence shows that 2 mg/kg/day causes significantly more behavioral side effects—particularly anxiety, hyperactivity, and aggressive behavior—without additional clinical benefit compared to 1 mg/kg/day in mild-to-moderate cases. 5

Duration and Tapering

• Continue treatment for 3–10 days until symptoms resolve and peak expiratory flow reaches 70% of predicted or personal best; 5 days is typical for outpatient management. 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 may lead to underdosing during the critical recovery period. 1, 2, 4

Route of Administration

• Oral administration is strongly preferred and equally effective as intravenous therapy when the child can tolerate oral intake and gastrointestinal absorption is intact. 1, 2, 4, 6

• Reserve intravenous corticosteroids (hydrocortisone 4–7 mg/kg IV every 8 hours or methylprednisolone 1–2 mg/kg/day IV) only for children who are actively vomiting, severely ill, or unable to swallow. 2, 4, 6

Concurrent Essential Therapy

• Administer systemic corticosteroids immediately upon recognizing a moderate-to-severe exacerbation—the anti-inflammatory effects require 6–12 hours to become clinically apparent, making early administration critical. 2, 4, 6

• Combine corticosteroids with nebulized albuterol 2.5 mg (for children <15 kg) or 5 mg (for children ≥15 kg) every 20 minutes for three doses, then every 1–4 hours as needed. 2, 4

• Add ipratropium bromide 0.25–0.5 mg to nebulized albuterol for severe exacerbations to reduce hospitalization risk. 2, 4

• Provide supplemental oxygen to maintain SpO₂ >92% in children with desaturation. 2, 4

Monitoring Response

• Measure peak expiratory flow 15–30 minutes after starting treatment and continue monitoring every 4 hours to assess therapeutic response. 2, 4

• If no improvement occurs within 15–30 minutes of initial bronchodilator and corticosteroid therapy, increase nebulized β-agonist frequency to every 30 minutes and consider escalation of care. 2, 4

Critical Pitfalls to Avoid

• Never delay corticosteroid administration while delivering repeated bronchodilator doses alone—underuse of systemic corticosteroids is a documented cause of preventable asthma deaths. 2, 4, 6

• Do not use doses exceeding 2 mg/kg/day or 60 mg/day—higher doses increase adverse effects (particularly behavioral changes, hyperactivity, and aggression) without providing additional clinical benefit. 1, 2, 5

• Do not taper short courses (<7–10 days)—this is unnecessary and may result in underdosing during the critical recovery period. 1, 2, 4

• Do not dose based on actual body weight in significantly overweight children—use ideal body weight to prevent excessive steroid exposure and associated side effects including behavioral changes, weight gain, and growth suppression. 2, 5

• Do not rely solely on clinical impression—objective measurement of peak expiratory flow or oxygen saturation is required to accurately assess severity and guide treatment intensity. 2, 4

Alternative: Single-Dose Dexamethasone

• Recent evidence suggests that a single dose of oral dexamethasone 0.3 mg/kg is noninferior to 3–5 days of prednisolone for mild-to-moderate exacerbations, with the advantages of easier administration, no vomiting of medication, and improved compliance. 7, 8

• However, dexamethasone-treated children have a higher rate of requiring additional systemic steroids within 14 days (13.1% vs 4.2%), suggesting possible rebound in some patients. 8

• Dexamethasone is an attractive option when compliance with multi-day regimens is a concern, but prednisolone/prednisone remains the guideline-recommended standard. 1, 2, 7, 8

Post-Acute Management

• Initiate or increase inhaled corticosteroid dose at discharge to address underlying poor asthma control. 2

• Provide a written asthma action plan, peak flow meter, and verify correct inhaler technique before discharge. 2, 4

• Arrange follow-up with the primary care provider within 1 week and a respiratory specialist within 4 weeks after the exacerbation. 2, 4