What are the recommended prednisolone dosing regimens in pediatric patients (mg/kg) for acute asthma exacerbations, viral croup, and chronic inflammatory or autoimmune diseases, including maximum daily dose and tapering recommendations?

Prednisolone Dosing in Pediatric Patients

Acute Asthma Exacerbations

For acute asthma exacerbations, administer prednisolone 1-2 mg/kg/day (maximum 60 mg/day) as a single daily dose or divided into two doses for 3-10 days, with no tapering required for courses under 7-10 days. 1

Dosing Details

• Standard dose: 1-2 mg/kg/day with an absolute maximum of 60 mg/day, regardless of calculated weight-based dose 1, 2
• Duration: 3-10 days for outpatient "burst" therapy 1
• Administration: Can be given as single daily dose or divided into 2 doses 1
• No tapering needed: For courses lasting less than 7-10 days, abrupt discontinuation is safe 1, 2

Evidence Strength

The 2007 NHLBI Expert Panel Report 3 guidelines explicitly state there is no advantage to higher corticosteroid doses in severe asthma exacerbations, and oral therapy is equivalent to IV administration when GI absorption is intact 1. A 2016 randomized trial demonstrated that single-dose dexamethasone 0.3 mg/kg is noninferior to 3 days of prednisolone 1 mg/kg/day 3, and a 1998 dose-ranging study found no clinical benefit to doses above 0.5 mg/kg/day 4, though the guideline-recommended range of 1-2 mg/kg remains standard practice.

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Viral Croup

For croup, give a single oral dose of prednisolone 1 mg/kg (no maximum specified for this indication), which is equally effective as dexamethasone and requires no repeat dosing or tapering. 5, 6

Critical Distinction

• Do NOT use the multi-day asthma regimen (1-2 mg/kg/day for 3-10 days) for croup 7
• Single dose only: One administration of 1 mg/kg prednisolone is sufficient 5, 6
• Alternative: Dexamethasone 0.15 mg/kg or 0.6 mg/kg are equally effective alternatives 5, 6

Evidence Base

A 2019 randomized controlled trial of 1,252 children demonstrated noninferiority of prednisolone 1 mg/kg compared to dexamethasone 0.6 mg/kg, with no significant differences in Westley Croup Scores at 1 hour or re-attendance rates over 7 days 6. A 2007 trial similarly found no differences between prednisolone 1 mg/kg and dexamethasone 0.15 mg/kg or 0.6 mg/kg 5.

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Chronic Inflammatory and Autoimmune Diseases

Nephrotic Syndrome (First Episode)

For initial presentation of nephrotic syndrome, administer prednisolone 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) as a single morning dose for 4-6 weeks, followed by alternate-day dosing at 40 mg/m² or 1.5 mg/kg (maximum 40 mg on alternate days) for 2-5 months with gradual tapering. 1, 2

Induction Phase (4-6 weeks)

• Daily dosing: 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg) 1, 2
• Timing: Single morning dose before 9 AM 2
• Minimum total duration: At least 12 weeks of corticosteroid therapy 1, 2

Maintenance Phase (2-5 months)

• Alternate-day dosing: 40 mg/m² or 1.5 mg/kg (maximum 40 mg on alternate days) 1, 2
• Gradual taper: Over the 2-5 month period 1

Nephrotic Syndrome (Relapses)

For infrequent relapses, give prednisolone 60 mg/m² or 2 mg/kg/day (maximum 60 mg) until remission for at least 3 days, then switch to alternate-day dosing at 40 mg/m² or 1.5 mg/kg (maximum 40 mg) for at least 4 weeks. 1, 2

Frequent Relapses or Steroid-Dependent Disease

• Acute treatment: Daily prednisolone until remission ≥3 days 1, 2
• Extended maintenance: Alternate-day dosing for ≥3 months 1, 2
• Steroid-sparing agents: Consider cyclophosphamide, levamisole, calcineurin inhibitors, or mycophenolate when adverse effects develop 1, 2

Multisystem Inflammatory Syndrome in Children (MIS-C)

For MIS-C, administer intravenous methylprednisolone 1-2 mg/kg/day as first-line therapy alongside IVIG, escalating to 10-30 mg/kg/day for refractory disease with persistent fever or ongoing organ involvement. 1, 2

• First-line: IV methylprednisolone 1-2 mg/kg/day with IVIG 2 gm/kg 1, 2
• Intensification: IV methylprednisolone 10-30 mg/kg/day for refractory cases 1, 2

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Tapering Protocols

When Tapering is Required

Taper prednisolone when treatment duration exceeds 10-14 days or when high-dose therapy (>1 mg/kg/day) has been given for more than 2 weeks. 2, 8

When Tapering is NOT Required

• Short courses <7-10 days: Can stop abruptly without adrenal insufficiency risk 1, 2, 8
• Concurrent inhaled corticosteroids: May not require taper even for courses up to 10 days 1

Structured Tapering Algorithm

For courses >10-14 days, reduce by 5 mg weekly until reaching 10 mg/day, then by 2.5 mg weekly until reaching 5 mg/day, then by 1 mg monthly to minimum effective dose or discontinuation. 2, 8

Step-by-Step Protocol

1. From high dose to 10 mg/day: Decrease by 5 mg every week 2, 8
2. From 10 mg/day to 5 mg/day: Decrease by 2.5 mg every week 2, 8
3. Below 5 mg/day: Decrease by 1 mg every month 2, 8

Condition-Specific Tapering

• Autoimmune hepatitis: Taper over 6-8 weeks to maintenance dose of 0.1-0.2 mg/kg/day or 5 mg/day 2, 8
• Nephrotic syndrome: Switch to alternate-day dosing (40 mg/m²) for 2-5 months with gradual reduction 1, 2, 8

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Critical Dosing Considerations

Weight-Based Calculations

Calculate prednisolone doses using ideal body weight rather than actual weight in overweight children to avoid excessive steroid exposure. 2, 8

Timing of Administration

Administer prednisolone as a single morning dose before 9 AM to minimize hypothalamic-pituitary-adrenal axis suppression and mimic physiologic cortisol secretion. 2, 8

Maximum Daily Doses

• Standard acute conditions: 60 mg/day maximum 1, 2
• Alternate-day maintenance: 40 mg maximum on dosing days 1, 2

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Monitoring and Prevention

Bone Health Protection

Initiate calcium and vitamin D supplementation immediately when starting prednisolone therapy to protect bone health in pediatric patients. 2

HPA Axis Suppression Risk

For therapy anticipated to last >2-3 weeks at doses above 5 mg/day (prednisone-equivalent), anticipate HPA axis suppression and provide stress-dose steroids during intercurrent illness. 2

Adrenal Insufficiency Monitoring During Tapering

Watch for fatigue, weakness, nausea, vomiting, hypotension, and hypoglycemia during tapering, which may indicate adrenal insufficiency. 8

Disease Flare Monitoring

Monitor for disease recurrence during tapering; rebound occurs in 14-37% of patients, requiring temporary dose increase. 8

Common Adverse Effects

• Growth suppression: Track linear growth closely in children on prolonged therapy 2, 8
• Cushingoid features: Monitor for weight gain, increased appetite, and characteristic appearance 2
• Hypertension: Check blood pressure regularly throughout treatment 2

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Common Pitfalls to Avoid

Never Abruptly Stop After Prolonged Use

Never abruptly discontinue prednisolone after >2 weeks of therapy without a structured taper due to adrenal crisis risk. 2, 8

Avoid Rapid Tapering from High Doses

Do not taper faster than 5 mg/week when reducing from doses above 10 mg/day; this evidence-based reduction rate minimizes flare risk. 2, 8

Do Not Confuse Croup and Asthma Dosing

Croup requires only a single 1 mg/kg dose, not the multi-day 1-2 mg/kg/day regimen used for asthma. 7