What is the appropriate systemic corticosteroid dose (e.g., oral prednisolone) for a 4‑year‑old child with asthma weighing about 15 kg during an acute exacerbation?

Steroid Dosing for 4-Year-Old with Asthma Exacerbation

For a 4-year-old child (~15 kg) with an acute asthma exacerbation, prescribe oral prednisolone 1–2 mg/kg/day (15–30 mg) divided into two doses daily for 3–10 days without tapering, continuing until symptoms resolve and peak expiratory flow reaches ≥70% of predicted or personal best. 1

Weight-Based Dosing Calculation

• Calculate the dose as 1–2 mg/kg/day for this 15 kg child, yielding 15–30 mg daily, divided into two doses (e.g., 7.5–15 mg twice daily). 1, 2
• The maximum daily dose is capped at 60 mg regardless of weight; for a 15 kg child, this cap is not reached. 1, 2
• Start at 1 mg/kg/day (15 mg total) for mild-to-moderate exacerbations where the child can speak in sentences, has SpO₂ >92% on room air, and peak flow >50% predicted. 1
• Use 2 mg/kg/day (30 mg total) for severe exacerbations characterized by difficulty speaking, SpO₂ <92%, peak flow <50% predicted, or poor response to initial bronchodilators. 1

Route of Administration

• Oral prednisolone is strongly preferred and equally effective as intravenous therapy when the child can tolerate oral intake and has intact gastrointestinal absorption. 1, 2
• Reserve intravenous hydrocortisone (4 mg/kg every 8 hours) only for children who are actively vomiting, severely ill, or unable to swallow. 1

Treatment Duration and Tapering

• Continue oral prednisolone for 3–10 days; a typical outpatient course is 5 days once symptoms resolve and peak flow reaches ≥70% of predicted. 1, 2
• No tapering is required for courses shorter than 7–10 days, especially when the child is already on inhaled corticosteroids; tapering may lead to under-dosing during the critical recovery period. 1

Timing of Administration

• Administer systemic corticosteroids immediately upon recognition of a moderate-to-severe exacerbation; anti-inflammatory effects become clinically apparent within 6–12 hours, making early administration essential. 1
• Consider systemic corticosteroids at the onset of a viral respiratory infection if the patient has a history of severe exacerbations. 3

Concurrent Essential Therapies

• Deliver nebulized salbutamol 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. 1
• For a 15 kg child, use 2.5 mg salbutamol per nebulization initially. 1
• Add ipratropium bromide 0.25 mg to each salbutamol nebulization for severe exacerbations, repeating every 6 hours until clinical improvement begins. 1
• Provide supplemental oxygen via face mask to maintain SpO₂ >92%. 1
• Continue or initiate inhaled corticosteroids at a higher dose than the pre-exacerbation regimen. 1

Monitoring Response

• Measure peak expiratory flow 15–30 minutes after initial treatment and then every 4 hours to assess response. 1
• Maintain continuous pulse-oximetry targeting SpO₂ >92%. 1
• If no improvement is observed within 15–30 minutes of the first bronchodilator and corticosteroid dose, increase nebulized β-agonist frequency to every 30 minutes and consider transfer to a pediatric intensive care unit. 1

Dosing Pitfalls to Avoid

• Do not use 2 mg/kg/day (30 mg) for mild-to-moderate exacerbations; the higher dose increases behavioral side effects (anxiety, hyperactivity, aggression) without delivering additional clinical benefit. 4
• Do not delay systemic corticosteroid administration while repeatedly giving bronchodilators alone; under-use of corticosteroids is a documented cause of preventable asthma deaths. 1
• Do not taper short courses (<7–10 days); tapering is unnecessary and may lead to under-dosing during the critical recovery period. 1
• Never use sedatives in a child with acute asthma; they are contraindicated and may be fatal. 1

Alternative Corticosteroid Options

• Oral prednisone can be substituted for prednisolone at the same dose (1–2 mg/kg/day, maximum 60 mg/day). 1, 2
• A single oral dose of dexamethasone 0.3 mg/kg has been shown to be non-inferior to a 3–5 day course of prednisolone for mild-to-moderate exacerbations, offering easier administration and better compliance; however, dexamethasone-treated children have a higher rate of requiring additional systemic steroids within 14 days (≈13% vs 4%). 1, 5
• Despite the convenience of dexamethasone, prednisolone/prednisone remains the guideline-recommended standard for pediatric acute asthma exacerbations. 1, 2

Discharge Planning

• Before discharge, ensure the child has been stable on discharge medications for at least 24 hours, with peak expiratory flow >75% of predicted and diurnal variability <25%, and confirm correct inhaler technique. 1
• Provide a written asthma action plan, a peak flow meter, and arrange follow-up with the primary-care provider within 1 week and a respiratory specialist within 4 weeks. 1

Evidence Quality Note

• These recommendations are based on high-quality evidence from the National Asthma Education and Prevention Program Expert Panel Report 3, FDA labeling for prednisolone, and British Thoracic Society guidelines. 1, 2