What oral dexamethasone dose is recommended for a 10‑year‑old child with reactive airway disease?

Oral Dexamethasone Dosing for Reactive Airway Disease in a 10-Year-Old

For a 10-year-old child with reactive airway disease (asthma exacerbation), administer a single oral dose of dexamethasone 0.6 mg/kg (maximum 16 mg). This provides equivalent efficacy to a 3–5 day course of prednisolone while eliminating compliance issues and reducing vomiting. 1, 2

Evidence-Based Dosing Regimen

Single-dose dexamethasone 0.6 mg/kg (maximum 16 mg) is the preferred treatment for mild to moderate asthma exacerbations in children, as it achieves comparable clinical improvement to multi-day prednisolone courses while offering superior tolerability. 1, 2

Key Clinical Advantages

• No tapering required: The therapeutic effect lasts 24–72 hours from a single dose, and adrenal suppression is minimal. 1
• Improved compliance: Eliminates the need for a 3–5 day course, removing the barrier of daily dosing and bitter taste associated with prednisolone. 3, 4
• Reduced vomiting: Studies demonstrate significantly less medication vomiting with dexamethasone compared to prednisolone (0% vs. 11% in one trial). 3
• Rapid onset: Clinical benefit is observable as early as 30 minutes after administration. 1

Supporting Clinical Trial Evidence

The highest-quality recent evidence comes from a 2016 randomized controlled trial that directly compared single-dose oral dexamethasone (0.3 mg/kg) to 3-day prednisolone (1 mg/kg/day) in 226 children aged 2–16 years with acute asthma exacerbations. 3 The study demonstrated:

• Non-inferior efficacy: Mean PRAM scores at day 4 were identical (0.91 vs. 0.91; 95% CI -0.35 to 0.34). 3
• No difference in hospital admission rates or unscheduled return visits to healthcare practitioners. 3
• Significantly less vomiting: 14 patients vomited prednisolone versus 0 patients with dexamethasone. 3

A 2006 trial using the higher 0.6 mg/kg dose confirmed similar findings, showing no difference in days needed for symptom resolution (5.21 vs. 5.22 days) or overall admission rates (13.4% vs. 14.9%). 4

Important Caveats and Considerations

Potential for Increased Rescue Steroid Use

One notable finding: The 2016 trial showed 13.1% of dexamethasone patients required additional systemic steroids within 14 days compared to 4.2% in the prednisolone group (absolute difference 8.9%; 95% CI 1.9%–16.0%). 3 This suggests:

• A small subset of children may benefit from the longer prednisolone course
• Close follow-up is essential, particularly for children with more severe baseline disease
• Parents should be counseled to return if symptoms worsen or fail to improve by day 4–5

Dosing Consensus Across Guidelines

European Respiratory Review guidelines report consensus on dexamethasone 0.6 mg/kg for asthma exacerbations, aligning with the American Academy of Pediatrics recommendation for croup at the same dose. 1, 2 This dose is higher than the 0.3 mg/kg used in some trials but provides a margin of safety and is supported by extensive clinical experience.

Practical Administration

• Route: Oral administration is preferred when the child can tolerate it; intramuscular or intravenous routes are equally effective but should be reserved for children unable to take oral medication. 1
• Maximum dose: Cap at 16 mg regardless of weight. 1, 2
• Timing: Administer as soon as the diagnosis is established; benefit begins within 30 minutes. 1, 5

Common Pitfalls to Avoid

• Do not use dexamethasone for non-specific cough, chronic cough, or pertussis-related cough—it provides no benefit in these conditions. 1
• Do not prescribe a tapering course—single-dose therapy is sufficient and tapering is unnecessary. 1
• Avoid in patients with diabetes or impaired glucose regulation—dexamethasone may interfere with glucose-insulin homeostasis. 2
• Ensure adequate follow-up—instruct caregivers to return if symptoms persist beyond 4–5 days or worsen, given the slightly higher rate of rescue steroid use. 3