In which pediatric conditions is systemic prednisone indicated, and what are the recommended weight‑based dosing and duration for each?

When to Give Prednisone to Children

Prednisone is indicated in children for nephrotic syndrome, acute asthma exacerbations, severe allergic reactions, and autoimmune conditions, with dosing at 1–2 mg/kg/day (maximum 60 mg/day) as a single morning dose for most acute conditions. 1, 2

Primary Indications and Weight-Based Dosing

Nephrotic Syndrome – First Episode

• Initial phase: Administer 60 mg/m² or 2 mg/kg per day (maximum 60 mg) as a single morning dose for 6 weeks. 3, 1
• Continuation phase: Switch to 40 mg/m² or 1.5 mg/kg on alternate days (maximum 40 mg) for another 6 weeks, then taper by 10 mg/m² per week until reaching 5 mg on alternate days. 3, 1
• Total duration: 16 weeks to account for the tapering phase. 3, 1
• For children <30 kg, weight-based dosing (2 mg/kg) systematically underdoses compared to BSA-based calculation; use the equation [2 × weight in kg + 8] to approximate 60 mg/m² when height is unavailable. 4, 5

Nephrotic Syndrome – Relapse

• Give 60 mg/m² or 2 mg/kg (maximum 60 mg) daily until remission is achieved (trace/negative proteinuria for ≥3 consecutive days). 3, 1
• After remission, continue 40 mg/m² on alternate days for ≥4 weeks, then taper by 10 mg/m² per week. 3, 1
• For frequent relapses or steroid-dependent disease, consider corticosteroid-sparing agents (cyclophosphamide, calcineurin inhibitors) rather than repeated courses. 3, 2

Acute Asthma Exacerbations

• Dose: 1–2 mg/kg per day (maximum 60 mg/day) for 3–10 days. 1, 6, 2
• No taper required for courses ≤7–10 days. 1, 2
• Administer as a single morning dose; oral prednisone is superior to inhaled fluticasone for severe acute asthma (FEV₁ <60% predicted), reducing hospitalization rates from 31% to 10%. 7
• Lower-dose option: 1 mg/kg/day provides comparable efficacy to 2 mg/kg/day with significantly fewer behavioral side effects (anxiety, aggression, hyperactivity); consider 1 mg/kg for mild-to-moderate exacerbations. 8
• Repeat courses may be given immediately for subsequent exacerbations without a mandatory waiting period. 1

Severe Allergic Reactions

• Give 1 mg/kg orally as a single dose (maximum 60–80 mg), followed by daily dosing for 2–3 days to prevent biphasic reactions. 1

Autoimmune Hepatitis

• Initial dose: 2 mg/kg per day (maximum 60 mg) for induction. 6, 2
• Taper over 6–8 weeks to maintenance dose of 0.1–0.2 mg/kg per day (approximately 2–4 mg daily) once remission is achieved. 6, 2

Administration Principles

Timing

• Always administer as a single morning dose before 9 AM to minimize HPA-axis suppression and mimic physiologic cortisol secretion. 1, 6, 2
• Single daily dosing is as effective as divided doses and reduces adrenocortical suppression. 1, 2
• Exception: If behavioral side effects (hyperactivity, emotional lability) occur, consider afternoon dosing after school. 6

Dose Calculation in Overweight Children

• Base the dose on ideal body weight rather than actual weight to avoid excessive steroid exposure. 1, 6, 2

Tapering Strategies

Short Courses (≤7–10 days)

• No taper needed; discontinue abruptly. 1, 2

Longer Courses (>10–14 days)

• Reduce by 5 mg each week until reaching 10 mg/day. 1, 2
• Then reduce by 2.5 mg each week until maintenance dose. 1, 2
• Finally reduce by 1 mg each month to the minimum effective dose. 1

Monitoring and Prevention

Bone Health

• Start calcium and vitamin D supplementation at therapy initiation for all courses >2 weeks. 1, 6
• Obtain baseline and annual DEXA scan of lumbar spine and hip for children receiving ≥30 mg daily for >30 days. 6, 2

Growth and Adverse Effects

• Monitor linear growth regularly; anticipate HPA-axis suppression for regimens >2–3 weeks at doses >7.5 mg/day. 1
• Behavioral changes (anxiety, aggression, hyperactivity) are dose-dependent; the number needed to harm is 4.8 for aggressive behavior at 2 mg/kg versus 1 mg/kg. 8
• Weight gain occurs even at low doses (5–10 mg), with increases of 1.6–5 kg over months. 6

Critical Caveats

Avoid in Specific Situations

• Do not use systemic corticosteroids for bronchiolitis in infants <2 years due to insufficient evidence of benefit. 2
• Single-dose home administration for asthma attacks is associated with increased outpatient visits and cannot be recommended. 9

When to Consider Steroid-Sparing Agents

• For nephrotic syndrome with frequent relapses (≥2 relapses in 6 months) or steroid-dependent disease, add cyclophosphamide (500 mg/m² IV monthly for 4 months) or calcineurin inhibitors. 3, 2
• Calcineurin inhibitors should be stopped if partial remission is not achieved at 6 months. 3