Initial Treatment for Nephrotic Syndrome in Children

Introduction to Treatment Protocol

The American Academy of Pediatrics recommends beginning oral prednisone at 60 mg/m²/day (or 2 mg/kg/day) as a single morning dose for 6 weeks, followed by 40 mg/m² on alternate days for another 6 weeks, then taper over 4 weeks for a total duration of 16 weeks 1, 2

For a 10 kg child, the weight-based calculation yields 2 mg/kg/day = 20 mg daily (maximum 60 mg/day) 1, 2
The dose should be given as a single morning dose to minimize adrenal suppression 3
Administering the dose with food can reduce gastric irritation 3

Phase 1: Daily Dosing (6 weeks) - Prednisone 20 mg once daily every morning for the full 6 weeks, regardless of when remission occurs 1, 2
Phase 2: Alternate-Day Dosing (6 weeks) - After 6 weeks of daily therapy, switch to 40 mg/m² (approximately 13-14 mg for a 10 kg child) on alternate days as a single morning dose 4, 5
Phase 3: Tapering (4 weeks) - Taper at the rate of 10 mg/m² per week (approximately 3 mg per week for a 10 kg child) until reaching 5 mg on alternate days 4, 5

Children younger than 1 year are more likely to have genetic causes and should be managed differently—do not use the standard regimen without further evaluation 2
The total treatment duration is 16 weeks 1, 2

Remission definition: Urine protein <1+ on dipstick for 3 consecutive days or urine protein-to-creatinine ratio <200 mg/g 1, 2
If no remission by 6 weeks of daily prednisone, suspect steroid-resistant nephrotic syndrome (SRNS) and consider kidney biopsy 1
Approximately 80% of children will achieve remission, but 50% will experience frequent relapses or become steroid-dependent 2

Treat with prednisone 60 mg/m²/day (20 mg for 10 kg child) until remission for at least 3 consecutive days 1, 2
Then switch to alternate-day prednisone 40 mg/m² for 4 weeks 1, 2
For frequent relapses (≥2 relapses in 6 months) or steroid-dependent disease, consider steroid-sparing agents with levamisole as first-line (if available), followed by cyclophosphamide 1, 4, 5

During upper respiratory infections, consider prophylactic prednisone 0.5 mg/kg/day for 5-7 days to prevent relapse 1, 2