Pediatric Systemic Steroid Dosing Guidelines

General Principles

The American Academy of Pediatrics recommends that for pediatric patients requiring systemic corticosteroids, the dose of prednisone or prednisolone should be 1-2 mg/kg/day with a maximum of 60 mg/day for most conditions 1, 2
Prednisone and prednisolone are equivalent medications and can be used interchangeably at the same dosage 1, 2
For significantly overweight children, dosing should be based on ideal body weight to avoid unnecessary steroid exposure 1, 2
The maximum daily dose is typically 60 mg, though in some cases up to 80 mg may be considered for specific conditions 1

For asthma exacerbations in children 0-4 years, a short-course burst of 1-2 mg/kg/day, maximum 60 mg/day for 3-10 days is recommended 3, 4
For asthma exacerbations in children 5-11 years, a short-course burst of 1-2 mg/kg/day, maximum 60 mg/day for 3-10 days is recommended 3, 5
For nephrotic syndrome, the initial episode treatment is 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) as a single daily dose for 4-6 weeks, followed by 40 mg/m²/day or 1.5 mg/kg/day on alternate days for 2-5 months with tapering 1
For infrequent relapses of nephrotic syndrome, 60 mg/m²/day or 2 mg/kg/day (maximum 60 mg/day) until remission for at least 3 days, then 40 mg/m²/day or 1.5 mg/kg/day on alternate days for at least 4 weeks 6, 1
For frequent relapses or steroid-dependent nephrotic syndrome, daily prednisone until remission for 3 days, followed by alternate-day prednisone for at least 3 months at the lowest effective dose 6, 1

For most conditions, administer as a single daily dose in the morning to minimize adrenocortical suppression 1, 2
For corticosteroid courses less than 7 days, there is no need to taper the dose 3, 5
For courses up to 10 days, tapering is probably not necessary, especially if patients are concurrently taking inhaled corticosteroids 3, 5
For longer courses, taper gradually by reducing the dose by 5 mg every week until reaching 10 mg/day, then by 2.5 mg/week until reaching maintenance dose 2

Assess for steroid-related adverse effects regularly, especially with prolonged use 1, 2
Monitor growth in children on long-term therapy 1, 2
Consider corticosteroid-sparing agents for children with frequent relapses or steroid dependence who develop steroid-related adverse effects 6, 1

Systemic corticosteroids are not recommended for routine use in bronchiolitis 7
For asthma exacerbations, there is no known advantage for higher doses of corticosteroids, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired 3, 5