Paediatric Corticosteroid Prescribing

Corticosteroids have anti-inflammatory and immunosuppressive effects and are prescribed in children for asthma, croup, nephrotic syndrome, inflammatory conditions, meningitis, replacement therapy and cerebral oedema. The dose, duration and speed of withdrawal decide the risk of adrenal suppression and growth failure.

Equivalent doses. Prednisolone 5 mg equals hydrocortisone 20 mg equals dexamethasone 0.75 mg. Dexamethasone has the longest action and no mineralocorticoid effect.

• Asthma exacerbation: prednisolone 1 to 2 mg/kg orally once daily (maximum 40 mg) for 3 to 5 days, or dexamethasone 0.6 mg/kg single dose (maximum 16 mg).
• Croup: dexamethasone 0.15 to 0.6 mg/kg orally once (maximum 10 mg).
• Nephrotic syndrome, first episode: prednisolone 60 mg/m2/day (maximum 80 mg) as a single morning dose for 4 to 6 weeks, then 40 mg/m2 on alternate days for 4 to 6 weeks, with tapering or stopping as directed by a specialist.
• Bacterial meningitis (after the neonatal period, where intensive care is available): dexamethasone 0.15 mg/kg intravenously every 6 hours for 4 days, started with or before the first antibiotic dose. Benefit is uncertain in low-resource settings and in African children with HIV.
• Adrenal insufficiency replacement and stress dosing: hydrocortisone 8 to 10 mg/m2/day, and 50 to 100 mg/m2 intravenously for crisis.
• Cerebral oedema from tumour: dexamethasone 0.25 to 0.5 mg/kg intravenously (maximum 10 mg), then 0.25 to 0.5 mg/kg/day in 4 divided doses, specialist directed.
• Immune thrombocytopenia, inflammatory bowel disease, rheumatic disease and malignancy: specialist-set regimens.

Timing. Give in the morning with food to reduce gastric and sleep effects. Alternate-day dosing reduces growth suppression in long-term use.

Adrenal suppression. Expect suppression after more than 2 to 3 weeks at a dose over 1 mg/kg/day of prednisolone equivalent, and after repeated short courses. Taper over weeks, and give stress cover for illness, surgery and trauma during taper and for up to 12 months after.

Infection risk. Avoid live vaccines during high-dose therapy (prednisolone 2 mg/kg/day, or 20 mg/day, for 14 days or more) and for 1 month afterwards. A non-immune child exposed to varicella needs aciclovir or immunoglobulin.

Region. In East Africa, screen for tuberculosis, test for HIV and treat strongyloidiasis (ivermectin 200 mcg/kg once) before long courses.

Special groups. Adolescents should be asked about pregnancy and mood. Diabetes needs insulin increased during therapy.

Monitoring. Blood pressure, weight, height velocity, glucose, mood and sleep, signs of infection, and cataract and glaucoma checks on long courses. Review potassium and bone density in prolonged therapy.

Referral and escalation. Refer for suspected adrenal crisis (vomiting, hypotension, hypoglycaemia), steroid psychosis, severe infection, fracture, and any course planned for over 4 weeks.

Stopping. Courses under 10 days can stop without taper. Longer courses taper, for example by 20 to 25% every few days to a physiological dose, and the morning cortisol may be checked before the final stop.