Can hydrocortisone (corticosteroid) injection be stopped abruptly in a 6-month-old infant after 2 days of administration?

Can Hydrocortisone Injection Be Stopped Abruptly After 2 Days in a 6-Month-Old Infant?

Yes, hydrocortisone injection can be safely stopped abruptly after only 2 days of administration in a 6-month-old infant without requiring a taper, as this short duration is insufficient to cause clinically significant hypothalamic-pituitary-adrenal (HPA) axis suppression. 1

Duration-Dependent Risk of Adrenal Suppression

The critical factor determining whether tapering is necessary is the duration of corticosteroid exposure, not the dose alone:

• Corticosteroid-induced adrenal suppression is duration-dependent, and patients receiving courses longer than 14 days are the ones who might benefit from tapering before discontinuation 1
• After only 2 days of treatment, the HPA axis remains intact and responsive, making abrupt discontinuation safe 1
• The FDA labeling for hydrocortisone states that gradual withdrawal is recommended "if after long-term therapy the drug is to be stopped," implicitly acknowledging that short courses do not require tapering 2

Clinical Context Matters

The indication for hydrocortisone determines the approach to discontinuation:

For Acute Stress Situations (Anaphylaxis, Sepsis, Surgery)

• In anaphylaxis management, hydrocortisone 25 mg is given as a single dose or short course for infants under 6 months, with no tapering protocol specified 1
• For pediatric septic shock, hydrocortisone doses ranging from 2-50 mg/kg/day are used and weaned "as tolerated to minimize potential long-term toxicities," but this refers to courses lasting days to weeks, not 2 days 1
• In perioperative stress coverage, children receive hydrocortisone 2 mg/kg every 4 hours following major surgery, which is discontinued when enteral intake is established—typically within 24-48 hours—without tapering 1

For Chronic Adrenal Insufficiency (Different Scenario)

• If this infant has underlying adrenal insufficiency (primary or secondary), the situation is entirely different—hydrocortisone should never be stopped at all, as it is physiologic replacement therapy 1, 2
• These patients require lifelong replacement and are at risk of adrenal crisis if glucocorticoids are withdrawn 2

Monitoring After Discontinuation

While tapering is unnecessary after 2 days, clinicians should:

• Monitor for recurrence of the original condition being treated (inflammation, shock, bronchospasm) rather than adrenal insufficiency 1
• Be aware that inflammation may recur after discontinuing corticosteroid therapy, especially when stopped abruptly, but this reflects the underlying disease process, not HPA suppression 1
• If the patient deteriorates after stopping (development of shock, need for mechanical ventilation), consider that the original pathology may not be fully resolved rather than assuming adrenal crisis 1

Common Pitfalls to Avoid

Do not confuse short-term therapeutic use with chronic replacement therapy:

• A 2-day course for acute illness is fundamentally different from chronic glucocorticoid therapy or physiologic replacement for adrenal insufficiency 1, 2
• The FDA warning about gradual withdrawal applies to "long-term therapy," which is not defined but clearly exceeds 2 days based on clinical context 2

Do not unnecessarily prolong corticosteroid exposure:

• Extending treatment beyond what is clinically necessary to allow for tapering after only 2 days would expose the infant to additional glucocorticoid burden without benefit 1
• In neonates and young children, minimizing corticosteroid exposure is particularly important given concerns about neurodevelopmental effects with prolonged use 1

The 14-Day Threshold

The evidence consistently identifies 14 days as the approximate threshold where HPA axis suppression becomes a concern:

• Patients receiving corticosteroids for more than 14 days "might be particularly likely to benefit from a taper before discontinuing and an evaluation of HPA axis function if in doubt" 1
• Typical treatment duration in sepsis trials was 7-14 days, with tapering considered for longer courses 1
• After 2 days, the infant is far below this threshold 1