Hydrocortisone Dosing in Children
Context-Specific Dosing Recommendations
The appropriate hydrocortisone dose for children varies dramatically by clinical indication, ranging from physiologic replacement doses of 8-12 mg/m²/day for adrenal insufficiency to stress doses of 2 mg/kg for perioperative coverage, and up to 50 mg/kg/day for catecholamine-resistant septic shock. 1, 2
Chronic Adrenal Insufficiency (Replacement Therapy)
Standard Replacement Dosing
- Target dose: 8-12 mg/m²/day divided into 3 doses 2, 3
- Administer the highest dose in the morning (mimicking physiological cortisol rhythm), with smaller doses at midday and evening 4
- For neonates (<28 days): 12 mg/m²/day initially, tapering to 8.6 mg/m²/day 3
- For infants (1 month-2 years): 9.8-12.2 mg/m²/day 3
- For children (2-8 years): 10.2-11.9 mg/m²/day 3
Critical Dosing Considerations
- Twice-daily dosing creates dangerous gaps: conventional regimens produce supraphysiological peaks 2 hours post-dose (629 nmol/L) and prolonged nadirs from 1400-1800h (42 nmol/L), with negligible cortisol levels in early morning (15 nmol/L at 0600h) 5
- Three-times-daily dosing better replicates physiological cortisol rhythm and prevents early morning hypoglycemia 5, 4
- Avoid tablet manipulation: crushing or dissolving tablets leads to highly variable dosing and iatrogenic Cushing syndrome 6
- Use pharmacy-compounded alcohol-free suspension or commercially available hydrocortisone granules (0.5,1,2,5 mg strengths) for accurate pediatric dosing 6, 3
Perioperative Stress Dosing
Major Surgery
- Induction dose: 2 mg/kg IV bolus 1
- Continuous infusion based on weight: 1
- Up to 10 kg: 25 mg/24h
- 11-20 kg: 50 mg/24h
- Over 20 kg (prepubertal): 100 mg/24h
- Over 20 kg (pubertal): 150 mg/24h
- Postoperative: 2 mg/kg IV/IM every 4 hours until stable, then double usual oral dose for 48h, tapering over up to one week 1
Minor Procedures with General Anesthesia
- Induction: 2 mg/kg IV or IM 1
- Postoperative: double normal dose for 24h once enteral feeding established 1
Minor Procedures WITHOUT General Anesthesia
- Double morning dose pre-operatively, then resume normal dosing 1
Septic Shock with Adrenal Insufficiency
Absolute Adrenal Insufficiency
- Indication: peak cortisol <18 μg/dL after ACTH stimulation or catecholamine-resistant shock 1
- Dose range: 2-50 mg/kg/day (titrate to shock resolution) 1
- Can be given as continuous infusion or intermittent dosing 1
- Wean as tolerated to minimize long-term toxicities 1
Important Caveats
- Routine stress-dose steroids are NOT recommended for all pediatric septic shock—only for documented adrenal insufficiency or catecholamine-resistant shock 1
- One large database study showed association between steroid use in severe sepsis and decreased survival 1
- Premature infants: 3 mg/kg/day hydrocortisone reduced dopamine requirements but did not improve mortality 1
High-Dose Corticosteroid Therapy (Non-Replacement Indications)
Nephrotic Syndrome
- Initial episode: 60 mg/m² or 2 mg/kg daily (maximum 60 mg/day) for 4-6 weeks 1, 2
- Then: 40 mg/m² or 1.5 mg/kg on alternate days (maximum 40 mg) for 2-5 months with tapering 1, 2
- For significantly overweight children, calculate based on ideal body weight 1, 2
Asthma Exacerbations
- Dose: 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1, 2, 7
- Administer as single morning dose 2, 7
- No tapering needed for courses <10 days 2, 7
- Do NOT use for viral bronchiolitis in previously healthy children without documented recurrent wheeze (≥3 episodes) 7
Autoimmune Hepatitis
- Initial: 1-2 mg/kg/day (maximum 60 mg/day) for 2 weeks 2
- Taper over 6-8 weeks to maintenance dose of 0.1-0.2 mg/kg/day or 5 mg/day 2
- Combination with azathioprine 1-2 mg/kg/day reduces corticosteroid-related side effects 2
Monitoring and Safety
Short-Term Therapy (<10 days)
- No routine monitoring required 7
- Watch for hyperglycemia, mood changes, increased appetite, hypertension 7
Long-Term Therapy
- Monitor growth regularly (growth suppression is a major concern) 2, 8
- Baseline and annual bone mineral density testing of lumbar spine and hip 2, 8
- Initiate calcium and vitamin D supplementation immediately when starting therapy 2
- Assess for steroid-related adverse effects at each visit 2, 8
- Consider steroid-sparing agents if side effects become problematic 1
Common Pitfalls to Avoid
- Never use actual body weight in obese children—always calculate based on ideal body weight 1, 2
- Never crush or dissolve tablets for dose adjustment—use appropriate pediatric formulations 6
- Never use twice-daily dosing for chronic replacement—three-times-daily prevents dangerous cortisol nadirs 5, 4
- Never use etomidate for intubation in septic shock—increases risk of adrenal insufficiency 1