Can Hydrocortisone Injections Be Given to Children?
Yes, hydrocortisone injections are routinely used in children across multiple clinical scenarios including perioperative stress coverage, septic shock with adrenal insufficiency, and acute severe illness. The route (intravenous or intramuscular) and dosing depend on the specific clinical indication. 1
Clinical Indications and Dosing
Perioperative Stress Coverage
All children with known or suspected adrenal insufficiency require intravenous hydrocortisone during surgery. 1
- Induction dose: 2 mg/kg IV bolus at the start of anesthesia for both minor and major surgery 1
- Postoperative dosing for major surgery: 2 mg/kg IV or IM every 4 hours until the child is stable and can take oral medications 1
- Alternative for unstable patients: Continuous IV infusion based on weight:
- Up to 10 kg: 25 mg/24 hours
- 11-20 kg: 50 mg/24 hours
- Over 20 kg (prepubertal): 100 mg/24 hours
- Over 20 kg (pubertal): 150 mg/24 hours 1
Once enteral intake is established, transition to double the normal oral dose for 48 hours, then taper to standard maintenance doses over 1-3 days for uncomplicated recovery. 1, 2
Septic Shock with Adrenal Insufficiency
Hydrocortisone should be administered to children with fluid-refractory, catecholamine-resistant shock who have suspected or proven absolute adrenal insufficiency. 1
- High-risk populations: Children with purpura fulminans, congenital adrenal hyperplasia, prior steroid exposure, or hypothalamic/pituitary abnormalities 1
- Dosing range: 2-50 mg/kg/day, titrated to reversal of shock 1, 3
- Administration: Can be given as intermittent boluses or continuous infusion 1
- Timing: Ideally obtain baseline cortisol level before administration, but do not delay treatment 1
Important caveat: Routine hydrocortisone is NOT recommended for all pediatric septic shock—only for documented adrenal insufficiency or when shock remains refractory to catecholamines. 1, 3
Obstetric/Labor Context
For pregnant adolescents with adrenal insufficiency, hydrocortisone 100 mg should be given IV at the onset of active labor, followed by either continuous infusion of 200 mg/24 hours or 50 mg IM every 6 hours. 1
Safety Considerations
Route of Administration
- Preferred: Central venous access for continuous infusions 1
- Acceptable alternatives: Peripheral IV in large bore vein or intraosseous access when central access unavailable 1
- Intramuscular: Appropriate for postoperative dosing when IV access is problematic 1
Monitoring Requirements
Blood glucose must be monitored hourly in children with adrenal insufficiency during perioperative fasting or acute illness. 1
- No child with adrenal insufficiency should be fasted for more than 6 hours 1, 2
- Hypoglycemia and hypocalcemia should be corrected promptly 1
- For children on vasopressors, measure blood pressure and heart rate every 5-15 minutes 1
Critical Pitfall to Avoid
Premature discontinuation of hydrocortisone therapy can precipitate life-threatening adrenal crisis. 2 Always taper gradually once the acute stress has resolved, and ensure families understand "sick day rules" for dose adjustment during subsequent illnesses. 2, 3
Special Population: Diabetes Insipidus
Children with both adrenal insufficiency and diabetes insipidus (typically from hypothalamic/pituitary disease) are at particularly high risk for hyponatremia and water intoxication if adequate hydrocortisone is not provided, since cortisol is required to excrete a water load. Strict fluid balance with adequate cortisol replacement is mandatory. 1
Formulation Considerations
While this question focuses on injections, note that when transitioning to oral therapy, accurate dosing in young children can be challenging. Hydrocortisone granules provide more accurate dosing than tablet manipulation for maintenance therapy. 4, 5