Hydrocortisone Use in Pediatric Patients
Hydrocortisone is indicated in pediatric patients for adrenal insufficiency replacement therapy, perioperative stress coverage, septic shock with catecholamine resistance, and acute severe asthma, with dosing ranging from 0.56-8 mg/kg/day for chronic replacement to 2-50 mg/kg/day for acute critical illness. 1
Chronic Adrenal Insufficiency Replacement
Standard Maintenance Dosing
- The initial dose range for chronic adrenal insufficiency is 0.56 to 8 mg/kg/day divided into three or four doses (equivalent to 20-240 mg/m²/day) 1
- For optimal physiological replacement, use thrice-daily weight-based dosing with the highest dose given first thing in the morning to mimic cortisol circadian rhythm 2
- Recent prospective data demonstrates that accurate dosing from birth results in hydrocortisone doses at the lower end of the recommended range (8-12 mg/m²/day) with normal growth and no adrenal crises 3
- For children with congenital adrenal hyperplasia specifically, median doses of 9.8-12.0 mg/m²/day divided three times daily maintain adequate control when monitored by salivary 17-OHP profiles 3
Monitoring Parameters
- Monitor blood glucose hourly during perioperative fasting or acute illness, as no child with adrenal insufficiency should be fasted for more than 6 hours 4
- Track growth velocity as the most sensitive indicator of systemic corticosteroid exposure, more so than HPA axis function tests 1
- Correct hypoglycemia and hypocalcemia promptly in any child with adrenal insufficiency 4
Perioperative Stress Dosing
Major Surgery Under Anesthesia
- Administer hydrocortisone 2 mg/kg IV bolus at induction, followed immediately by continuous IV infusion based on weight: 5
- 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 5
- Postoperatively, give hydrocortisone 2 mg/kg IV or IM every 4 hours until stable 5
- Once stable and taking oral feeds, provide double the usual oral dose for 48 hours, then reduce to normal doses over up to one week 5
- Add fludrocortisone when enteral feeding is established if the child has primary adrenal insufficiency 5
Minor Procedures Requiring General Anesthesia
- Give hydrocortisone 2 mg/kg IV or IM at induction 5
- Postoperatively, double normal hydrocortisone doses for 24 hours once enteral feeding is established 5
Minor Procedures NOT Requiring General Anesthesia
- Simply double the morning dose of hydrocortisone pre-operatively, then resume normal dosing 5
Septic Shock with Suspected Adrenal Insufficiency
Indications for Treatment
- Administer hydrocortisone to children with fluid-refractory, catecholamine-resistant shock who have suspected or proven absolute adrenal insufficiency 4
- Approximately 25% of children with septic shock have absolute adrenal insufficiency (basal cortisol <18 μg/dL and peak ACTH-stimulated cortisol <18 μg/dL) 6, 7
- Death from absolute adrenal insufficiency and septic shock can occur within 8 hours of presentation, making timely administration crucial 6
Dosing for Septic Shock
- For newborns with birth asphyxia and potential adrenal insufficiency, start with 50 mg/m²/24 hours (approximately 5-6 mg/kg/day), which can be titrated up to 50 mg/kg/day if needed to reverse shock 6
- For older children, the dosing range is 2-50 mg/kg/day, titrated to reversal of shock 4
- Draw blood for baseline cortisol level determination before starting therapy, but do not delay treatment while waiting for results in a critically ill child 6
Administration and Monitoring
- Administer intermittently every 6-8 hours or as continuous infusion 6
- Monitor blood pressure and hemodynamic parameters, with measurements every 5-15 minutes in children on vasopressors 4
- Monitor serum glucose for hyperglycemia, and serum electrolytes (particularly potassium and sodium) 6
- Continue treatment until shock resolves, then taper gradually 6
Evidence Limitations
- There is insufficient evidence to support or refute routine use of stress-dose hydrocortisone in all children with septic shock 5
- However, stress-dose corticosteroids may be considered in children with septic shock unresponsive to fluids and requiring vasoactive support 5
- One pediatric RCT found no survival benefit with low-dose hydrocortisone, though another demonstrated earlier shock reversal 5
Acute Severe Asthma
Systemic Corticosteroid Use
- Systemic corticosteroids produce significant improvements for children admitted to hospital with acute asthma, including earlier discharge (OR 7.00,95% CI: 2.98-16.45, NNT=3) and fewer relapses within 1-3 months (OR 0.19,95% CI: 0.07-0.55, NNT=3) 8
- The oral route is always preferred in pediatrics for asthma exacerbations 9
- When IV corticosteroids are required in PICU settings, methylprednisolone, hydrocortisone, and dexamethasone have equivalent efficacy when used at appropriate doses 10
Critical Pitfalls to Avoid
Drug Interactions and Contraindications
- Avoid etomidate for intubation in children with septic shock or suspected adrenal insufficiency, as it suppresses the HPA axis and increases mortality risk 5, 7
- If etomidate is used, recognize the increased risk of adrenal insufficiency and consider hydrocortisone supplementation 5
Administration Errors
- Never abruptly discontinue hydrocortisone therapy after prolonged use; always taper gradually 6, 1
- Do not use dexamethasone instead of hydrocortisone for neonatal adrenal insufficiency, as hydrocortisone has better mineralocorticoid activity and safety profile 6
- Delaying treatment while waiting for cortisol test results in a critically ill child with suspected adrenal insufficiency can be harmful 6
Monitoring Failures
- Failing to monitor for hyperglycemia during hydrocortisone therapy can lead to complications 6
- Children with both adrenal insufficiency and diabetes insipidus are at particularly high risk for hyponatremia and water intoxication if adequate hydrocortisone is not provided 4
- Corticosteroids may suppress reactions to skin tests and diminish response to vaccines, so routine vaccination should be deferred until therapy is discontinued if possible 1