What is the recommended stress dose of steroid (corticosteroid) for a child with adrenal insufficiency?

Stress Dose Steroids in Children with Adrenal Insufficiency

For children with adrenal insufficiency requiring stress dose steroids, administer hydrocortisone 2 mg/kg IV bolus initially, followed by weight-based continuous infusion or intermittent dosing every 4-6 hours, with total daily doses ranging from 25-150 mg/24 hours depending on weight and pubertal status. 1, 2

Perioperative Stress Dosing (Major Surgery)

For major surgery under anesthesia, give hydrocortisone 2 mg/kg IV bolus at induction, then immediately start continuous IV infusion based on weight: 1, 2

• Up to 10 kg: 25 mg/24 hours 1, 2
• 11-20 kg: 50 mg/24 hours 1, 2
• Over 20 kg (prepubertal): 100 mg/24 hours 1, 2
• Over 20 kg (pubertal): 150 mg/24 hours 1, 2

Postoperatively, administer hydrocortisone 2 mg/kg IV or IM every 4 hours until stable and able to take oral medications. 1, 2 Once stable, double the usual oral hydrocortisone doses for 48 hours, then reduce to normal doses over up to one week. 1

Minor Procedures

For minor procedures requiring general anesthesia: Give hydrocortisone 2 mg/kg IV or IM at induction, then double normal oral doses for 24 hours once enteral feeding is established. 1, 2

For minor procedures NOT requiring general anesthesia: Simply double the morning dose of hydrocortisone pre-operatively, then resume normal dosing. 1, 2

Acute Illness and Adrenal Crisis

For severe illness or suspected adrenal crisis (Grade 3-4 symptoms): Administer hydrocortisone 50-100 mg IV every 6-8 hours initially (adult dosing from guidelines), or use the pediatric equivalent of 2 mg/kg every 4-6 hours. 1, 3, 2 This translates to approximately 30-50 mg/m²/day (roughly 10-15 mg/kg/day) divided every 6-8 hours for moderate stress. 3

For moderate illness (Grade 2): Use 2-3 times maintenance dosing (approximately 30-50 mg total daily dose for typical children, or prednisone 20 mg daily equivalent), then decrease to maintenance after 2 days. 1

Critical Monitoring Parameters

Monitor blood glucose every 1-2 hours in severely ill children, as hypoglycemia can develop rapidly. 3, 2 Never fast a child with adrenal insufficiency for more than 6 hours without IV dextrose. 3, 2

Monitor electrolytes (sodium and potassium), blood pressure, and hemodynamic parameters closely. 1, 3, 2 In children on vasopressors, measure blood pressure and heart rate every 5-15 minutes. 2

Essential Clinical Pitfalls to Avoid

Do not delay stress dosing while trying to determine if the child "really needs it"—err on the side of treatment. 3 Death from adrenal crisis can occur within 8 hours of presentation. 4

Do not use dexamethasone as the sole glucocorticoid in children with primary adrenal insufficiency, as it lacks mineralocorticoid activity and doesn't provide adequate replacement. 3 However, dexamethasone 6-8 mg IV can suffice for 24 hours in adults with secondary adrenal insufficiency during surgery. 1

Do not forget mineralocorticoid replacement (fludrocortisone) at usual maintenance doses once enteral feeding is established, unless the child is receiving very high-dose hydrocortisone (>100 mg/day), which has intrinsic mineralocorticoid activity. 3

Never abruptly stop stress dosing—taper gradually over 5-7 days to prevent precipitating adrenal crisis. 1, 3

Avoid etomidate for intubation in children with suspected adrenal insufficiency, as it suppresses the hypothalamic-pituitary-adrenal axis and increases mortality risk. 2

Alternative Routes of Administration

Rectal hydrocortisone (100 mg/m²) can be used as an alternative to intramuscular administration when IV access is unavailable, achieving adequate serum cortisol concentrations (mean 1212 nmol/L) within 1-3 hours. 5 However, approximately 14% of children may not achieve adequate levels, so this route should only be used after documenting adequate absorption with a test dose. 5

Evidence Considerations

The 2020 UK guidelines from the Association of Anaesthetists, Royal College of Physicians, and Society for Endocrinology provide the most comprehensive and recent pediatric-specific recommendations. 1 Research suggests that current stress dosing protocols may actually overestimate physiologic needs in some situations 6, while other data indicates that major surgery, trauma, and serious bacterial infections may require even higher doses than traditionally recommended. 7 The continuous IV infusion approach is supported by pharmacokinetic data showing it maintains more consistent cortisol levels compared to intermittent bolus dosing. 8