Hydrocortisone Pediatric Dosing
The recommended hydrocortisone dose for children varies by indication: for adrenal insufficiency maintenance use 8–10 mg/m²/day divided three times daily; for septic shock with suspected adrenal insufficiency give 2 mg/kg IV bolus followed by 2–50 mg/kg/day continuous infusion or divided doses; and for perioperative stress dosing administer 2 mg/kg IV bolus at induction followed by weight-based continuous infusion (25–150 mg/24 hours depending on weight and pubertal status). 1
Maintenance Therapy for Adrenal Insufficiency
For chronic adrenal insufficiency or congenital adrenal hyperplasia (CAH), administer 8–10 mg/m²/day of hydrocortisone divided into three daily doses. 2, 3
In neonates and infants <3 months, doses may range from 9.9–12.0 mg/m²/day, while children 1–5.9 years typically require 14.0 mg/m²/day, and those 6 years to puberty need 14.2 mg/m²/day. 3
During puberty, do not exceed 17 mg/m²/day as higher doses significantly impair pubertal growth and final height without improving disease control. 4
Four-times-daily dosing (at 06:00,12:00,18:00, and 24:00) better maintains physiological cortisol levels throughout the 24-hour period compared to three-times-daily dosing, though both regimens are acceptable. 5
Perioperative Stress Dosing
For major surgery under general anesthesia, give hydrocortisone 2 mg/kg IV bolus at induction, then start continuous IV infusion based on weight: 1
- 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
Postoperatively, administer 2 mg/kg IV or IM every 4 hours until the child is stable and can resume oral medications. 1
For minor procedures not requiring general anesthesia, double the morning hydrocortisone dose pre-operatively, then return to normal maintenance dosing. 1
Septic Shock with Suspected Adrenal Insufficiency
For fluid-refractory, catecholamine-resistant septic shock with suspected or proven absolute adrenal insufficiency (basal cortisol <18 μg/dL and peak ACTH-stimulated cortisol <18 μg/dL), give hydrocortisone 2 mg/kg IV bolus immediately after drawing baseline cortisol, then 2–50 mg/kg/day as continuous infusion or divided every 6–8 hours, titrating to reversal of shock. 6, 1
Approximately 25% of children with septic shock have absolute adrenal insufficiency, and death can occur within 8 hours of presentation if untreated. 1
The 2020 Surviving Sepsis Campaign guidelines suggest against routine hydrocortisone use if adequate fluid resuscitation and vasopressors restore hemodynamic stability, but recommend considering it for catecholamine-resistant shock. 6
The evidence is mixed: one pediatric RCT showed no mortality benefit from low-dose hydrocortisone, while another demonstrated earlier shock reversal. 1
Continue treatment until shock resolves, then taper gradually to minimize long-term toxicities—never stop abruptly. 6, 1
Neonatal Dosing for Birth Asphyxia
For a newborn with birth asphyxia and potential adrenal insufficiency, start with 50 mg/m²/24 hours (approximately 5–6 mg/kg/day for a 3 kg infant), which can be increased up to 50 mg/kg/day if needed to reverse refractory shock. 7
Administer as intermittent doses every 6–8 hours or as continuous infusion. 7
Critical Monitoring Parameters
Monitor blood glucose hourly in critically ill children or those with adrenal insufficiency during fasting or acute illness, as hypoglycemia can develop rapidly. 1
Check serum electrolytes (particularly sodium and potassium) regularly, as hydrocortisone affects mineralocorticoid balance. 1
In children on vasopressors, measure blood pressure and heart rate every 5–15 minutes. 1
Monitor for hyperglycemia, as hydrocortisone commonly causes elevated blood glucose requiring insulin therapy. 6
Essential Pitfalls to Avoid
Never use etomidate for intubation in children with septic shock or suspected adrenal insufficiency, as it suppresses the hypothalamic-pituitary-adrenal axis and increases mortality risk. 1
Do not delay hydrocortisone administration while waiting for cortisol test results in critically ill children—draw baseline cortisol then start treatment immediately. 1, 7
Never fast a child with adrenal insufficiency for more than 6 hours without IV dextrose, as they are at high risk for hypoglycemia. 1
Do not use dexamethasone as the sole glucocorticoid in children with CAH, as it lacks mineralocorticoid activity and doesn't provide adequate replacement. 8
Avoid abrupt discontinuation of stress-dose hydrocortisone, as this can precipitate adrenal crisis—always taper gradually. 6, 1
Be aware that even low systemic doses may decrease growth velocity in children without laboratory evidence of HPA axis suppression, so titrate to the lowest effective dose. 1