Management of adrenal insufficiency during the stress of medical illness and surgery

To the Editor: The recent article by Jung and Inder1 provides sensible advice for the safe management of adults with adrenal insufficiency (AI) during illness and surgery, without risking adrenal crisis or excessive steroid dosing. However, the authors make no reference to paediatric practice and no guidelines have been provided for the body-size-related steroid doses required in paediatric patients with AI, either for routine steroid replacement or during illness and surgery. It is important that doctors be aware that the doses recommended by Jung and Inder are not suitable for children with AI.

In keeping with recent studies of daily cortisol production, daily hydrocortisone replacement doses of 6–8 mg/m2/day are now recommended for children with secondary AI (eg, due to adrenocorticotropic hormone deficiency), provided the patient has no hypoglycaemia or symptoms of cortisol deficiency.2 In children with primary AI, higher hydrocortisone doses are often necessary (up to 10–15 mg/m2/day) — for example, to minimise adrenal androgen secretion in children with congenital adrenal hyperplasia.3

During minor illness (as defined in Box 3 of Jung and Inder’s article1), a child’s usual daily oral dose of glucocorticoid should be doubled or tripled until recovery.3,4 However, for children with secondary AI who are on the lower doses of daily hydrocortisone (about 6–8 mg/m2/day), these multiples may not constitute adequate doses during stress. In these patients, per-m2 dosing is more accurate (ie, 30–40 mg/m2/day for minor illnesses).

During moderate-to-severe illness, for patients who are vomiting, those who have experienced trauma and those undergoing anaesthesia and surgery, the following doses of intravenous hydrocortisone are recommended:

• For children aged < 3 years: 25 mg initial dose then 25–30 mg/day;

• For children aged 3–12 years: 50 mg initial dose then 50–60 mg/day; and

• For adolescents and adults: 100 mg initial dose then 100 mg/day.

These doses are in keeping with national4 and international3 recommendations, and equate to doses of 60–100 mg/m2/day of hydrocortisone. The more accurate per-m2 dosing should be used for children who are not within the normal weight range for their age.

These recommendations for children are extrapolated from adult studies and also based on expert consensus. Attention to the specific body-size dose adjustments required in paediatric prescribing can provide safe levels of steroid cover while avoiding exposure to excessive steroid doses.