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Child Health Guideline Identifier

Stress Steroid Management

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High Risk Groups

High-Risk groups for Adrenal Crisis are:

Primary adrenal deficiency:

  • Congenital Adrenal Hyperplasia
  • Addison's disease or adrenal hypoplasia

Secondary (pituitary) ACTH deficient conditions:

  • Hypopituitarism (congenital/idiopathic)
  • Septo-optic dysplasia or midline CNS abnormalities

Recent treatment with high dose synthetic steroids for prolonged periods

All children at risk of adrenal insufficiency should be discussed with and/or admitted under the Paediatric Endocrinology Team with appropriate steroid replacement.


The classic triad for primary adrenal crisis: ↓ serum Na, ↑ serum K, and ↓ serum Glucose

Symptoms seen in Adrenal Crisis: (not all have to be present)

  • Dehydration, shock
  • GI symptoms (Vomiting, Diarrhea, Abdominal Pain, Constipation)
  • Syncope
  • Fever
  • Tachycardia
  • Hypoglycemia
  • Hypotension (postural drop).
  • Acidosis
  • Lethargy, weakness


Blood tests (for known at risk patients on steroids already):

  • Electrolytes (particularly Na, K, glucose)
  • Calcium
  • FBC
  • +/-cap gas.

Clinical tests:

  • Monitor vital signs (BP, Pulse, Temperature)
  • Tachycardia with postural drop

Principles of Management

  1. Increased Cortisol is needed in times of stress
    In normal subjects increases approximately 5+ fold during any major physical stress such as illness, anesthesia and surgery.
  2. Goal: to replace appropriate cortisol response in children who are adrenally insufficient
  3. The preferred route is IV (or IM); hydrocortisone is the steroid of choice.
    A continuous IV infusion is ideal
    - Intermittent boluses 6 x per day (4 hourly) are another option
  4. High doses (stress) of hydrocortisone also provide full mineralocorticoid effect.
    The exception is dexamethasone: has no significant mineralocorticoid effect.
  5. Stress doses of hydrocortisone can be reduced rapidly for short illness
    - Back to simple replacement doses as the patient recovers.
    - "Tapering" the dose is not usually needed in this setting.
  6. Don't forget to treat the underlying cause of the stress
    Consider occult infection/appendicitis/UTI etc 
  7. Those already on high dose steroids (daily Prednisone etc) should continue their medication.
    The key is not to stop or go to IV.

Management Details

A - Severely Unwell:

Unstable / Crisis OR Unwell (vomiting, diarrhoea, drowsy), unable to tolerate oral hydrocortisone

  • Bolus IV fluids: 10-30 ml/kg 0.9% saline, then maintenance 0.9% saline + 5% dextrose.
  • Start IV steroids
    Bolus - Hydrocortisone: 75-100 mg/m2 IV (or IM) - then
    Infusion - Hydrocortisone 55-100mg/m2/day until stable.
  • Body surface area: √(height (cm) x weight (kg)/3600) or use BSA calculator.

Table 1 gives rapid estimates of hydrocortisone doses.

Table 1: Rapid Estimates of Hydrocortisone Dose if Weight or BSA not available

Age Initial bolus dose of hydrocortisone succinate (IM or IV   Hydrocortisone Infusion
(50 mg hydrocortisone in 50 ml 0.9% saline)
0 - 6 months   12.5 mg 1ml/hr : infants
2 ml/hr: pre-schoolers
3 ml/hr: older children   
6mo - 5 years  25 mg
5 -10 years   50 mg 
>10 years  100 mg

Presumed adrenal insufficient patient undergoing CNS tumour resection:

Dexamethasome given for raised ICP is already sufficient (see Table 3 for potency compared to hydrocortisone).

Review once off steroid in view of possible ACTH deficiency from surgery (can be weeks to months later)

Moderately Unwell

Stable with fever, reduced activity:
If able to tolerate oral hydrocortisone: give 50 mg/m2/day
e.g.: Give 5x (five times) the patient's normal total daily dose hydrocortisone, as 4-5 divided doses (breakfast, lunch, afternoon tea, dinner, bedtime)

Gastroenteritis: Stable with mild diarrhea:
If able to tolerate oral fluids start oral hydrocortisone 50mg/m2/day as above
If unable to tolerate oral fluids give IV/IM hydrocortisone (see 'A' above)

Mildly Unwell

Respiratory, ear infection, no fever, vomiting or diarrhoea, and looks well
Continue normal maintenance doses of steroid.
No Fever >38 degrees, not on antibiotics.

Elective surgical procedures

Simple elective surgery
Can be managed by increased oral hydrocortisone for 24-48 hours. (2-3x)
Often an oral dose of hydrocortisone at the onset of the 'Nil by mouth' (eg for gastroscopy) period can suffice: discuss with anaesthetist regarding when Nil by mouth period starts

For more acute surgery or prolonged illness/surgery

Table 2: Peri-operative Stress Steroids

Weight (kg) Single dose Hydrocortisone PRE-operatively
PO - prior to being NBM 
Rate of infusion INTRA- and POST-operatively:
50 mg hydrocortisone in 50 ml 0.9% saline (ml/hr = mg/hr) 
3 - 10  25 mg   1
10 - 20  50 mg   2
>20  100 mg   3
  • Maintenance IV fluid rate of 0.9% NaCl with 5% glucose.
  • If weight is unknown dosing can be based on age:
    En route to surgery, prior to anaesthesia:
    0-3 yrs : Hydrocortisone 25 mg IV bolus, then 50 mg/m2 (~25 mg) infusion for remaining 24 hrs
    3-12 yrs : Hydrocortisone 50 mg IV bolus, then 50 mg/m2 (~50-60 mg) infusion for remaining 24 hrs
    12 yrs : Hydrocortisone 100 mg IV bolus, then 50 mg/m2 )~100 mg) infusion for remaining 24 hrs
  • Once stable: switch to maintenance oral hydrocortisone (~10mg/m2/day).


  1. 12 year old male with CAH, on steroids (fludrocortisone and hydrocortisone), acute vomiting, abdominal pain, temperature of 38.5, hypotensive:
    Administer 100 mg hydrocortisone IM/IV followed by a continuous infusion of 100mg/m2/day until clinically stable. (Fludrocortisone not normally needed when on IV steroids of such doses) 
  2. 9 month old male with congenital hypopituitarism with upper respiratory infection and fever of 38.3°C. Usual medication hydrocortisone 2 mg am, 1.25 mg midday, and 1.25 mg at night. So total is 5 mg/day.
    Give 5 mg hydrocortisone x 5 times per day until fever resolves, then go back to maintenance dose.
    See GP to investigate cause of fever.

Steroid Potency

Table 3: Steroid Potency

  Glucocorticoid effect in relation to hydrocortisone/cortisol=1.0 Sodium Retention Effect Equivalent to 0.1 mg Florinef PO  Stress dose for individual glucocorticoid preparations equivalent to 100mg Cortisol PO 
Cortisol (Hydrocortisone) 20 100mg
Cortisone  0.8  20 125 mg 
Prednisone  4 - 6  50  25 mg 
Prednisolone 6 - 8  50  20 mg 
Methylprednisolone (Solumedrol)  6 - 8  0 15-20 mg 
Dexamethasone  80 to 120  1.5 mg 
9a-Fluorocortisone (Florinef)   ~None; but 15x mineralocorticoid effect 0.1  N/A 

References and Further Reading

Pediatric Endocrinology, Sperling, 3rd ed. 2008

Practical Endocrinology and Diabetes in Children 2nd ed. 2006

Pediatric Practice: Endocrinology, Michael Kappy, David Allen, Mitchell Geffner, 2010,

Australasia Paediatric Endocrine Group - Adrenal Gland

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Document Control

  • Date last published: 26 January 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Endocrinology
  • Author(s): Craig Jefferies
  • Owner: Craig Jefferies
  • Editor: Greg Williams
  • Review frequency: 2 years

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