Adrenal Insufficiency and Stress Dose Steroids

These instructions are for Children's Hospital of Philadelphia (CHOP) patients with adrenal insufficiency (AI) who require oral steroids or Solu-Cortef® injections.

Important information:

The pituitary gland sends messages to the adrenal glands to make and release hormones.

• Adrenal insufficiency (AI) is a condition in which the body cannot make normal amounts of the hormone cortisol and - in some cases - the hormone aldosterone. Some children have AI their whole lives, for others, it can be temporary. Learn more about adrenal insufficiency.

• Adrenal insufficiency is treated by replacing the hormone cortisol with either hydrocortisone or prednisone therapy. Some children will take this medicine as a tablet every day. Others may only need it during periods of "stress" to the body, called "stress dosing."

• For those taking daily cortisol replacement medicine, it should never be stopped unless your healthcare provider tells you it is no longer needed. You should not stop abruptly - your provider will give you a schedule for reducing the medicine slowly.

What is stress dosing:

• During times of illness or stress the body needs larger amounts of cortisol to heal. Children with adrenal insufficiency do not make enough cortisol to help the body recover from illness or injury. They will need to be given extra hydrocortisone. Often this can be taken by mouth.

  • In some emergency situations, you will need to give cortisol as an injection. This could happen if your child is sick and unable to take the medicine by mouth, or if they cannot swallow or keep the pills down due to vomiting.

  • If your child has a serious accident that requires immediate medical attention or hospitalization, or they are having surgery, the healthcare team will give the hydrocortisone through an IV.

• Your healthcare provider will give you written instructions and prescriptions for the medicines your child needs. It is a good idea to ask about sick day management during your child's regular visits so you will be prepared.

Instructions for stress dosing:

Any illness or other physical stress may affect your child's health.

If your child has any of the following symptoms, begin stress dosing:

• Fever higher than 101°F

• Bacterial infection (for example strep throat, ear infection, pneumonia)

• Vomiting

• Concussion

• Broken bone

• Tooth removal by a dentist

• Seizure

• All day sports tournament or running a marathon

Stress dosing is not needed for mild cold symptoms such as a runny nose, dry cough, mild sore throat, routine dental visit, minor cuts and scrapes. Encourage your child to drink extra fluids (8-12 ounces every hour while awake) to help prevent dehydration.

If your child's illness includes repeated vomiting or diarrhea your child will not be able to absorb stress doses given by mouth. They will need to be given an injection of Solu-Cortef.

Continue stress dosing for 24 hours beyond the end of the illness or medical problem.

Call your healthcare provider if you are still giving the stress dose after 5 days.

If your child needs stress dosing and does not get it, you may see:

• Vomiting

• Weakness

• Severe pains in stomach, legs, and back

• Cold, sweaty skin

• Pale face

• Lower body temperature

• Fast heart rate

• Dizziness

• Signs of dehydration, such as dry tongue or thirst

• Thirst

• Fast breathing

• Confusion

If you are unsure if your child needs stress dosing, call your healthcare provider.

Instructions for stress dose injections:

• If your child is sick and cannot take the stress dose by mouth, or has any of the symptoms below, give the stress dose as an injection. A child who needs the injection and does not get it can quickly go into shock. You will not harm your child by giving a Solu-Cortef injection. The injection can save their life.

• Be prepared for an emergency, always keep a vial of Solu-Cortef with your child. Your child should wear personal identification, such as a medical alert bracelet or necklace that states they have "adrenal insufficiency". These specific words are important, rather than your child's underlying diagnosis like congenital adrenal hyperplasia, Addison's disease. This way, emergency medical personnel will know how to quickly treat your child in your absence.

Give the injection immediately if your child:

• Vomits 1 time and looks very ill

• Vomits more than once

• Extreme weakness

Give the injection and call 911 if your child has any of these emergencies:

• Unresponsive

• "Looks bad," pale, sweaty, or breathing fast

• Feels weak or is unable to respond normally

• Faints

• Has a serious injury

These are life-threatening emergencies and your child needs an injection immediately.

Injecting Solu-Cortef:

Watch how to give the injection.

1. Wash hands

2. Gather supplies: (See Figure 1)
   

   • Solu-Cortef Act-O-Vial

   • Syringe with needle

   • Alcohol pad or rubbing alcohol

   • Cotton ball

3. Push down on the top of the Act-O-Vial to release cork (See Figure 2).
   

4. Gently swirl to mix (See Figure 3).
   

5. Remove plastic cover from top and wipe with alcohol (See Figure 4).
   

6. Take cap off syringe and push needle through middle of rubber stopper (See Figures 5 left and 6 right).
   

7. Turn vial upside down and pull back on the plunger, keeping tip of needle under the liquid (See Figure 7).
   

8. Pull back until you have the correct amount.

9. Push out any air bubbles and recheck for the correct amount.

10. Remove needle from vial and carefully replace the cap.

11. Clean the top of the outer thigh with alcohol pad (See Figure 8).
    

12. Remove needle cap. Hold syringe like a dart or pencil (See Figure 9).
    

13. Use your thumb and fingers to grasp the muscle of the outer thigh.

14. Insert the needle quickly straight into the leg, at a 90° angle.

15. Inject slowly by pushing the plunger all the way down into the syringe.

16. Pull the needle out quickly.

17. Hold pressure with cotton ball or gauze (See Figure 10).
    

18. Do not recap needle.

19. Place needle and syringe in a hard container, such as a detergent or bleach bottle, with a cap and call your township office to find out how to dispose of it.

20. Call your healthcare provider after giving the injection.

Reviewed on February 13, 2023, by Marissa Kilberg MD