Adrenal insufficiency in children, emergency management protocol

November 2023: This guidance is currently under review as it has gone beyond the standard review date. It reflects best practice at the time of authorship / last review and remains safe for use. If there are any concerns regarding the content then please consult with senior clinical staff to confirm.

Conditions: Children on daily replacement hydrocortisone treatment, eg.

• Congenital Adrenal Hyperplasia
• Congenital Adrenal Hypoplasia
• Adrenal Insufficiency
• Multiple Pituitary Hormone Deficiency

1. If child has an intercurrent illness, but is well, feeding, playing and tolerating medication normally, there is no need for increase in hydrocortisone.
   
   
2. If child is unwell with fever and reduced activity, but tolerating oral medication, double largest daily hydrocortisone dose and administer three times per day for 48 hours. 
   (e.g. if normally on 10mg morning and 5mg evening – give 20mg three times/day - parents will usually be aware of their child’s emergency hydrocortisone regime.)
   
   
3. If severely unwell- unresponsive/vomiting:
   • Check blood sugar and urea & electrolytes including full blood count
   • If capillary glucose <3mmol/l give 2ml/kg of 10% dextrose, repeat if BM remains low
   • Fluid bolus may also be required (10-20ml/kg 0.9% saline) if indicated.
   • Give IV hydrocortisone bolus (IM if delay in IV access) and start IV infusion (table below).
   • Start IV maintenance fluids + deficit (e.g. 5% dex/0.45% saline)
   • Consider double dose hydrocortisone therapy once able to tolerate oral medications

DO NOT DISCHARGE HOME without discussing with endocrine team