Table 3 Management of pediatric adrenal insufficiency in specific situations. Adapted from [1]

Home management of illness with fever.

Unable to tolerate oral medications due to gastroenteritis or trauma

Hydrocortisone replacement doses doubled (> 38 °C) or tripled (> 39 °C) until recovery (usually 2 to 3 days); increased consumption of electrolyte containing fluids as tolerated

IM/SC Hydrocortisone 50 mg/m² or estimate; infants 25 mg, school-aged children 50 mg, adolescents 100 mg.

Minor to moderate surgical stress

Intramuscular/Intravenous Hydrocortisone 50 mg/m² or hydrocortisone replacement doses doubled or tripled

Major Surgical Stress with general anesthesia, trauma, or diseases that require intensive care

Hydrocortisone 50 mg/m2 intravenous followed by hydrocortisone 50–100 mg/m²/d divided q6 h

Weight-appropriate continuous intravenous fluids (dextrose containing)

Rapid tapering and switch to oral regimen depending on clinical state

Acute adrenal crisis

Rapid bolus of normal saline (0.9%) 20 mL/kg. Can repeat up to a total of 60 mL/kg within 1 h for shock.

Hydrocortisone 50–100 mg/m2 bolus followed by hydrocortisone 50–100 mg/m²/d divided q 6 h

For hypoglycemia: dextrose 0.5–1 g/kg of dextrose or 2–4 mL/kg of D25W (maximum single dose 25 g) infused slowly at rate of 2 to 3 mL/min. Alternatively, 5–10 mL/kg of D10W for children < 12 y old

Cardiac monitoring: Rapid tapering and switch to oral regimen depending on clinical state