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This resource explains about adrenal insufficiency (cortisol deficiency) and how it is treated. It also contains information about how to manage steroid replacement with illnesses, accidents and other stressful events in children.
Steroid replacement is vital for your child to grow and develop normally. If the correct dose is used, there are no side effects. This is because the treatment is just replacing what the body should normally produce.
Normally, people produce more cortisol than usual in response to illness, injury and surgery. It is very important that children and young people receiving steroid replacement therapy increase their normal dose of steroids to copy this response.
The adrenal glands are on top of the kidneys. They produce important hormones (chemical messages) to control how the body works. One of these hormones is called cortisol. Cortisol is the body’s natural steroid and has 3 main functions:
If a someone cannot make cortisol (cortisol deficiency), they will need to take tablets to replace it. The most common medication used is hydrocortisone, but other forms may be prescribed.
Cortisol deficiency is easily managed with replacement hydrocortisone tablets given a few times a day.
However, if someone with cortisol deficiency becomes unwell or their body is stressed, they are unable to make more cortisol in their system to help the body cope and this could be life threatening.
If this happens, the amount of hydrocortisone given needs to be increased. This is done by either:
The information provided in this resource will guide you as to how to manage steroid replacement. However, if you are uncertain about your child’s treatment, speak to your doctor or specialist nurse.
This medication is vital and should not be missed. Please make sure:
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Your child is likely to need an increase in their dose of hydrocortisone when they are:
An extra dose will not do any harm, so if in doubt it is better to give extra hydrocortisone and then contact the specialist endocrine team for advice about what to do next.
In the event that your child needs a hydrocortisone injection then they should be taken to the nearest emergency department (A&E) immediately by paramedic ambulance for further assessment.
If your child is less alert than usual you should call a paramedic ambulance. The paramedics do not carry hydrocortisone for injection so if you haven’t given the injection, please make sure you give the emergency kit to the paramedic.
Your child will be taken in to hospital for 12 hours. This is because the hydrocortisone injection takes about 8 hours to wear off and we need to make sure that it is safe for your child to go home.
If your child is only sick 1 time, an hour or longer after taking the oral hydrocortisone, you will not need to repeat it. However, you should think about why they have been sick. It may be a one-off, or a warning of underlying illness.
However, if your child is being sick within 1 hour of taking their hydrocortisone tablet then give a 2nd dose of hydrocortisone.
If your child is sick again then give them 3rd the dose of oral hydrocortisone. Seek medical advice early to make sure your child does not become more unwell.
If they are being sick repeatedly or in large amounts, give them a hydrocortisone injection and bring your child to hospital in a paramedic ambulance. Your child may need to stay in hospital to receive intravenous (IV drip) hydrocortisone until they have stopped being sick.
If your child has diarrhoea, there is a risk that the oral hydrocortisone will pass through their too quickly and will not be absorbed. You will need to double or treble the usual dose of oral hydrocortisone until the diarrhoea stops.
If your child has severe diarrhoea and is also being sick, you should give them a hydorcortisone injection into their thigh and call an ambulance to go to hospital immediately.
If your child has a cough and cold without a temperature then there is no need to increase their dose of steroids. However, if you are uncertain about what to do, ask your doctor.
Normal body temperature is 36 degrees Celsius to 37.5 degrees Celsius.
If your child has a high temperature because of an infection or if they are on antibiotics to treat infection, then either double or treble their dose of steroids until 24 hours after the infection has cleared.
If they are moderately unwell (see table) then double their dose of steroids.
If they are very unwell (see table) then treble their dose of steroids.
If your child is on antibiotics for longer than 10 days, ask your doctor about how long to increase your child’s dose of steroids. Also give your child a double morning dose of hydrocortisone at 4am if they are very unwell. Always ask your doctor or specialist nurse if you are not sure.
Children on hydrocortisone replacement should treble their dose of steroids and also have an oral aciclovir (anti-viral medication). You can get Aciclovir from your GP.
Cold or cough without temperature. They can go to school.
|No change in dose|
Maybe keep them off school if their temperature is less than 38.5 degrees Celsius. They may need an antibiotic.
|Double dose of steroids|
If their temperature is above 38.5degrees Celsius and will need an antibiotic. May be chicken pox
|Treble dose of steroids|
If your child is having a dental check up or teeth cleaning they do not need to increase their dose of hydrocortisone.
If your child needs a dental procedure that does not need a general anaesthetic, then double their dose of hydrocortisone for 24 hours after the procedure.
If they need a general anaesthetic, please see the information on general anaesthetics.
Children taking hydrocortisone should have all recommended childhood immunisations. If they are unwell or develop a temperature after their immunisation, then treble their dose of steroid until they improve.
If your child needs a general anaesthetic then they will need intravenous (IV) hydrocortisone which will be given before the operation or procedure. This includes MRI scans.
Please make sure that the doctors and nursing staff know that your child is on steroid replacement. If their operation is in the morning your child should have their normal dose of hydrocortisone the night before their operation.
If their operation is in the afternoon, your child should have their normal morning dose of hydrocortisone. The specialist team will let you know what to do with your child’s dose of steroids following their operation.
If your child has a minor injury such as a bump, cut or graze and they can recover straight away and resume activities, then you do not need to increase their dose of hydrocortisone.
If your child has a significant injury such as:
Then give the hydrocortisone injection and call a paramedic ambulance to bring your child to hospital.
If your child becomes unconscious, it is vital that you give them an injection of hydrocortisone into their thigh immediately and then call a paramedic ambulance to bring them to hospital.
If your child is taking desmopressin (DDAVP) and needs to increase their dose of hydrocortisone because they are unwell, do not give more desmopressin until you have spoken to the specialist team.
Let your child drink water or other soft drinks freely.
When your child is unwell, giving these medications together may mean their sodium level drops. Because of this, they will need to have their sodium level checked in hospital.
The correct dose of hydrocortisone should be given by injection in emergencies. Remember that no harm can come from giving an unnecessary hydrocortisone injection. The dose that should be given is:
Use a syringe to prepare the hydrocortisone solution. You should give your child their injection given in the middle of the outer side of their thigh. This is because there are no important structures that can be damaged. The injection will go into the muscle.
Your child’s condition should improve quickly, but you should still take them to hospital if you have given the hydrocortisone injection.
Please use the pictures below as a guide to giving the hydrocortisone injection:
If at all possible wash your hands before starting.
Find the coloured dot on the side of the glass ampoule. Apply pressure to the dot and bend to break the ampoule. Use a tissue when breaking the ampoule to stop the glass from cutting your finger.
Open the syringe package. Make sure that the needle is firmly attached to the syringe. If the needle touches any surface including your hand it is no longer sterile and should be changed.
It is very important to remove bubbles in the syringe. To do this hold the syringe at 90 degrees with the needle pointing upwards and tap the side of the syringe until the air bubbles have moved to the top. The air can then be removed by pushing up the syringe plunger until the air has passed through the neck of the syringe.
Make sure that you ring for an ambulance or go straight to the nearest Accident & Emergency Department.
Great Ormond Street Hospital have recently developed a free training app for giving an emergency injection of hydrocortisone. The app is a real time video showing the technique.
There is a silent video, and also a tab with the step by step photographs of the procedure on it.
Parents and carers can input doses, contact numbers and what to do when an A&E doctor takes over the care of your child.
The My Cortisol app is available for both Apple (Apple Store) and Android (Google Play) devices.
A time difference of 1 to 3 hours should not cause any problems. Do not change the time you give your child their hydrocortisone.
For these journeys it is better to switch to 8 hourly treatment programme.
The same sick-day rules apply with hydrocortisone:
Date of birth: //
My oral hydrocortisone replacement dose is:
Double oral steroids
Triple oral steroids
My hydrocortisone injection expires:
In emergencies, phone 999 and ask for a paramedic ambulance. Do not forget to tell the paramedics that your child is on steroid replacement.
To bleep a member of the team, please phone the Sheffield Children’s hospital switchboard on: 0114 271 7000.
Doctor Neil Wright, Doctor Nils Krone and Professor Paul Dimitri: 0114 271 7118
Endocrinology registrar: 0900 1700 via switchboard
Endocrine specialist nurses: 0900 1700 via switchboard
Telephone: 0114 226 7815
Bleep number: 024
Tanya Urquhart – Nurse Specialist in Late Effects
Telephone: 0114 226 7815
Bleep number: 209
Medical Doctor on-call (out of hours): 0114 271 7000
Please note: this is a generic information sheet relating to care at Sheffield Children’s NHS FT. These details may not reflect treatment at other hospitals. This information is not intended as a substitute for professional medical care. Always follow your healthcare professionals’ instructions. If this resource relates to medicines, please read it alongside the medicine manufacturer’s patient information leaflet. If this information has been translated into another language from English, efforts have been made to maintain accuracy, but there may still be some translation errors. If you are unsure about any of the guidance in this resource or have specific questions about how it relates to your child, always ask your healthcare professional for further advice.
Switchboard: 0114 271 7000
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