Cortisol under pressure: can we improve hydrocortisone stress dosing in illness, surgery and psychological stress in children with adrenal insufficiency?

Cortisol plays a vital role in the body’s stress response. Current paediatric guidelines emphasise the necessity of increasing cortisol supplementation for adrenal insufficiency (AI) from replacement doses to ‘sick day’ doses at times of medical illness and surgery. Recent updates have standardised doses and offered clear, pragmatic guidance for the management of children with AI during these periods. However, authors of these guidelines also note that there are insufficient data, especially within the paediatric population, to specify what is the threshold required to escalate to sick day doses and to define the optimal dosing in an evidence-based manner. This review provides a summary of the existing paediatric guidelines, addresses the risks of both overdosing and underdosing, identifies where current research is being undertaken and highlights further areas for investigation.