ReviewEmergency and perioperative management of adrenalOPEN ACCESSinsufficiency in children and young people:BritishSociety for Paediatric Endocrinology and Diabetesconsensus guidanceTalat MushtaqSalma R Ali2 Nabil Boulos,3 Roisin Boyle,Tim Cheetham,5Justin Huw Davies,Charlotte Jane Elder,?Hoong-Wei Gan,3Peter C HindmarshHarshini Katugampola,Nils KroneMaria Salomon Estebanez,Savitha Shenoy,2 Sally Tollerfield,Sze Choong Wong,4Fiona Regan,13 Developed by the Paediatric Adrenal Insufficiency Group on behalf ofthe British Society for Paediatric Endocrinology and Diabetes(BSPED)For numbered affiliations seeABSTRACTend of article.Adrenal insufficiency (Al)is characterised by lackWHAT IS ALREADY KNOWN?of cortisol production from the adrenal glands.ThisPatients with adrenal insufficiency (Al)are atCorrespondence tocan be a primary adrenal disorder or secondary torisk of an adrenal crisis and death if they areDr Talat Mushtag,Departmentof Paediatric Endocrinology,adrenocorticotropic hormone deficiency or suppressionnot treated with additional glucocorticoidsLeeds Teaching Hospitals NHSfrom exogenous glucocorticoids.Symptoms of Al induring illness or surgery.Trust,Leeds LS1 3EX,UK:children may initially be non-specific and includeThere is variation in the management oftalat.mushtag@nhs.netgrowth faltering,lethargy,poor feeding,weight loss,paediatric Al with differing recommendationsReceived 10 December 2022abdominal pain,vomiting and lingering illnesses.Al isfor glucocorticoid doses for sick days andAccepted 25 February 2023treated with replacement doses of hydrocortisone.Atsurgerytimes of physiological stress such as illness,trauma orWHAT THIS STUDY ADDS?surgery,there is an increased requirement for exogenousglucocorticoids,which if untreated can lead to an adrenalAn adrenal crisis in children should be treatedcrisis and death.There are no unified quidelines for thosepromptly with intramuscular (or intravenous)<18years old in the UK,leading to substantial variationhydrocortisone:25mg in less than 1 year,50 mgin the management of Al.This paper sets out guidancein 1-5 years,100mg 6 years and over.for intercurrent illness,medical,dental and surgicalFor surgery under a general anaesthetic,procedures to allow timely and appropriate recognitionhydrocortisone at a dose of 2 mg/kgand treatment of Al and adrenal crisis for children andintravenously (max 100mg)is recommended atyoung peo ple.induction,followed by 1 mg/kg intravenously(max 50 mg)every 6hours (for neonates thedoses are 4mg/kg intravenously at inductionfollowed by 2 mg/kg intravenously everyBACKGROUND6hours).Alternatively,a hydrocortisone infusionMost forms of adrenal insufficiency (AI)are char-can be used following the induction dose ofacterised by lack of cortisol production from thehydrocortisone.adrenal glands.Children with AI have a dailyOur recommended approach of oralrequirement for glucocorticoid at a replacementglucocorticoid for sick day episodes is a totaldose,but at times of physiological
