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PubMed This is a summary of 27 peer-reviewed journal articles Updated
Pediatrics · Classic Congenital Adrenal Hyperplasia

Adrenal Crisis: Preventing and Managing Emergencies

At a Glance

An adrenal crisis is a life-threatening emergency in children with CAH caused by severe physical stress. To prevent a crisis, caregivers must double or triple oral hydrocortisone during moderate illnesses and immediately administer a Solu-Cortef injection if the child vomits or shows signs of shock.

An adrenal crisis is a life-threatening emergency that occurs when the body’s demand for cortisol far exceeds its supply [1][2]. In children with classic CAH, the adrenal glands cannot produce the “burst” of cortisol needed to survive physical stress.

Acting quickly to give stress doses or emergency injections is the single most important thing you can do to protect your child against life-threatening complications [3][4].

Why Crises Happen

When the body is under significant stress—such as from a high fever, severe injury, or surgery—it naturally requires up to three times its normal amount of cortisol [1][5]. Because your child’s adrenal glands cannot meet this demand, their blood pressure can drop dangerously low, and their heart rhythm can become unstable [6][7].

Common triggers include:

  • Infections with high fever (usually over 101°F or 38.5°C) [8][9].
  • Gastrointestinal illnesses involving vomiting or diarrhea [10][11].
  • Major physical trauma or surgery [1][5].

Recognizing the Warning Signs

A crisis can move quickly. You must act if you see any of the following “red flags” [12][2]:

  • Vomiting: This is a critical sign because the child cannot keep down their life-saving oral medication [13][14].
  • Hypoglycemia (Low Blood Sugar): Because cortisol helps regulate blood sugar, a sudden drop is a rapid-onset and dangerous feature of an impending crisis, especially in infants and toddlers. Signs include shakiness, extreme paleness, and sweating [5].
  • Extreme Lethargy: The child is unusually weak, floppy, or difficult to wake up [5][15].
  • Abdominal Pain: Intense stomach pain is a common, often overlooked sign of early crisis [12].
  • Confusion or Grayish Skin: These indicate advanced shock and require immediate action [13][16].

The Emergency Protocol: Stress Dosing

To prevent a crisis, you must follow “sick-day rules” to increase your child’s steroid levels during stress [17][18]. Note: Only hydrocortisone is increased; fludrocortisone stays at its normal dose.

1. Oral Stress Dosing

If your child has a fever or a moderate illness but is not vomiting, you will typically double or triple their normal dose of hydrocortisone for 24 to 48 hours [19][1]. Always follow the specific dosing chart provided by your endocrinologist. It is also important to offer sugar-containing fluids (like Pedialyte or juice) during illnesses to prevent hypoglycemia.

2. The Emergency Injection (Solu-Cortef)

If your child is vomiting, loses consciousness, or shows signs of shock, you must give an intramuscular (IM) injection of hydrocortisone (Solu-Cortef) immediately [20][21].

  • The 30-Minute Rule: If your child vomits within 30 to 45 minutes of taking their oral hydrocortisone, assume the medication was not absorbed and give the injection [13][22].
  • Where to Inject: Administer the injection into the large muscle of the outer thigh [23].
  • Do Not Wait: It is safer to give the injection when it might not be needed than to wait until it is too late [22][24].
  • Go to the ER: After giving the injection, your child must be evaluated in an emergency room to receive IV fluids and monitoring [3][22].

Your Safety Checklist

Preparation is the best defense against a fatal crisis.

  • Emergency Kit: Always carry an unexpired vial of Solu-Cortef, syringes, and needles [17][25].
  • Medical Alert: Your child should wear a medical alert bracelet or necklace that says: “Adrenal Insufficiency: Needs Stress Doses” [17].
  • Emergency Letter: Keep a copy of an ER instruction letter from your doctor in your diaper bag and give one to your child’s school or daycare [26][27].
  • Practice: Periodically practice the injection technique (even on an orange) so you are confident during a real emergency [23][17].

Common questions in this guide

When should I give my child with CAH an emergency Solu-Cortef injection?
You should give the injection immediately if your child is vomiting, loses consciousness, shows signs of shock, or vomits within 45 minutes of taking their oral hydrocortisone. It is always safer to give the injection when it might not be needed than to wait until it is too late.
How do I adjust my child's CAH medication when they are sick?
For a fever or moderate illness without vomiting, you will typically double or triple your child's normal oral hydrocortisone dose for 24 to 48 hours. Fludrocortisone stays at its normal dose. Always follow the specific sick-day plan provided by your endocrinologist.
What are the early warning signs of an adrenal crisis?
Early warning signs include intense abdominal pain, unexplained vomiting, extreme lethargy, and signs of low blood sugar like shakiness and pale skin. If you notice these symptoms, you must act quickly to provide stress doses of cortisol.
What do I need to keep in my CAH emergency kit?
Your emergency kit should always include an unexpired vial of Solu-Cortef (injectable hydrocortisone), syringes, needles, and a formal emergency instruction letter from your pediatric endocrinologist for the ER staff.
Do I need to give a stress dose for a common cold?
Minor illnesses, such as a common cold without a fever, typically do not require a stress dose of hydrocortisone. However, you should monitor your child closely and consult your healthcare provider if you are ever unsure.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.What is my child's specific weight-based dose for an emergency hydrocortisone (Solu-Cortef) injection?
  2. 2.Under exactly what circumstances should I switch from doubling the oral dose to giving the emergency injection?
  3. 3.Can you provide a formal 'emergency letter' for the ER and my child's school that explains the need for immediate treatment?
  4. 4.How often should we review the injection technique with your nursing staff to ensure I am ready to act in a crisis?
  5. 5.Which illnesses (like a cold with no fever) do not require a stress dose, and which ones always do?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (27)
  1. 1

    Perioperative glucocorticoid management based on current evidence.

    Seo KH

    Anesthesia and pain medicine 2021; (16(1)):8-15 doi:10.17085/apm.20089.

    PMID: 33445232
  2. 2

    Acute Gastroenteritis Induced Adrenal Crisis in a patient with Congenital Adrenal Hyperplasia: A Case Report.

    Chapagain N, Adhikari A, Adhikari N, et al.

    JNMA; journal of the Nepal Medical Association 2023; (61(257)):84-86 doi:10.31729/jnma.7926.

    PMID: 37203925
  3. 3

    Mortality in children with classic congenital adrenal hyperplasia and 21-hydroxylase deficiency (CAH) in Germany.

    Dörr HG, Wollmann HA, Hauffa BP, et al.

    BMC endocrine disorders 2018; (18(1)):37 doi:10.1186/s12902-018-0263-1.

    PMID: 29884168
  4. 4

    Congenital Adrenal Hyperplasia.

    Fraga NR, Minaeian N, Kim MS

    Pediatrics in review 2024; (45(2)):74-84 doi:10.1542/pir.2022-005617.

    PMID: 38296783
  5. 5

    Emergency and perioperative management of adrenal insufficiency in children and young people: British Society for Paediatric Endocrinology and Diabetes consensus guidance.

    Mushtaq T, Ali SR, Boulos N, et al.

    Archives of disease in childhood 2023; (108(11)):871-878 doi:10.1136/archdischild-2022-325156.

    PMID: 37045585
  6. 6

    Congenital Adrenal Hyperplasia Presenting as Pulseless Ventricular Tachycardia in a Neonate.

    Manzoor N, Minhaj A, Akmal M

    Cureus 2019; (11(5)):e4749 doi:10.7759/cureus.4749.

    PMID: 31363431
  7. 7

    Conduct protocol in emergency: Acute adrenal insufficiency.

    Fares AB, Santos RA

    Revista da Associacao Medica Brasileira (1992) 2016; (62(8)):728-734 doi:10.1590/1806-9282.62.08.728.

    PMID: 27992012
  8. 8

    Routine vaccinations as a precipitant of adrenal crisis in adrenal insufficiency.

    Major A, Chacko K

    Internal medicine journal 2018; (48(3)):360-361 doi:10.1111/imj.13720.

    PMID: 29512322
  9. 9

    Adrenal crisis and death following transarterial chemoembolization of sarcoma liver metastases.

    Afiat TP, Johns C, Smith J, et al.

    Clinical imaging 2021; (69()):79-81 doi:10.1016/j.clinimag.2020.06.023.

    PMID: 32693227
  10. 10

    Longitudinal Assessment of Illnesses, Stress Dosing, and Illness Sequelae in Patients With Congenital Adrenal Hyperplasia.

    El-Maouche D, Hargreaves CJ, Sinaii N, et al.

    The Journal of clinical endocrinology and metabolism 2018; (103(6)):2336-2345 doi:10.1210/jc.2018-00208.

    PMID: 29584889
  11. 11

    Real-World Estimates of Adrenal Insufficiency-Related Adverse Events in Children With Congenital Adrenal Hyperplasia.

    Ali SR, Bryce J, Haghpanahan H, et al.

    The Journal of clinical endocrinology and metabolism 2021; (106(1)):e192-e203 doi:10.1210/clinem/dgaa694.

    PMID: 32995889
  12. 12

    Darkened skin, vomiting, and salt cravings in a teenager · Dx?

    Lee T, Kapadia C

    The Journal of family practice 2016; (65(6)):E1-3.

    PMID: 27474827
  13. 13

    Management of Acute Adrenal Insufficiency-Related Adverse Events in Children with Congenital Adrenal Hyperplasia: Results of an International Survey of Specialist Centres.

    Ali SR, Bryce J, Krone NP, et al.

    Hormone research in paediatrics 2022; (95(4)):363-373 doi:10.1159/000525075.

    PMID: 35569445
  14. 14

    Variations in the management of acute illness in children with congenital adrenal hyperplasia: An audit of three paediatric hospitals.

    Chrisp GL, Maguire AM, Quartararo M, et al.

    Clinical endocrinology 2018; (89(5)):577-585 doi:10.1111/cen.13826.

    PMID: 30086199
  15. 15

    A Novel Steroidogenic Acute Regulatory Protein (StAR) Mutation Causing Adrenal Insufficiency in a Neonate: A Case Report of a Rare Medical Condition.

    Rawat A, Karotkar S, Lakra M, et al.

    Cureus 2024; (16(8)):e66080 doi:10.7759/cureus.66080.

    PMID: 39229408
  16. 16

    Patient and caregiver experiences with hydrocortisone injections in adrenal crisis: a mixed-methods cross-sectional study.

    Llahana S, Anthony J, Sarafoglou K, et al.

    Frontiers in endocrinology 2025; (16()):1544502 doi:10.3389/fendo.2025.1544502.

    PMID: 40331138
  17. 17

    Diagnosis and management of secondary adrenal crisis.

    Martel-Duguech L, Poirier J, Bourdeau I, Lacroix A

    Reviews in endocrine & metabolic disorders 2024; (25(3)):619-637 doi:10.1007/s11154-024-09877-x.

    PMID: 38411891
  18. 18

    The effect of patient-managed stress dosing on electrolytes and blood pressure in acute illness in children with adrenal insufficiency.

    Chrisp GL, Torpy DJ, Maguire AM, et al.

    Clinical endocrinology 2020; (93(2)):97-103 doi:10.1111/cen.14196.

    PMID: 32301148
  19. 19

    Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency: Guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK.

    Woodcock T, Barker P, Daniel S, et al.

    Anaesthesia 2020; (75(5)):654-663 doi:10.1111/anae.14963.

    PMID: 32017012
  20. 20

    Audit of management of children and adolescents with congenital adrenal hyperplasia as per recent Endocrine Society guidelines.

    S L, Krishna Prasad H, Ramjee B, et al.

    Pediatric endocrinology, diabetes, and metabolism 2023; (29(1)):10-15 doi:10.5114/pedm.2022.122547.

    PMID: 36734395
  21. 21

    Treatment and Follow-up of Congenital Adrenal Hyperplasia Due to 21-hydroxylase Deficiency in Childhood and Adolescence

    Peltek Kendirci HN, Ünal E, Dündar İ, et al.

    Journal of clinical research in pediatric endocrinology 2025; (17(Suppl 1)):12-22 doi:10.4274/jcrpe.galenos.2024.2024-6-26-S.

    PMID: 39713876
  22. 22

    Electrolyte abnormalities and stress dosing predict illness-related hospitalizations among infants and toddlers with congenital adrenal hyperplasia.

    Tseng T, Seagroves A, Tanawattanacharoen VK, et al.

    Clinical endocrinology 2023; (98(4)):536-542 doi:10.1111/cen.14876.

    PMID: 36593179
  23. 23

    Acute Illness and Death in Children With Adrenal Insufficiency.

    Worth C, Vyas A, Banerjee I, et al.

    Frontiers in endocrinology 2021; (12()):757566 doi:10.3389/fendo.2021.757566.

    PMID: 34721304
  24. 24

    Adrenal crises: perspectives and research directions.

    Rushworth RL, Torpy DJ, Falhammar H

    Endocrine 2017; (55(2)):336-345 doi:10.1007/s12020-016-1204-2.

    PMID: 27995500
  25. 25

    The Key to Adrenal Insufficiency Education: Repetition, Repetition, Repetition.

    Keil MF, Van Ryzin C

    Pediatric endocrinology reviews : PER 2017; (14(Suppl 2)):448-453 doi:10.17458/per.vol14.2017.kr.keyadrenalinsufficiency.

    PMID: 28647949
  26. 26

    Treatment and Prevention of Adrenal Crisis and Family Education

    Çamtosun E, Sangün Ö

    Journal of clinical research in pediatric endocrinology 2025; (17(Suppl 1)):80-92 doi:10.4274/jcrpe.galenos.2024.2024-6-12-S.

    PMID: 39713905
  27. 27

    Adrenal crisis in infants and young children with adrenal insufficiency: Management and prevention.

    Bizzarri C, Capalbo D, Wasniewska MG, et al.

    Frontiers in endocrinology 2023; (14()):1133376 doi:10.3389/fendo.2023.1133376.

    PMID: 36860362

This page provides educational information on managing adrenal crises in children with CAH. Always consult your pediatric endocrinologist for your child's specific stress dosing and emergency protocol.

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