What Should I Do If My Child Vomits CAH Medication?

This information is for caregivers of children with known classic congenital adrenal hyperplasia (CAH) who have a prescribed hydrocortisone emergency plan. Always follow your child’s specific endocrinology sick-day plan.

Vomiting can be extremely dangerous for a child with classic CAH. Gastrointestinal illnesses that cause vomiting are a well-known trigger for adrenal crisis, a life-threatening complication that occurs when the body does not have enough cortisol ^[1][2].

What you should do depends on whether this is a single, isolated episode or continuous vomiting, and what your child’s written emergency plan advises.

1. For a Single Episode of Vomiting (Child is Alert)

If your child spits up or vomits once immediately after taking their oral hydrocortisone and otherwise seems fine, they likely did not absorb the dose. Check your child’s written endocrinology sick-day plan for their specific redosing instructions. Generally, plans suggest:

• Waiting a short time (often 15 to 30 minutes) to let their stomach settle
• Offering small, frequent sips of an age-appropriate fluid (such as an oral rehydration solution or breast milk/formula, as advised by your doctor)
• Giving the oral dose again as directed by your child’s plan

Note: During an acute illness, children with CAH require increased stress-dose hydrocortisone ^[1][2]. Make sure you are giving the correct stress dose, not just the routine daily dose.

2. When to Use the Emergency Injection

If your child cannot absorb oral medication due to vomiting, they are at high risk for an adrenal crisis, which can cause dangerously low blood sugar (hypoglycemia), seizures, severe dehydration, and dangerous drops in blood pressure (hypotension) ^[3][4].

Do NOT give anything by mouth if your child is unconscious, having a seizure, or unable to swallow.

You must administer the prescribed emergency intramuscular hydrocortisone injection (such as Solu-Cortef) promptly without delaying for transport if:

• Your child vomits the repeat oral dose or cannot retain the prescribed stress dose
• Your child is continuously vomiting
• Your child shows warning signs of an adrenal crisis, such as:
  • Inability to wake up, extreme drowsiness, or confusion
  • Fainting or collapse
  • Pale, cold, or clammy skin
  • Severe or unusual weakness
  • Seizure
  • Very low urine output or markedly fewer wet diapers ^[5][4]

Delayed or missed administration of stress-dose hydrocortisone is a known major risk factor for adrenal crisis and poor outcomes ^[6]. Treat the inability to keep medicine down as an emergency, even before obvious symptoms of a crisis appear.

3. Seeking Emergency Care

After giving the emergency injection, you must seek immediate emergency medical assessment.

• Call 911 if your child is faint, confused, having a seizure, or otherwise unstable. Tell the dispatcher clearly that your child has congenital adrenal hyperplasia (adrenal insufficiency) and needs immediate medical assistance.
• If you do not have an injection kit, it is expired, or no one is trained to give it, call 911 immediately and state your child’s condition.
• Always bring your child’s emergency plan, medication list, and emergency injection kit to the hospital.

Prepare for Emergencies

• Make sure you have unexpired emergency injection kits at home, at school, and wherever your child spends time.
• Ensure that all caregivers, teachers, and family members know how to mix and give the injection, and where it is stored (keep it accessible, not locked away).
• Review your child’s sick-day plan with your endocrinologist regularly to ensure you know the exact dosage for their emergency injection.