When Should I Stress Dose My Child With CAH for an Illness?

This guide applies to children diagnosed with classic congenital adrenal hyperplasia (CAH) who are prescribed daily hydrocortisone (a type of glucocorticoid, or medication replacing the cortisol the body cannot make).

If your child has a minor illness like a simple runny nose, mild cough, or a small scrape without a fever, and they are otherwise acting well, they generally do not need extra hydrocortisone. Stress dosing (giving extra medication) is reserved for moderate to severe physical stress—like a fever, vomiting, infection, or major surgery—which causes the body to need more cortisol than usual to cope. You must always refer to the specific written sick-day plan provided by your pediatric endocrinologist and never start stress dosing unless your medical team has prescribed a plan.

When NOT to Stress Dose

If your child is otherwise energetic, drinking fluids, alert, and able to take their routine medication, extra hydrocortisone is usually not needed for:

• Mild, afebrile illnesses: A common cold, sniffles, or minor allergies without a fever.
• Minor injuries: Small scrapes, cuts, or bruises.

Research, including an international survey of pediatric CAH centers, shows that routine practice does not recommend increasing hydrocortisone for mild illnesses without a fever, provided the child is otherwise well ^[1]. Giving extra steroids when it isn’t necessary can lead to overexposure over time, which carries its own health risks. However, if a “minor” illness worsens, or if you are ever unsure, contact your endocrinology team for guidance.

When Stress Dosing is Required

When a child experiences significant physical stress, their body needs more hydrocortisone. The exact dose should be adjusted according to the severity of the illness ^[2].

• Fever: A fever is the most consistent trigger for stress dosing. In an international survey, all participating pediatric centers agreed that a fever requires extra hydrocortisone ^[1]. While exact thresholds vary, many clinics use a temperature of 100.4°F (38.0°C) or 101°F (38.3°C) as the cutoff. Your child’s specific written plan dictates your exact temperature threshold.
• Gastrointestinal Illnesses and Vomiting: Infections that cause vomiting or diarrhea are very common triggers for an adrenal crisis (a life-threatening medical emergency that occurs when the body severely lacks cortisol) ^[3]. Vomiting is especially dangerous because the child may not absorb their oral hydrocortisone ^[1]. Your sick-day plan should specify what to do if your child vomits a single dose (often repeating the dose). However, if your child is repeatedly vomiting, has severe diarrhea, or cannot keep oral medication down, you must give the emergency intramuscular (IM) (injected into the muscle) hydrocortisone injection immediately and seek emergency medical care ^[1]. Do not wait for other warning signs to develop.
• Significant Trauma or Surgery: Major physical injuries (like broken bones) or surgeries requiring anesthesia require increased hydrocortisone ^[4]. For surgeries, this is usually managed by the medical team with IV steroids. Always inform surgical and anesthesia teams in advance about your child’s CAH.

How to Give a Stress Dose

While you may hear other parents talk about “doubling or tripling” their child’s dose ^[1], you must never calculate or modify the dose independently. Always follow your child’s individualized Adrenal Insufficiency Action Plan ^[5].

This written plan from your pediatric endocrinologist should clearly outline:

• Your child’s routine daily hydrocortisone and fludrocortisone doses. (Generally, fludrocortisone is continued at its normal dose during illness, but follow your doctor’s specific instructions).
• The exact oral stress dose in milligrams (mg) and how often to give it.
• The correct dose for an emergency IM injection.
• When to call the doctor and when to go to the hospital.

Warning Signs of an Adrenal Crisis

If your child’s body cannot get enough cortisol during an illness, they can develop an adrenal crisis. Early warning signs can worsen quickly. Watch closely for:

• Unusual lethargy, severe fatigue, lack of energy, or being difficult to wake up ^[1][6].
• Repeated nausea, vomiting, abdominal pain, or poor feeding ^[1][6].
• Pale, cold, or clammy skin, and signs of dehydration or low blood sugar, known as hypoglycemia ^[7].
• Dizziness, faintness, or low blood pressure ^[1].

Emergency Action: If you see these signs, or if your child cannot retain their oral medication due to vomiting, do not delay.

1. Inject immediately: Administer the emergency IM hydrocortisone injection ^[1].
2. Call for help: Call emergency services (e.g., 911) right after injecting ^[5]. Tell them your child has adrenal insufficiency and is having an adrenal crisis.