How is CAH stress dosing managed for fever in children?

For children with classic congenital adrenal hyperplasia (CAH), standard Endocrine Society guidelines state that a fever typically over 101°F (38.5°C) requires stress dosing ^[1]. When a child has a significant fever, their body is under physical stress and needs extra cortisol to prevent a life-threatening adrenal crisis (a severe, sudden lack of cortisol that can cause shock and be fatal) ^[2]. The standard recommendation is usually doubling the oral dose of hydrocortisone, but you must always follow the exact instructions in your child’s written sick-day plan ^[2].

Managing a Fever (Sick Day Rules)

When your child’s temperature reaches the threshold—typically 101°F (38.5°C)—infections are placing stress on their body ^[3]. Here is how to manage it:

• Increase the Dose: Follow your child’s written sick-day plan. Usually, this means doubling (and sometimes tripling) their normal daily hydrocortisone dose ^[2].
• Give Every 8 Hours: Because the body burns through cortisol faster when sick, the stress dose is usually divided into three doses given every 8 hours ^[2].
• Use Fever Reducers Wisely: Treat the underlying illness to make your child comfortable. Acetaminophen is standard. Ibuprofen can also be used, but avoid ibuprofen if your child is dehydrated or vomiting. Remember: reducing the fever does not stop the body’s stress. Do not stop stress dosing just because the fever medicine temporarily brought the temperature down.
• Hydrate Constantly: Keep your child well-hydrated. Offer fluids frequently. Dehydration happens fast with a fever and increases the risk of a crisis.
• Continue Other Meds: If your child takes fludrocortisone, continue it exactly as prescribed unless your endocrinologist tells you otherwise.

Note for Infants: A rectal temperature of 100.4°F (38°C) or higher in an infant under 3 months old requires immediate emergency medical evaluation, not just stress dosing ^[4].

When to Stop Stress Dosing

How long do you continue the doubled dose? You should follow your written plan, but generally, stress dosing continues until the fever has completely broken (without the help of fever reducers) and your child is clinically recovered, eating, and drinking normally.

Medical Emergencies: Vomiting and Adrenal Crisis

If your child is vomiting or cannot keep their oral hydrocortisone down, pills will not work ^[5]. This is a medical emergency.

Immediate Action for Vomiting or Severe Illness:

1. Give the Emergency Injection: Immediately administer your child’s prescribed emergency intramuscular (IM) injection (a shot given deep into the muscle, often called Solu-Cortef) ^[2][6]. Do not wait for symptoms of a crisis to appear.
2. Call Emergency Services (911): After giving the injection, seek emergency medical care immediately ^[2].

Signs of an Adrenal Crisis:
An adrenal crisis can happen quickly if stress dosing is missed or not absorbed. Watch for:

• Unusual or severe weakness, fatigue, or extreme sleepiness ^[7]
• Repeated vomiting or severe abdominal pain ^[2][8]
• Pallor (pale skin) or fainting
• Signs of hypoglycemia (low blood sugar), such as jitteriness or seizures ^[7][3]

Always keep an unexpired emergency injection kit at home, at school, and while traveling. Ensure all caregivers know how and when to use it.