CAH Infant Hydrocortisone Dosing Tool
Source: Dabas A, et al. Management of Infants with Congenital Adrenal Hyperplasia. Indian Pediatrics 2020;57:159–164. (Delhi Pediatric Endocrinology Newborn Screening Group consensus.)
Scope: classical CAH (21-hydroxylase deficiency — SW or SV) from newborn period through early childhood. Not for non-classical CAH, post-pubertal, or adult patients.
STEP 1 — Confirm the indication
Use this dosing for:
- Newborn / infant / child with classical CAH (salt-wasting OR simple-virilizing).
- Diagnosis confirmed on 17-OHP ± genetics; gender assignment counselling done where relevant.
Do NOT use this skill for:
- Non-classical CAH (different dosing, often no GC needed).
- Post-pubertal or adult patients (longer-acting agents become appropriate).
- Adrenal crisis management — use [[cah-adrenal-crisis-protocol]].
STEP 2 — Choose the agent (and what to avoid)
| Agent |
Use in infants/young children? |
| Hydrocortisone (oral tablet) |
First-line. Short half-life mimics physiological cortisol rhythm. |
| Prednisolone |
Avoid in young children — overdosing risk, poor 17-OHP suppression, shorter adult height. Acceptable post-puberty. |
| Dexamethasone |
Avoid in young children — too potent, growth suppression. Acceptable in adults. |
| Modified / extended-release hydrocortisone |
Not advisable in paediatrics. |
| Cortisone acetate |
Not recommended (variable conversion). |
STEP 3 — Calculate the daily dose
Physiological replacement dose: 10–15 mg/m²/day of oral hydrocortisone.
- Endogenous cortisol production rate ≈ 5.7–7.4 mg/m²/day; the 10–15 mg/m²/day target accounts for first-pass metabolism and bioavailability (~94%).
- Stay within this range. Higher chronic doses → Cushingoid features, growth failure. Lower doses → virilization, accelerated bone age.
Body surface area (BSA) — Mosteller formula:
BSA (m²) = √[ (Height in cm × Weight in kg) / 3600 ]
Worked example:
A 6-month-old, weight 7 kg, length 65 cm:
- BSA = √(65 × 7 / 3600) = √0.126 = 0.355 m²
- Daily dose = 0.355 × 12 mg/m² (mid-range) ≈ 4.3 mg/day
STEP 4 — Split into a thrice-daily schedule
- Three divided doses per day. Twice-daily achieves normal serum cortisol in only ~15% of patients vs ~60% with TDS.
- Morning dose: as early as possible (matches circadian rhythm).
- Do NOT delay the evening dose till bedtime — it does not improve morning 17-OHP suppression.
Suggested split (for a TDD of ~4.5 mg):
| Time |
Dose |
| Early morning (on waking) |
~1.5 mg (largest or equal share) |
| Mid-day / lunch |
~1.5 mg |
| Early evening |
~1.5 mg |
Some clinicians give a slightly larger morning dose (e.g. 40 / 30 / 30 split); evenly divided is also acceptable.
STEP 5 — Prepare and administer correctly
- Use tablet form. Crush the tablet and mix with milk or liquid as a fresh preparation immediately before each dose.
- Do NOT pre-dissolve or pre-suspend hydrocortisone in liquid for later use — drug delivery becomes uneven.
- Oral hydrocortisone has ~94% bioavailability; no need for an IV route in stable outpatients.
STEP 6 — Build in stress-dose rules and a disease card
Every CAH infant/child must have:
- Sick-day rule prescription (see [[cah-adrenal-crisis-protocol]] for details):
- Minor illness (URI, mild fever, mild diarrhoea): double oral hydrocortisone.
- Moderate–severe illness (vomiting, fever > 38.5 °C, lethargy, dehydration, surgery, trauma): 3–5× oral or switch to IV.
- Disease/identification card to carry at all times (school, travel, picnic):
- Name, DOB, gender, parent contact, diagnosis "Congenital Adrenal Hyperplasia", emergency steroid instructions, treating doctor.
STEP 7 — Plan monitoring at every visit
Clinical (every visit): weight, length/height, BP, genital exam, signs of virilization, skin pigmentation, Cushingoid features.
Biochemical:
- First 3 months: monthly serum electrolytes; baseline 17-OHP recorded.
- 3–12 months: 3-monthly electrolytes + 17-OHP (sample before the morning HC dose).
- 12–30 months: 4-monthly electrolytes + 17-OHP; bone age annually after 24 months.
- Optional adjuncts: androstenedione, total testosterone, ACTH, plasma renin activity, aldosterone:renin ratio.
Targets:
- 17-OHP: 5–10 ng/mL (do NOT push to age-appropriate normal — implies over-treatment).
- Total testosterone (>6 months, pre-puberty): < 20 ng/dL.
- Normal growth velocity, normal BP, no progressive virilization, no Cushingoid features.
STEP 8 — Adjust the dose
| Pattern |
Likely problem |
Action |
| Growth spurt + accelerated bone age + virilization signs |
Under-treatment |
↑ HC dose (stay ≤ 15 mg/m²/day; rule out missed doses, poor preparation) |
| Weight gain, Cushingoid features, poor growth velocity, hypertension |
Over-treatment |
↓ HC dose toward 10 mg/m²/day |
| Persistently high 17-OHP but good growth + no virilization |
Acceptable — do NOT chase normal 17-OHP |
No change |
Adjust by ~10–20% at a time and re-check in 4–6 weeks.
Quick reference card
- Drug: Oral hydrocortisone tablet (crushed, fresh in milk).
- Dose: 10–15 mg/m²/day.
- Schedule: 3 divided doses; morning as early as possible.
- Avoid in young children: prednisolone, dexamethasone, modified-release HC.
- Add: fludrocortisone (all classical CAH) + salt 1–3 g/day (SW first year).
- Always: sick-day plan + disease card.
- Monitor: 17-OHP target 5–10 ng/mL, growth velocity, bone age, BP, electrolytes.
1---2name: cah-infant-hydrocortisone-dosing3description: CAH Infant Hydrocortisone Dosing Tool4---56# CAH Infant Hydrocortisone Dosing Tool78**Source:** Dabas A, et al. Management of Infants with Congenital Adrenal Hyperplasia. *Indian Pediatrics* 2020;57:159–164. (Delhi Pediatric Endocrinology Newborn Screening Group consensus.)910Scope: classical CAH (21-hydroxylase deficiency — SW or SV) from newborn period through early childhood. Not for non-classical CAH, post-pubertal, or adult patients.1112---1314## STEP 1 — Confirm the indication1516Use this dosing for:1718- Newborn / infant / child with **classical CAH** (salt-wasting OR simple-virilizing).19- Diagnosis confirmed on 17-OHP ± genetics; gender assignment counselling done where relevant.2021Do **NOT** use this skill for:2223- Non-classical CAH (different dosing, often no GC needed).24- Post-pubertal or adult patients (longer-acting agents become appropriate).25- Adrenal crisis management — use [[cah-adrenal-crisis-protocol]].2627---2829## STEP 2 — Choose the agent (and what to avoid)3031| Agent | Use in infants/young children? |32|---|---|33| **Hydrocortisone (oral tablet)** | **First-line.** Short half-life mimics physiological cortisol rhythm. |34| Prednisolone | **Avoid** in young children — overdosing risk, poor 17-OHP suppression, shorter adult height. Acceptable post-puberty. |35| Dexamethasone | **Avoid** in young children — too potent, growth suppression. Acceptable in adults. |36| Modified / extended-release hydrocortisone | **Not advisable** in paediatrics. |37| Cortisone acetate | Not recommended (variable conversion). |3839---4041## STEP 3 — Calculate the daily dose4243**Physiological replacement dose: 10–15 mg/m²/day of oral hydrocortisone.**4445- Endogenous cortisol production rate ≈ 5.7–7.4 mg/m²/day; the 10–15 mg/m²/day target accounts for first-pass metabolism and bioavailability (~94%).46- Stay within this range. Higher chronic doses → Cushingoid features, growth failure. Lower doses → virilization, accelerated bone age.4748**Body surface area (BSA) — Mosteller formula:**4950> BSA (m²) = √[ (Height in cm × Weight in kg) / 3600 ]5152**Worked example:**53A 6-month-old, weight 7 kg, length 65 cm:54- BSA = √(65 × 7 / 3600) = √0.126 = **0.355 m²**55- Daily dose = 0.355 × 12 mg/m² (mid-range) ≈ **4.3 mg/day**5657---5859## STEP 4 — Split into a thrice-daily schedule6061- **Three divided doses per day.** Twice-daily achieves normal serum cortisol in only ~15% of patients vs ~60% with TDS.62- **Morning dose: as early as possible** (matches circadian rhythm).63- Do **NOT** delay the evening dose till bedtime — it does not improve morning 17-OHP suppression.6465**Suggested split (for a TDD of ~4.5 mg):**6667| Time | Dose |68|---|---|69| Early morning (on waking) | ~1.5 mg (largest or equal share) |70| Mid-day / lunch | ~1.5 mg |71| Early evening | ~1.5 mg |7273Some clinicians give a slightly larger morning dose (e.g. 40 / 30 / 30 split); evenly divided is also acceptable.7475---7677## STEP 5 — Prepare and administer correctly7879- Use **tablet form**. Crush the tablet and mix with milk or liquid as a **fresh preparation immediately before each dose**.80- Do **NOT** pre-dissolve or pre-suspend hydrocortisone in liquid for later use — drug delivery becomes uneven.81- Oral hydrocortisone has ~94% bioavailability; no need for an IV route in stable outpatients.8283---8485## STEP 6 — Build in stress-dose rules and a disease card8687Every CAH infant/child must have:88891. **Sick-day rule prescription** (see [[cah-adrenal-crisis-protocol]] for details):90 - Minor illness (URI, mild fever, mild diarrhoea): **double** oral hydrocortisone.91 - Moderate–severe illness (vomiting, fever > 38.5 °C, lethargy, dehydration, surgery, trauma): **3–5×** oral or switch to IV.922. **Disease/identification card** to carry at all times (school, travel, picnic):93 - Name, DOB, gender, parent contact, diagnosis "Congenital Adrenal Hyperplasia", emergency steroid instructions, treating doctor.9495---9697## STEP 7 — Plan monitoring at every visit9899Clinical (every visit): weight, length/height, BP, genital exam, signs of virilization, skin pigmentation, Cushingoid features.100101Biochemical:102- First 3 months: monthly serum electrolytes; baseline 17-OHP recorded.103- 3–12 months: 3-monthly electrolytes + 17-OHP (sample **before** the morning HC dose).104- 12–30 months: 4-monthly electrolytes + 17-OHP; bone age annually after 24 months.105- Optional adjuncts: androstenedione, total testosterone, ACTH, plasma renin activity, aldosterone:renin ratio.106107**Targets:**108- 17-OHP: 5–10 ng/mL (do NOT push to age-appropriate normal — implies over-treatment).109- Total testosterone (>6 months, pre-puberty): < 20 ng/dL.110- Normal growth velocity, normal BP, no progressive virilization, no Cushingoid features.111112---113114## STEP 8 — Adjust the dose115116| Pattern | Likely problem | Action |117|---|---|---|118| Growth spurt + accelerated bone age + virilization signs | **Under-treatment** | ↑ HC dose (stay ≤ 15 mg/m²/day; rule out missed doses, poor preparation) |119| Weight gain, Cushingoid features, poor growth velocity, hypertension | **Over-treatment** | ↓ HC dose toward 10 mg/m²/day |120| Persistently high 17-OHP but good growth + no virilization | Acceptable — do NOT chase normal 17-OHP | No change |121122Adjust by ~10–20% at a time and re-check in 4–6 weeks.123124---125126## Quick reference card127128- **Drug:** Oral hydrocortisone tablet (crushed, fresh in milk).129- **Dose:** 10–15 mg/m²/day.130- **Schedule:** 3 divided doses; morning as early as possible.131- **Avoid in young children:** prednisolone, dexamethasone, modified-release HC.132- **Add:** fludrocortisone (all classical CAH) + salt 1–3 g/day (SW first year).133- **Always:** sick-day plan + disease card.134- **Monitor:** 17-OHP target 5–10 ng/mL, growth velocity, bone age, BP, electrolytes.
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