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Evaluating the Low-Dose ACTH Stimulation Test in Neonates: Ideal Times for Cortisol Measurement
Robyn LeDrew1, Erika Bariciak2,3, Richard Webster4
1Department of Pediatrics, Division of Endocrinology, Saint John Regional Hospital, Saint John, New Brunswic, Canada.
Context:
Low-dose adrenocorticotropic hormone stimulation testing (LDST) can be used to diagnose central adrenal insufficiency. However, uncertainty remains over optimal times to draw serum cortisol levels.
Objective:
To determine optimal times to draw serum cortisol levels for the LDST in neonates.
Design:
A retrospective chart review of LDSTs performed on neonates from January 1, 2009 to September 30, 2017.
Setting:
Children's Hospital of Eastern Ontario (CHEO), a tertiary-care outborn pediatric center.
Patients:
Forty-nine patients were included: 23 (46.9%) born at term, 12 (24.5%) born very preterm to late preterm, and 14 (28.6%) born extremely preterm.
Intervention:
Cortisol levels were drawn at baseline and 15, 30, and 60 minutes following administration of Cortrosyn 1 mcg/kg (maximum dose 1 mcg).
Main Outcome Measure:
Timing of peak cortisol level and marginal value of drawing a second and third cortisol sample at 15, 30, or 60 minutes was determined.
Results:
Cortisol peaked at 15-, 30-, and 60-minute sampling times for 4%, 27%, and 69% of patients, respectively. The probability that a failed LDST changes to a pass by adding a 15- or 30-minute sample to the superior 60 minute sample is 5.6% (1% to 25.8%) and 11% (3.1% to 32.6%), respectively, for a cortisol pass threshold of 18.1mcg/dL (500 nmol/L).
Conclusions:
In contrast to studies of older children, we found that the majority of neonatal LDST cortisol peaks occurred at the 60-minute sampling time with the addition of a 30-minute sample providing substantial benefit. It is questionable if a 15-minute sample provides any benefit, making a case to revise LDST protocols to sample cortisol later for neonates.
