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Urinary free cortisol values in children under stress
Insights
Current glucocorticoid dose recommendations for stressed children may be insufficient. Studies show urinary free cortisol (UFC) increases significantly during severe illness or trauma, potentially exceeding current dosage guidelines for pediatric adrenocortical insufficiency.
Area of Science:
- Pediatric Endocrinology
- Critical Care Medicine
- Biochemistry
Background:
- Children with adrenocortical insufficiency typically require 3-5x glucocorticoid dose increases during stress.
- The accuracy of these recommendations during significant physiological stress is not well-established.
- Urinary free cortisol (UFC) is a key indicator of endogenous glucocorticoid production.
Purpose of the Study:
- To evaluate if current glucocorticoid replacement guidelines reflect actual UFC changes in stressed children.
- To assess UFC excretion patterns in pediatric patients experiencing critical illness, surgery, or infection.
Main Methods:
- Measured 24-hour UFC excretion in 78 pediatric patients admitted for severe illness or surgery.
- Re-evaluated 43 patients post-recovery.
- Compared UFC levels with 127 healthy children and analyzed correlations with age, creatinine, and body surface area.
Main Results:
- UFC levels correlated positively with age, but UFC per surface area was age-independent.
- Greatest UFC increases per square meter surface area were observed in children undergoing cardiothoracic surgery and those with multiple trauma.
- Bacterial infections led to significantly higher UFC increases than viral infections.
Conclusions:
- Current 3-5x glucocorticoid dose increase recommendations may underestimate needs for children with major surgery, trauma, or severe bacterial infections.
- Further production rate studies are necessary to refine stress-related glucocorticoid dosing in pediatric patients.
- UFC monitoring offers insights into the physiological stress response in children.
Abstract:
Children with adrenocortical insufficiency are commonly instructed to increase their baseline glucocorticoid replacement doses by three to five times during periods of stress such as surgery or febrille illness. We conducted this to determine whether these recommendations reflect the actual change in urinary free cortisol (UFC) output during stress. The 24-hour UFC excretion was determined in 78 children who were admitted to a general pediatric department or intensive care unit with temperature > 38.7 degrees C, after major surgery, or during status epilepticus; we reevaluated 43 of the patients 2 weeks after recovery. In addition, the 24-hour UFC levels were determined in 127 healthy children aged 1.8 to 17 years. The UFC level positively correlated with age (r = 0.254; p < 0.001). The amount of UFC per gram of creatinine was inversely correlated with age (r = 0.255; p < 0.001). The amount of UFC per surface area was independent of age. The mean change in the level of UFC per square meter surface area was highest among children who had cardiothoracic surgery and those with multiple trauma. The increase in UFC level during bacterial infection was significantly greater than that during viral infection. The current recommendation to increase the dose to three to five times the baseline glucocorticoid dose during times of stress may underestimate the changes in UFC found in some patients with major surgery, trauma, or certain serious bacterial infections. Production rate studies are needed to prove this point.