What Does It Mean When Your Child Has Secondary Adrenal Insufficiency?

pituitary gland in the brain

Stress is regulated by a hormone called cortisol — and it’s vital to your child’s health and wellbeing. Stress can happen if your child gets sick with the flu or breaks a bone.

Cortisol is the “stress hormone.” It helps to keep your child’s blood pressure and blood sugar normal and helps the body respond to stress. It is especially important when their body needs to fight an infection or recover from illness or injury.

Some cancers and cancer treatments affect the parts of the body that make cortisol, which can make cortisol levels lower than normal. This can cause a condition called secondary adrenal insufficiency.

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Secondary Adrenal Insufficiency: The Basics

Secondary adrenal insufficiency occurs when your child’s pituitary gland — a small pea-sized organ located at the bottom of the brain — doesn’t make enough of a hormone called adrenocorticotropin (ACTH). If ACTH is low, cortisol levels in the adrenal glands (located above their kidneys) may also decrease or may be absent.

There are two major causes of secondary adrenal insufficiency:

  1. The use of high dose steroid medications (glucocorticoids) for long periods of time. Glucocorticoids are steroid hormones that act like cortisol and send signals to the pituitary gland to make less ACTH.
  2. Diseases or procedures that cause an absence of ACTH. For example, pituitary tumors and the surgery to remove them, radiation therapy to the pituitary gland, and some inflammatory diseases. If ACTH is absent, the adrenal glands won’t make cortisol.

How Is Secondary Adrenal Insufficiency Diagnosed?

Your child’s provider can determine if they have secondary adrenal insufficiency based on the way their body responds when they are given intravenous (IV) Cortrosyn — a synthetic (imitation) form of ACTH.

Before and after the injection, your child’s provider will take a sample of your child’s blood and/or urine. If the cortisol levels in their blood and/or urine don’t increase, your child may have secondary adrenal insufficiency.

What Are The Signs And Symptoms Of Adrenal Insufficiency?

Symptoms of secondary adrenal insufficiency can come on gradually, and it can take a while to diagnose the exact cause, as many of these symptoms are side effects of other cancer treatments. Signs and symptoms of secondary adrenal insufficiency include:

  • Tiredness
  • Depression
  • Diarrhea
  • Weakness
  • Decreased appetite
  • Weight loss
  • Irritability
  • Low blood pressure
  • Nausea or vomiting
  • Stomach pain
  • Low blood sugar

How is Secondary Adrenal Insufficiency Treated?

Secondary adrenal insufficiency is treated with steroid replacement. Your child will take steroids by mouth three times a day. The largest dose is given in the morning, with two smaller doses given mid-afternoon and before bedtime. This dosing will act the same as their body’s normal cortisol levels would throughout the day.

Steroid replacement may only be needed for a few months (if the cause is from high-dose steroids), or it may be life-long (if the cause is from a pituitary tumor).

Regular doses are important in keeping your child healthy. If two or more doses are missed, please contact the Oncology Clinic at 402-955-3950.

What is “Stress Dosing” — And When Does Your Child Need It?

During a time of injury or illness, children with secondary adrenal insufficiency can’t make the cortisol they need to keep them safe. If this happens, a triple dosing of the steroid replacement may be needed to maintain their cortisol levels.

If your child has any of the symptoms below, please call the Oncology Clinic at 402-955-3950 for stress dosing instructions. A provider will instruct you on when to start and stop stress dosing.

Your child may need a stress dose if they:

  • Have a fever higher than 100.4°F
  • Experience a trauma, such as broken bones, head injury, or an auto accident
  • Have a serious medical problem which requires emergency care
  • Have a viral illness that would keep them home from school (mild illnesses, such as a runny nose or cough, do not require stress dosing)
  • Undergo surgery or dental procedures that require sedation or anesthesia (please call the Oncology clinic prior to the procedure for dosing instructions)

If your child requires stress dosing for more than 5 days, do not immediately switch back to normal dosing. Please call the Oncology Clinic at 402-955-3950 for tapered dose instructions.

Adrenal Crisis: Signs, Symptoms, And Treatment

If your child experiences an illness or injury and their symptoms worsen or become more
noticeable, your child may be experiencing an adrenal crisis. An adrenal crisis is a medical emergency and needs treatment right away.

Signs and symptoms of an adrenal crisis include:

  • Confusion
  • Headache
  • Depression
  • Dizziness
  • Lethargy
  • Fatigue
  • Restlessness
  • Weakness
  • Diarrhea
  • Nausea or vomiting
  • Decreased appetite
  • Pale skin
  • Fever
  • Dehydration
  • Decreased urine output
  • Decreased muscle tone

An adrenal crisis may be caused by:

  • Repeated vomiting (more than once)
  • Repeated episodes of diarrhea (more than 3 times in 1 hour)
  • Unconsciousness or seizure
  • Serious trauma

When Do You Need To Give An Emergency Dose Of Solu-Cotef?

If your child is experiencing an adrenal crisis, give the emergency intermuscular (IM), Solu-Cortef, and call the Oncology Clinic at 402-955-3950 and go to the Emergency Department.

If left untreated, an adrenal crisis can be life-threatening.

What To Do Next

For Patients

To make an appointment, contact the Children’s Hospital & Medical Center Hematology/Oncology Program at 402-955-3950.

For Referring Providers

The Physicians’ Priority Line is your 24-hour link to pediatric specialists at Children’s for referrals, emergency and urgent consults, physician-to-physician consults, admissions, and transport services. Call 855-850-KIDS (5437).

Learn more about referring patients.


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