Altered Adrenal Function
Kathy Clark
RN CS MSN Pediatric Nurse Practitioner   

The adrenal gland produces an array of hormones, some of which are also synthesized elsewhere in the body. Cortisol and aldosterone are essential to life, Under the action of the adrenocorticotrophic hormone (ACTH) produced by the pituitary gland, the adrenal cortex releases the cortisol continuously, but increases the production in times of physical or emotional stress.s Disorders that prevent the production or the release of these hormones present some of the most devastating and dangerous endocrine problems seen in children.

Because 90% of adrenocortical function can be lost before symptoms become apparent, children with adrenal dysfunction may not appear ill; however they are at great risk of severe complications when they are sick. The marginally adequate adrenal reserves suddenly become inadequate to meet the rising demand for cortisol during times of stress.

Children with acute adrenal insufficiency may present in a condition that quickly becomes life-threatening. An adrenal crisis occurs when there is severe depletion of cortisol due to either an increased need for cortisol or a decreased availability of cortisol.

Adrenal crisis precipitates gastrointestinal symptoms such as nausea, vomiting, diarrhea that may be accompanied by signs of central nervous system involvement (convulsions, stupor, coma). As the child's condition deteriorates, the pulse becomes rapid and weak, the blood pressure declines, and respiration become shallow, and the skin becomes cold, clammy, and cyanotic. These signs herald circulatory collapse, which is fatal when the condition is untreated.

Diagnostic Studies
When adrenal failure is suspected, measurements of the serum cortisol, glucose, and electrolyte levels are obtained immediately, because there children are at risk for shock and vascular collapse. If the child is already in shock, the diagnosis may be made using clinical manifestations alone, and the treatment with replacement fluid and hormones begins immediately. Laboratory values are not consistent, but, hypoglycemia, hyponatremia, and hyperkalemia are often evident in primary adrenocortical insufficiency. The plasma concentration of cortisol is low in a early morning specimen or when the child is stressed.

Monitoring Physical Signs
When the child is hospitalized, the nurse monitors the blood pressure and intake and output closely. Accurate and frequent blood pressure measurement is important because hypotension indicates inadequate hormone replacement and electrolyte imbalance. In contrast hypertension may signal excessive replacement. Hydration is assessed by carefully recording intake and output and by observation of skin turger. Level of consciousness should be assessed regularly while the child is ill.

Parent Teaching In times of stress, the normal adrenal gland increases it production of cortisol, and this response must be mimicked in the child with the adrenal insufficiency. A rule of thumb approach is that when a child has a minor illness the cortisol dose should be doubled at at each administration until the child is well. A more serious illness that keeps the child home from school requires a tripling of the dose. Vomiting, accidents, severe fatigue, surgery, and other highly stressful situations produce immediate and intense needs that can be best met with and injection of hydrocortisone. Parents must be educated in the administration of the intramuscular injections. The are instructed to give the injection immediately when the need is recognized, before they call the physician or go the the emergency department.

Most parents are reluctant to give their child intramuscular injections even when they have been taught the technique. By hesitating to provide this injection to their child, the child becomes more ill and in risk of shock and death. Parents who witness the miraculous recovery of an almost comatose child after and injection of cortisol will never hesitate again. Giving an unnecessary dose of cortisol has little impact on the health of a child, but failing to give the needed dose may lead to a fatal outcome.