Firstly, we are talking a little more than simply double dosing---we are talking about the fact that a child with CAH has technically gone without a dose of cortisol for 16 hours or longer if you discover it much later.  When there is a fall in cortisol in the blood (which would occur certainly after the 6-8 hours dose) then that is when androgen is made.  Forget or be late with one or two doses in a week and you are seeing a problem of escaped andrgen that should not be there and especially in a little girl.  I won't explain why, becuase I think most people are aware of the detrimental effects of those- even on brief level.  When children grow out of a dose their hormone levels escape.  We talked about stomping as a way of overcoming the escaped homrones before we resume on the normal course of the newly adjusted dose.  A forgotten dose in effect has a similar effect that I'm sure most people will realise is going to impossible for one dose of cortisol to"fix."  Normal temporary steroid users don't need to double dose because if they miss one out of a two week course, it is no big deal---they arn't going to have an adrenal crisis if they so happened to be mentally stressed at the time---much less produce large amounts of androgens or suffer the ill effects of such.  This is what we are discussing here---emulating an adrenal gland---not treating a temporary inflammatory condition that needs a short dose of steroids.  That is why I say that I feel that the rationale is all wrong for our children because at a time when their own body would be making a slightly larger amount to help it balance things before resuming the normal doses makes a great deal of sense.  Especially so on the days when we have forgotten the childs dose and they have had a stressful day---the reason?  Because mental stress as well as physical stress call upon a demand for more cortisol anyway.  Heaven help the child who has the combination of "being sick" and Mom forgetting a dose too!  I was more concerned with the fact that understanding the normal bio feedback between the pituitary gland and the adrenal gland as I do now that this in itself was enough of a reason for me to double the dose.  I believe that deficits like that build up and could effect the next lot of blood tests in themselves---especially if the blood tests are a few days later---and half the time my childs doctor says not to double dose my child if I forget because it will effect his blood tests!!

So in trying to do what is right for my boy, I beleive that a double dose is exactly what he should receive in the above scenario as his own adrenals cannot do that for him.  That is the whole crux of this matter.  Not allowing their levels to leave them vulnerable in the first place and understanding when you need to be doubling the HCT and especially when your child is on a minimal dose to allow for good healthy growth.

JH