If the pre-school will not administer the solu-cortef, then will they call an ambulance?  Will the pre-school keep the solu-cortef and meds at the school?  Will they give the oral meds? Surely they have kids there on some kind of meds? What is the policy for the other kids? Is this just a few hours or all day? What about the 7am and 3pm doses?  Do you give it or does the school? Do they have extra cortef pills there? Tylenol and motrin? Therometer?  Field trips... what about the meds? Crying is not physcially stress..or tantums.  Emotional stress is not a reason to be too concerned. I have never seen my kids go into an adrenal crisis from not getting their way (and he is seven years old now). But I do remember at age 3 or so, at Sunday School... don't go mommy, I need you.

How long will it take the ambulance? Can ambulance medic  give the solu-cortef?-How long is it to the hospital? Surely the hospital can give solu-cortef and IVs. But the hospital ER staff will not act quickly without instructions. Do you have written instructions at the daycare with the ped endo signature so that ER or hospital can act without calling the ped endo?

Fever, illness, vomiting, diahrea, injury is very serious for a CAH child. A fever is an emergency!! No, 101 (f) fever may not be a high fever but the daycare lawyers and doctors (this was at the Pentagon Pre-school before it was closed down from the attack) didn't want to chance it. And it is a HIGH fever for an infant or child under 3 years of age with or without CAH. And it was too much to argue what is a high fever and what does a fever mean??? Doctors really don't know. What if the staff wasn't reading the therometer right and it is actually higher than what the therometer is reading? So this may be over board but I didn't want to chance it.  Any child over 2 years of age 100 mg of solu-cortef is not too much during a stress because a normal child would produce 4 to 10 times more cortef. You can not overdose but if you don't give enough the child (your little toddler... or any CAH or addisons person at any age) will die. Also the ambulance is need to get the IV fluids going as soon as possible. Yes.. maybe a mild illness you can just give the extra oral fluids and extra cortef but if she/he was mildly ill ... she/he would be at home with you. My daughter died from a fever and adrenal crisis at age 2.  So don't chance a fever!! Don't try to treat it over the phone. Go to the ER (call the ambulance if the fever will not go down). The fever should go down after tylenol with 30 or 45 minutes. The child should not be left sleeping. Wake him/her for fluids and meds... every 4 to 6 hours. Cortef is short lasting. During a fever .. or severe illness the solu-cortef needs to be giving every 6 hours and not 8 hours!!  Also the ER can keep you the waiting room too long!! Do you know how to give the solu-cortef??

Not taking any chances here is a letter than I had the doctor write a very strong letter for the ER(the daycare had to give this to the ER).  Here it is... copy this and take it to the ped endo to sign... and take to the school (they should give it to the ER doctors). IF.. And hopefully IF will never happend but what if??

RE: Stephen Preston

DOB: 12/22/93

To Whom It May Concern:

 

Stephen Preston is a young man with congenital adrenal hyperplasia. Due to this condition he is adrenally insufficient. His regular medications are Cortef and Florinef

In the event of a high fever; that is 101 degrees F orally or greater, severe lethargy, or recurrent vomiting/diarrhea, or injury, Stephen needs immediate attention. He should receive Solu-Cortef 100 mg IM or IV as well as IV hydration. The IV hydration should initially include normal saline at 10 cc per kg IV bolus, and then D5-D10 half normal saline at approximately 1 and 1/2 maintenance rate. In the event of severe hypoglycemia or hyperkalemia, a 10% dextrose solution may be beneficial. Any underlying condition should be treated. Obviously sepsis is a major concern in a young child with a high fever and hypertension. The IV hydration should be maintained for approximately 48 hours after the initial onset of the illness. As the illness improves, the hydrocortisone can be decreased by about 25% every 24 hours until maintenance dose is maintained. Usually by 48-72 hours the child can return to his maintenance Cortef and Florinef dosages. Blood pressure should be monitored as well as temperature and electrolytes. Because children with congenital adrenal hyperplasia can deteriorate quickly. Stephen will need to receive immediate attention.

If there is any questions about appropriate treatment or management for Stephen Preston, please do not hesitate to call Northern Virginia Endocrinologist at 703 849-4440. I can also be reached on my beeper, 703 550-4440. Please feel free to call.

Sincerely

Kathleen M. Link, MD