10ng/dl is low.  Very low.  I am surprised that that is what it read 4 hours after her morning dose.  But then I would wonder exactly how long the Doctor expects that morning dose to last.  if it is until 3pm onwards then it may be ok.  If it is supposed to be another dose at 12.00noon, then I would be dropping the morning dose.    It all depends how long the Doctor expects that dose to last really.  Could be 12 hours on twice daily dosing, 8 hours on three times a day and 4-6 on four times a day dosing.   I assume that as long as your consistent with where you take the bloods and where you give the med’s though, and she has been growing well on her clincial assessments (within normal limits for a child of that age that is), then usually I’d say it shouldn’t matter where the bloods are done.  (However later down you may discover why I don’t like to take the bloods after the dose.)  If you change the timing, you get different results, and I would have thought that changes can occur from hour to hour after the med’s are given.  So I would make sure you always get the bloods done at the same time to be consistent and pick up any problems anyway. 

I would to take them before the med’s are given because I want to know what the levels have been doing for the whole of the dose period---and what the bottom line is at the end of the last dose.  Thing is when you do it at the other end and after med’s are given, you can never be sure about over treatment for sure as really they tend to put the low 17 OHP down to the fact that you have just given the med’s.  Since some children metabolise cortisol faster than others, there is never anyway of knowing really if the dose was too high or too low without checking at the end of the dosing period--meaning, checking right at the point before the next dose is due.  That would show you for certain that a dose was too high or too low.  The other way around means having to go months and months monitoring growth and height to make sure that the low readings ARE really because you have given the med’s and that the child can grow ok on that dose.  

I presume that the smaller the levels of 17 OHP, the more quickly that cortisol levels can kn0ock them back.  Large elevations seem to take a long time.  I think when Ashley had levels of 426* nmol/L (over 15’000ng/dl) they had to do it slowly on a day to day basis.  To try to rectify such a high level of 17 OHP within a day or so and bring levels back to normal would probably need to high a dose of hydrocortisone than a person can cope with.  I mean they had to give him one thrid more per day than his normal dose to get that level back to normal ranges and it took some 6 weeks.  However, if say for that brief period between 3-4am and 7-8am they make large amounts that measure something like 50-60nmol/L then that is awkaward really, because I imagine you would need a double dose of cortisol say to sought it out, but you just don’t know--because the child is not ill, and therefore as each day goes by, I feel that it possibly may accumulate.  The excess left over everyday adds to it kind of thing.  Well thats what I imagine happens.  After a while it would snowball because the Hypothalmus is sensing that and of course needs to rectify the situation and as THAT gets higher, IT wants to secrete more amounts of ACTH which in turn would probably really I imagine lead to a higher amount escaping everyday.  Well that is how imagine what happens when a child outgrows their dose.  It can take weeks or months to get to where Ashley was after a growth spurt and needing a larger dose but not having that fact picked up.  

I guess it is possible for there to be a high level accumulate between 3-7am and for that to be stamped out because the morning dose is too large though.  So taking bloods after the dose is also confused the issue, because unless you take the blood before the dose, in essence you don’t really pick that fact up.  You just never know whether the 10pm dose covered them in other words.

Cheers

Anne-Marie