A new JAMA Network Open study reports that in children and adolescents without glucocorticoid (GC) deficiency, circulating cortisol levels were higher during acute illnesses compared to when they were otherwise healthy. In particular, cortisol levels also varied according to different types of acute illness.
Study: Cortisol levels during acute diseases in children and adolescents. Image credit: Axel_Kock / Shutterstock.com
Fund
Acute illnesses can have a significant impact on a person’s well-being and can even threaten their survival. These acute physical events usually initiate a physiological stress response involving the hypothalamic-pituitary-adrenal axis to achieve homeostasis.
This response to acute stress leads to a rapid increase in cortisol secretion, which affects intravascular blood volume, glucose metabolism, and cardiovascular function. This fight or flight response is altered in individuals with a glucocorticoid (GC) deficiency, thus increasing the risk of an acute adrenal crisis. Thus, researchers have hypothesized that GC replacement therapy could induce a reaction similar to the increase in cortisol release that is normally triggered by stress.
Standard clinical protocols for “stress” or “sick day” doses in the prevention of an adrenal crisis involve double or triple GC replacement doses. However, there is still limited evidence to support this approach, as well as what doses would be appropriate for this type of treatment in both children and adolescents.
About the study
The current systematic review has been carried out in accordance with the PRISMA (Reporting Items for Systematic Reviews and Meta-analyzes) guidelines. The Advanced Health Database Search (HDAS) platform was used for the search, which included CINAHL, Cochrane Database of Systematic Reviews, Cochrane Library, Embase, and MEDLINE databases.
In total, 15 hospital studies were selected comprising 864 participants for the study. Of these, 14 were prospective observational studies and one was part of a clinical trial. Patients treated with etomidate were excluded from a study.
Study results
None of the reviewed studies reported febrile illness, vomiting, viral infections, urinary tract infections (UTIs), otitis media, and upper or lower respiratory infections (URTI / LRTI). Patients were classified according to the severity of the acute illness. Each subgroup consisted of a small number of studies except sepsis.
In the five studies that included control groups, cortisol levels within the blood were acquired between 8 and 9 p.m. These measures were evaluated primarily by non-isotopic immunoassays, including chemiluminescence, enzyme-linked immunosorbent assay (ELISA), and radioimmunoassay.
Higher cortisol levels were observed in all groups compared with controls, with higher levels more than four times detected among those with bacterial meningitis compared with controls. The lowest cortisol levels were recorded in patients with mild to moderate bronchiolitis.
In the subgroup with sepsis, among those with shock, lower cortisol levels were detected compared to those without shock. It should be noted that survivors showed equivalent cortisol levels compared to non-survivors.
Meanwhile, higher cortisol levels were detected in patients with severe gastroenteritis who needed rehydration of intravenous fluids compared with those with bronchiolitis, sepsis, or another critical illness. However, cortisol levels in the subgroups combined with noncritical disease were not significantly different from those of patients with critical illness, including sepsis.
Conclusions
The results of the study indicate that the intact hypothalamic-pituitary-adrenal axes of children and adolescents resulted in higher circulating cortisol levels during episodes of acute disease compared to controls. This effect varied according to the types of acute illnesses.
Extensive studies are needed in the future to determine whether equivalent cortisol levels are essential when obtained from exogenous GC treatment among children and adolescents with GC deficiency who experienced episodes of acute disease.