Table 2 Clinical and biochemical features of suspected CIRCI at various age and suggested management approach

Neonatal age

(No clear definition/ evidence about CIRCI)

 Asphyxiated newborns

Preterm newborns

Hemodynamic instability

Increasing need for catecholamine administration

Increasing risk for heart dysfunction

Yes, low dose ACTH test

- Random cortisol levels < 15 mcg/dl

- Total stimulated cortisol levels after ACTH administration < 17 mcg/dl

Hydrocortisone 50 mg/m2/day or 1 mg/kg every 8 h

Careful evaluation of patients susceptible to hydrocortisone treatment because of the risk of neurodevelopmental and gastrointestinal adverse effect

Pediatric age

 Septic shock

Fluid unresponsive shock, vasopressor-dependent shock, hypoglycemia

Yes, high dose ACTH test (250 mcg)

Stimulated cortisol increment < 9 mg/dl over baseline

Hydrocortisone bolus of 100 mg/m2 followed by 25 mg/m2/dose every 6 h without any taper, especially until laboratory results

Consider also treatment with 50 mg/m2/day of hydrocortisone as alternative treatment

Discontinuation of treatment if criteria are not met

 Acute respiratory distress syndrome (ARDS)

Shock, strong dependence/ difficult weaning from mechanical ventilation

Not clarified

Not clarified

Corticosteroids are not recommended as routine therapy

Consider methylprednisolone at a dose of 1 mg/kg/day if ARDS and a PaO2/FiO2 < 200 within the first 6 days of illness with slow tapering

 Meningococcal disease

Fluid unresponsive shock, vasopressor-dependent shock, hypoglycemia

Yes, high dose ACTH test (250 mcg)

Stimulated cortisol increment < 9 mg/dl over baseline

Early Hydrocortisone bolus of 100 mg/m2 followed by 25 mg/m2/dose every 6 h without any taper, especially until laboratory results

 Major trauma

Severe burns

Uncontrolled inflammation, vasopressor dependency

Not clarified

Not clarified

Steroid supplementation is not recommended because of the absence of improvement in short-term mortality