South Australian Neonatal Medication Guidelines

Hydrocortisone
100mg injection, 4mg tablet,
1mg/mL oral mixture*, 1% topical
© Department for Health and Wellbeing, Government of South Australia. All rights reserved.

Note:
This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and facilitate
standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based on a review of
published evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not
sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and
professionally assess the applicability of the relevant guideline to that clinical situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the
patient’s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful
confidential discussion. This includes:
• The use of interpreter services where necessary,
• Advising consumers of their choice and ensuring informed consent is obtained,
• Providing care within scope of practice, meeting all legislative requirements and maintaining standards of
professional conduct, and
• Documenting all care in accordance with mandatory and local requirements

Synonyms
Cortisol

Dose and Indications

Treatment of pressor and volume resistant hypotension
Intravenous

1mg/kg/dose

Doses up 2.5mg/kg/dose have been used for inotrope resistant hypotension.

Gestational Age (weeks) at birth Frequency

< 34 Every 6 to 12 hours

≥ 34 Every 6 to 8 hours
Use for the least possible duration, until stable off inotropes (usually 2 – 5 days).

Refractory Hypoglycaemia
Intravenous, Oral
1 - 2.5mg/kg/dose every 6 hours as required
For oral administration, dose should be rounded to the nearest whole milligram.

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Hydrocortisone
100mg injection, 4mg tablet, 1mg/mL oral mixture*, 1% topical

Surgical stress to cover adrenal suppression in neonates currently on

dexamethasone or previously finished a course of dexamethasone lasting
more than 1 week less than 4 weeks ago
Intravenous
1mg/kg prior to surgery, then 1mg/kg every 6 hours for up to 48 hours

Physiological Replacement in primary adrenal insufficiency

(including Congenital Adrenal Hyperplasia (CAH)) and hypopituitarism
IV/IM/Oral
2
3 – 5mg/m /dose every 8 hours

Seek endocrinology advice when starting treatment. A dose towards the higher end of the
range is often required for CAH.

For oral administration, dose should be rounded to the nearest whole milligram.

Body Surface Area (BSA) Calculation

𝐡𝐞𝐢𝐠𝐡𝐭(𝐜𝐦) × 𝐰𝐞𝐢𝐠𝐡𝐭(𝐤𝐠)
𝐁𝐒𝐀 (𝐦𝟐 ) = �
𝟑𝟔𝟎𝟎

Stress (surgery, acute illness) in primary adrenal insufficiency or

hypopituitarism
Intravenous, Intramuscular
Initial dose: 25mg (standard dose)
st
Subsequent dose: 5mg to 10mg (standard dose) every 6 hours for the 1 24-48 hours of
2
illness then reduce to 10mg/m /dose every 8 hours

Inflammation of skin
Topical
Apply 1% hydrocortisone ointment or cream to the affected area 1 or 2 times a day.

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Hydrocortisone
100mg injection, 4mg tablet, 1mg/mL oral mixture*, 1% topical

Preparation and Administration

Intravenous
There are TWO STEPS to this process.

STEP ONE: Add 2mL of Water for Injection to the vial (100mg) and shake gently to dissolve
(to a total volume of 2mL). The resulting solution contains 50mg/mL hydrocortisone.
The ACT-O-VIAL product is stable for 24 hours stored under refrigeration – check with local
policy about re-accessing vial for the same patient.
STEP TWO: Further dilute 1mL of the 50mg/mL hydrocortisone solution with 9mL of
compatible fluid (to a total volume of 10mL). The resulting solution contains 5mg/mL
hydrocortisone.

Dose 0.5mg 1mg 2.5mg 5mg 7.5mg 10mg

Volume 0.1mL 0.2mL 0.5mL 1mL 1.5mL 2mL

Administer over 3 to 5 minutes.

Oral
Oral tablets

Using a tablet cutter, cut a 4mg tablet in halves or quarters (depending on the dose required).
Crush the portion of the tablet required for the dose, and disperse in 1-2mL of sterile water or
milk for administration to the patient. Discard the remaining portion of the tablet.

> Note: Hydrocortisone is not soluble in water or milk. Inaccurate dosing can occur when a
whole 4mg tablet is dispersed in water, and a proportion of the final volume administered.
First cut the tablet in halves or quarters and disperse the required dose in water/milk as
above.

Oral Mixture
*The 1mg/mL oral mixture is not commercially available however is manufactured at Women’s
& Children’s Health Network Pharmacy.
Dose 0.5mg 1mg 2.5mg 5mg

Volume 0.5mL 1mL 2.5mL 5mL

Doses should be administered during or after a feed to reduce stomach discomfort.

Topical

Apply sparingly. Avoid topical application to large body surface areas since appreciable
absorption may occur resulting in systemic effects.

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Hydrocortisone
100mg injection, 4mg tablet, 1mg/mL oral mixture*, 1% topical

Compatible Fluids
Glucose 5%, glucose 10%, glucose/sodium chloride solutions, sodium chloride 0.9%

Adverse Effects
These occur when hydrocortisone is used at pharmacological doses. The incidence of
adverse effects is related to dose and duration of treatment. Systemic effects may result from
topical treatment.
Common
Adrenal suppression, increased susceptibility to infection, masking of signs of infection,
sodium and water retention, hypertension, hypokalaemia, hyperglycaemia, osteoporosis,
fractures, delayed wound healing, skin atrophy, bruising, hirsutism, growth restriction,
myopathy, muscle wasting, cushingoid appearance, weight gain, cataracts

Monitoring
> blood pressure
> plasma glucose
> signs of infection as per local unit protocol.

Practice Points
> Hydrocortisone in the eye is used under ophthalmology recommendation only.
> Topical hydrocortisone is a mild corticosteroid and is contraindicated in untreated skin
infections.
> When applying topically, avoid contact with eyes.
> Use cautiously in patients with gastrointestinal ulceration, hypertension, hyperglycaemia,
renal impairment or hypothyroidism.
> Phenobarbitone, phenytoin and rifampicin all increase steroid metabolism.
> Frusemide, chlorothiazide, amphotericin B are associated with potassium depletion which
may be exacerbated by hydrocortisone therapy.
> Acute cardiovascular collapse may occur when corticosteroids are abruptly stopped or if
adrenal response is inadequate in periods of stress such as infection, trauma, surgery and
blood loss.
> Hydrocortisone is not routinely recommended for prevention and treatment of chronic lung
1,2
disease due to the current lack of evidence.

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Hydrocortisone
100mg injection, 4mg tablet, 1mg/mL oral mixture*, 1% topical

Steroid equivalents (glucocorticoid activity of oral

or intravenous dose)
Cortisone Acetate 1.25mg
Dexamethasone 0.04mg
Hydrocortisone 1mg
Methylprednisolone 0.2mg
Prednisolone / Prednisone 0.25mg

Steroid equivalents (sodium retaining activity of

oral or intravenous dose)
Cortisone Acetate 1.25mg
Dexamethasone Minimal activity
Hydrocortisone 1mg
Methylprednisolone 2mg
Prednisolone / Prednisone 1.25mg

References

1. American Academy of Paediatrics Committee on fetus & newborn, AAP policy

statement, Postnatal corticosteroids to prevent or treat bronchpulmonary
dysplasia, Paediatrics, October 2010, Vol 126, issue 4

2. Baud O, Maury L, Lebail F et al, Effect of early low-dose hydrocortisone on

survival without bronchopulmonary dysplasia in extremely low preterm infants
(PREMILOC): a double-blind, placebo controlled, multicentre, randomised trial,
Lancet, February 2016; Vol 387:1827-1836

3. Brunton L, Hilal-Dandan R, Knollmann B, Goodman & Gilman’s: The

Pharmacological Basis of Therapeutics, 13e Adrenocorticotrpoic Hormone,
Adrenal Steroids, and the Adrenal Cortex, Table 46-3 ‘Relative Potencies and
Equivalent Doses of Representative Corticosteroids

4. Adrenal crisis and acute adrenal insufficiency, The Royal Children’s Hospital
Melbourne, Clinical Practice Guidelines, 2016

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Hydrocortisone
100mg injection, 4mg tablet, 1mg/mL oral mixture*, 1% topical

Document Ownership & History

Developed by: SA Maternal, Neonatal & Gynaecology Community of Practice
Contact: [email protected]
Endorsed by: SA Health Safety and Quality Strategic Governance Committee
Next review due: 12/02/2024
ISBN number: 978-1-74243-403-2
PDS reference: CG033
Policy history: Is this a new policy (V1)? N
Does this policy amend or update and existing policy? Y
If so, which version? V2
Does this policy replace another policy with a different title? N
If so, which policy (title)?

Approval Who approved New/Revised

Version Reason for Change
Date Version

SA Health Safety and Quality

Formally reviewed in line with 5 year
12/02/2019 V3 Strategic Governance
scheduled timeline for review
Committee
SA Health Safety and Quality
June 2014 V2 Strategic Governance Dosage regimen changes
Committee
2012
SA Maternal & Neonatal Original SA Maternal & Neonatal
approval V1
Clinical Network Clinical Network approved version.
only

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