Adult-onset of low levels of the adrenal hormone cortisol may have several origins, one of which around 2008 the medical community had just begun to understand, is adrenal fatigue. Because chronic stress causes the adrenal glands to overwork, eventually they become exhausted and release too little cortisol, which can result in symptoms such as fatigue and depression. Children, however, who are experiencing these symptoms, yet have not been exposed to decades of chronic stress, should be evaluated for a dangerous condition known as Addison's disease.
Addison's Disease
The adrenal glands are responsible for releasing the hormones--primarily cortisol--that regulate the body's response to stress. In a child who has Addison's disease, or primary adrenal insufficiency, these glands are not working adequately, usually due to an autoimmune reaction or a chronic infection that causes her own body to destroy 90 percent or more of her adrenal cortex, which is the outermost layer of the adrenal glands. As a result, she may become particularly vulnerable and develop several alarming symptoms during high-stress times of illness, trauma, rapid growth and development, and even emotional distress.
Symptoms
Because the symptoms of Addison's disease are elusive and usually appear and progress gradually, they can sometimes be disregarded. Early symptoms include loss of appetite resulting in weight loss, fatigue and general muscle weakness. If early detection does not occur, a child may begin to develop more overt symptoms: headache, sweating, nausea, vomiting, diarrhea, orthostatic hypotension and hypoglycemia. If intervention, such as alleviation or eradication of the stressor, cannot or does not occur at this point, the child's condition can progress to Addisonian crisis. Addisonian crisis is extremely dangerous and can result in death if emergency intervention is not initiated. Symptoms of this crisis include extreme hypotension; dehydration, or hyponatremia; hyperkalemia, resulting from vomiting and diarrhea; and loss of consciousness.
Medical Evaluation and Laboratory Detection
Due to the emergent nature of Addisonian crisis, medical evaluation--by a family practitioner, pediatrician or endocrinologist--of a child experiencing symptoms of adrenal insufficiency is imperative. The doctor will assess the child by checking his blood pressure and glucose levels. If the child is old enough to describe how he is feeling, the doctor may supplement his parent's description of his symptoms with that information. If this initial assessment warrants further evaluation and a suspicion of adrenal insufficiency, the doctor will require that the child undergo laboratory evaluation through specific testing.
The gold standard for diagnosis of Addison's disease is the ACTH stimulation test. During the test, a technician will perform a preliminary blood draw from which baseline cortisol levels will be established. Then, the technician will administer a dose of adrenocorticotropic hormone, or ACTH. In a healthy child, the synthetic ACTH will stimulate the adrenal glands to produce an adequate response of increased cortisol secretion. In a child with Addison's disease, baseline serum cortisol levels either do not rise, or they do not rise enough to counteract the effects of stress on the body. If the result of the ACTH stimulation test is positive for Addison's disease, the doctor will consider further testing to determine the cause of the adrenal insufficiency.
Treatment
The only way to treat Addison's disease is to replace, or supplement, the hormones that are not being secreted in sufficient quantities by the adrenal glands. The child's doctor will initiate glucocorticoid therapy, which is replacement of cortisol with one of several oral steroids several times daily.
Because child-onset of adrenal insufficiency is usually primary, the child may also require the addition of a medication, fludrocortisone acetate, to treat low levels of aldosterone, which is a hormone secreted by the adrenal glands that regulates the sodium retention and potassium excretion of the kidneys. Balancing this process through the addition of this medication lowers the child's risk of hypotension.
Living With Addison's Disease
Children with Addison's disease require medication therapy for the duration of their lives to maintain their health. During high-stress periods of rapid growth and development, such as that occurring during puberty, illness, trauma and emotional distress, ongoing careful monitoring of the delicate balance of adrenal hormones is crucial. As soon as a child is old enough to understand the symptoms of his disease, his doctor will educate him regarding signs and symptoms indicating inadequate medication supplementation. A child may minimize or ignore symptoms in an effort to avoid being "different" from his peers; therefore, he must learn that ignoring such symptoms can result in rapid decline and Addisonian crisis.
During these periods, increased doses of glucocorticoid are required to mirror the normal response of a healthy adrenal gland. Increased medication dosage is necessary until the stress of illness or injury has passed. It is imperative that a child with Addison's disease wear medical identification at all times indicating that during an emergency, such as trauma resulting from an accident, he requires immediate increased glucocorticoid treatment.
