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In response to Dr Shabih Manzar regarding ACTH and cortisol response to critical illness in term and late-preterm neonates

Journal of Perinatology volume 29, page 526 (2009)Cite this article

In response to Dr Manzar's question of treating with adrenocorticotropin (ACTH) or corticotropin-releasing hormone (CRH) rather than hydrocortisone, there are currently no therapeutic indications in relative adrenal insufficiency for use of CRH or ACTH expect for diagnostic testing.1 This route of treatment has not been studied for this problem because CRH and ACTH administration may result in a large variation of cortisol levels that are unregulated and would be difficult to predict as opposed to giving the end product, cortisol directly.

Regarding mechanisms for adrenal insufficiency, the ill newborn infant may be at risk for adrenal insufficiency due to shifts of central hormonal production during the transition to extrauterine life. However, the preterm newborn is, additionally, at risk for adrenal insufficiency from adrenal immaturity and immature adrenal enzymes. The fetal adrenal gland generally does not synthesize cortisol de novo until about 30 weeks.2 Before 30 weeks, the fetus uses progesterone from the placenta to bypass 3β-hydroxysteroid dehydrogenase, which is needed for de novo synthesis of cortisol. Preterm infants may be at risk for a prolonged period for developmental immaturity, as shown by decreased cortisol, and response to ACTH for several weeks after birth.3 In addition to immature enzymes, the fetal hypothalamic–pituitary–adrenal axis is suppressed in early gestation.2 There is suppression of the axis by passive transmission of maternal cortisol across the placenta. As gestation progresses, there are increasing levels of 11β-hydroxysteroid dehydrogenase 2, which metabolizes maternal cortisol so that there is decreasing exposure of the fetus to cortisol, thereby releasing the fetal axis from suppression by maternal cortisol.

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References

  1. Fernandez EF, Montman R, Watterberg KL . ACTH and cortisol response to critical illness in term and late preterm neonates. J Perinatol 2008; 28: 797–802.

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  2. Mesiano S, Jaffe RB . Developmental and functional biology of the primate fetal adrenal cortex. Endocr Rev 1997; 18: 378–403.

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  3. Watterberg KL, Gerdes JS, Cole CH, Aucott SW, Thilo EH, Mammel MC et al. Prophylaxis of early adrenal insufficiency to prevent bronchopulmonary dysplasia: a multicenter trial. Pediatrics 2004; 114: 1649–1657.

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  1. Department of Pediatrics/Neonatology, University of New Mexico School of Medicine, Albuquerque, NM, USA

    E F Fernandez

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Fernandez, E. In response to Dr Shabih Manzar regarding ACTH and cortisol response to critical illness in term and late-preterm neonates. J Perinatol 29, 526 (2009). https://doi.org/10.1038/jp.2009.47

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