Management of critically ill very low-birth-weight infants with the clinical picture of vasopressor-resistant shock in the neonatal intensive care unit is a complex issue. Once airway and breathing have been stabilized and hypotension has been treated with volume and vasopressors with no improvement, the issue of cardiovascular insufficiency must be addressed. After cultures have been performed and antibiotic therapy started, the question of adrenal insufficiency arises. This article discusses of the development of the hypothalamic-pituitary-adrenal axis during gestation, aspects of what is considered normal function, and the diagnosis and management of the entity of relative adrenal insufficiency in the premature infant.

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