SUMMARY Serial blood spot and saliva samples were collected at home by 18 patients being treated for congenital adrenal hyperplasia to determine the circadian rhythm of 170H-progesterone as an index of therapeutic control. There was a strong correlation between the magnitude of the circadian fall and a single morning measurement of the plasma testosterone concentration taken near the time of the 170H-progesterone rhythm samples. Poor control in pubertal girls produced an exaggerated circadian fall in 170H-progesterone concentrations that were raised at all sampling times. Optimal control (plasma testosterone 1-5-2-5 nmol/l) was associated with blood spot and salivary 170H-progesterone concentrations at 0800 hours of between 30-70 nmol/l and 260-1000 pmol/l, respectively, falling thereafter to <10 nmol/l and <150 pmol/l, respectively. Similar results were obtained in prepubertal patients. Nomograms have been constructed to interpret the daily profiles of blood spot or salivary measurements of 170H-progesterone, or both. The analysis of 170H-progesterone circadian rhythms is useful in monitoring treatment in patients with congenital adrenal hyperplasia, particularly those who may be overtreated.

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SUMMARY The adrenocortical response to stress was studied longitudinally in 10 ill preterm infants using measurements of cortisol and 170H-progesterone concentrations in filter paper blood spots. Mean cortisol and 170H-progesterone concentrations reached a peak of 2200 nmol/l and 65 nmolIl, respectively, between the third and fifth days of life. These concentrations far exceeded those observed in older children and adults subjected to stress as a result of surgery. Further pulses of endogenous cortisol production of 4000 nmolI or more occurred in association with clinical complications such as intraventricular haemorrhage. These results indicate that infants undergoing intensive care are unduly stressed. Consideration should be given to providing enough sedation and appropriate analgesia for ill preterm infants during painful procedures such as insertion of venous cannulae and arterial puncture.Increased plasma concentrations of 170H-progesterone (17P) and cortisol in ill preterm infants have previously been reported.' 2 These observations, which indicated a presumed stress response, were based only on single random measurements of plasma steroid concentrations. Little is known about the magnitude and duration of the adrenocortical response to stress in the newborn. A study of ill infants during the first three days after birth by Gutai et al showed that there was no significant increase in plasma cortisol concentrations. Most of the infants studied were not unduly stressed when assessed by clinical criteria.3 In a study of ill preterm infants with hyaline membrane disease,4 however, the peak plasma glucocorticoid response achieved was related to the severity of respiratory distress.Studies, in which serial measurements of plasma steroid concentrations in ill preterm infants have been made, have been limited by the difficulty of collecting venous samples from small infants. A steroid assay, which uses whole blood spotted on to filter gaper, has recently been developed however, and this technique, which requires only a small volume of blood, has been used to obtain longitudinal data on 17P and cortisol concentrations as an index of the adrenocortical response to stress in a group of ill preterm infants. Patients and methodsTen preterm patients were studied longitudinally for the first 13 days of life. All were very ill and required assisted ventilation for severe hyaline membrane disease. Table 1 (umbilical or radial) were inserted shortly after birth for measurements of blood gas and invasive blood pressure monitoring. When an arterial sample was collected additional drops were spotted on to a Guthne card sufficient to fill completely four 10 mm circles. The date and time of each sample collection was recorded for each infant. The filter paper card was left to dry at room temperature before being sent to the laboratory for analysis. In five of the infants blood spots were obtained at about six hourly intervals for three to five days.Blood spot 17P concentrations were determined by a specific radioimmunoassa...

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