(or viral gastroenteritis) can lead within hours to reduced blood pressure, shock, and death. To prevent this, all persons taking replacement glucocorticoids are taught to increase their doses in the event of illness, surgery, severe injury, or severe exhaustion. More importantly, they are taught that vomiting warrants an injection within hours of hydrocortisone (e.g., SoluCortef) or other glucocorticoid. This recommendation applies to both children and adults. Because young children are more susceptible to vomiting illnesses than adults, pediatric endocrinologists usually teach parents how to give hydrocortisone injections. As an additional precaution, persons with adrenal insufficiency are advised to wear a medical identification tag or carry a wallet card to alert those who may be providing emergency medical care of the urgent need for glucocorticoids. Reconstructive surgery Surgery need never be considered for genetically male (XY) infants because the excess androgens do not produce anatomic abnormality. However, surgery for severely virilized XX infants is often performed and has become a subject of debate in the last decade. Surgical reconstruction of abnormal genitalia has been offered to parents of severely virilized girls with CAH since the first half of the 20th century. The purposes of surgery have generally been a combination of the following: To make the external genitalia look more female than male To make it possible for these girls to participate in normal sexual intercourse when they grow up To improve their chances of fertility To reduce the frequency of urinary infections In the 1950s and 1960s, surgery often involved clitorectomy (removal of most of the clitoris), an operation that also reduced genital sensation. In the 1970s, new operative methods were developed to preserve innervation and clitoral function. However, a number of retrospective surveys in the last decade suggest that (1) sexual enjoyment is reduced in many women even after nerve-sparing procedures, and (2) women with CAH who have not had surgery also have a substantial rate of sexual dysfunction. (See Intersex surgery for an overview of procedures and potential complications, and History of intersex surgery for a fuller discussion of the controversies.) Many patient advocates and surgeons argue for deferring surgery until adolescence or later, while some surgeons continue to argue that infant surgery has advantages. Optimizing growth in CAH It is unclear what concentration of adrenal androgens is best for normal growth, puberty, and bone health. One of the challenging aspects of long-term management is optimizing growth so