Bedtime Salivary Cortisol as a Screening Test for Cushing Syndrome in Children
Open accessAbstract
Background: Diagnosing Cushing syndrome (CS) can be challenging. The 24-hour urine free cortisol (UFC) measurement is considered gold standard. This is a laborious test, dependent on correct urine collection. Late-night salivary cortisol is easier and is used as a screening test for CS in adults, but has not been validated for use in children. Objective: To define liquid chromatography tandem mass spectrometry (LC-MS/MS)-based cutoff values for bedtime and morning salivary cortisol and cortisone in children, and validate the results in children with and without CS. Methods: Bedtime and morning salivary samples were collected from 320 healthy children aged 4 to 16 years. Fifty-four patients from the children’s outpatient obesity clinic and 3 children with pituitary CS were used for validation. Steroid hormones were assayed by LC-MS/MS. Cutoff levels for bedtime salivary cortisol and cortisone were defined by the 97.5% percentile in healthy subjects. Results: Bedtime cutoff levels for cortisol and cortisone were 2.4 and 12.0 nmol/L, respectively. Applying these cutoff levels on the verification cohort, 1 child from the obesity clinic had bedtime salivary cortisol exceeding the defined cutoff level, but normal salivary cortisone. All 3 children with pituitary CS had salivary cortisol and cortisone far above the defined bedtime cutoff levels. Healthy subjects showed a significant decrease in salivary cortisol from early morning to bedtime. Conclusions: We propose that bedtime salivary cortisol measured by LC-MS/MS with a diagnostic threshold above 2.4 nmol/L can be applied as a screening test for CS in children. Age- and gender-specific cutoff levels are not needed.
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A ratio cut-off around 1 is probably dependable for detecting sample contamination with most LC-MS/MS assays.
“The 97.5th percentile for the salivary cortisol:cortisone ratios was close to 1 for all three tested LC-MS/MS methods, making this likely to be a reliable cut-off for most LC-MS/MS methods to indicate sample contamination [2,13,16,44].”
From Salivary cortisol and cortisone in diagnosis of Cushing's syndrome: a comparison of six different analytical methods (2023) · cites this paper as [16]
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Cites
Williams Textbook of Endocrinology
Melmed, S., & Polonsky, K. С. (2016) · Elsevier eBooks · doi:10.1016/c2013-0-15980-6 · Cited by 3,716 · see citing works
The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline.
Nieman, L. K., Biller, B. M. K., Findling, J. W., Newell-Price, J., Savage, M. O., Stewart, P. M., & Montori, V. M. (2008) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2008-0125 · Cited by 2,718 · cited 6× · see citing works
“Late-night salivary cortisol measurement is established as a valid screening test for CS in adults [11].”
BackgroundMethodInfluentialInfluence of statistical method used on the resulting estimate of normal range.
Reed, A. H., Henry, R. J., & Mason, W. B. (1971) · Clinical Chemistry · doi:10.1093/clinchem/17.4.275 · Cited by 598 · see citing works
Cushing's syndrome in children and adolescents. Presentation, diagnosis, and therapy.
Magiakou, M. A., Mastorakos, G., Oldfield, E. H., Gomez, M. T., Doppman, J. L., Cutler, G. B., Nieman, L. K., & Chrousos, G. P. (1994) · New England Journal of Medicine · doi:10.1056/nejm199409083311002 · Cited by 430 · see citing works
On dividing reference data into subgroups to produce separate reference ranges
Harris, E. K., & Boyd, J. C. (1990) · Clinical Chemistry · doi:10.1093/clinchem/36.2.265 · Cited by 380 · see citing works
Kiess, W., Meidert, A. S., Dressendörfer, R. A., Schriever, K., Kessler, U., Köunig, A., Hp, S., & Strasburger, C. J. (1995) · Pediatric Research · doi:10.1203/00006450-199504000-00020 · Cited by 319 · see citing works
Time to diagnosis in Cushing's syndrome: a meta-analysis based on 5367 patients
Rubinstein, G., Osswald, A., Hoster, E., Losa, M., Elenkova, A., Zacharieva, S., Machado, M. C., Hanzu, F. A., Zopp, S., Ritzel, K., et al. (2020) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgz136 · Cited by 180 · cited 1× · see citing works
“Delayed diagnosis is a recognized problem [24], and it is suspected that several children with CS actually have had this condition from childhood, but remain undiagnosed until adulthood.”
BackgroundSelf-citationCushing Syndrome in Pediatrics
Stratakis, C. A. (2012) · Endocrinology and Metabolism Clinics of North America · doi:10.1016/j.ecl.2012.08.002 · Cited by 161 · see citing works
Cushing’s Syndrome in Pediatrics
Lodish, M. B., Keil, M. F., & Stratakis, C. A. (2018) · Endocrinology and Metabolism Clinics of North America · doi:10.1016/j.ecl.2018.02.008 · Cited by 161 · see citing works
Circadian Rhythm of Salivary Cortisol, 17α-Hydroxyprogesterone, and Progesterone in Healthy Children
Gröschl, M., Rauh, M., & Dörr, H.-G. (2003) · Clinical Chemistry · doi:10.1373/49.10.1688 · Cited by 145 · cited 2× · see citing works
“There are a few studies that report on expected normal levels of salivary cortisol in children [15-17], but none of these use highly specific analytical methods such as liquid chromatography tandem mass spectometry (LC-MS/MS).”
BackgroundMethodBaid, S. K., Sinaii, N., Wade, M., Rubino, D., & Nieman, L. K. (2007) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2006-2861 · Cited by 144 · see citing works
Perogamvros, I., Owen, L. J., Newell-Price, J., Ray, D. W., Trainer, P. J., & Keevil, B. G. (2009) · Journal of Chromatography B · doi:10.1016/j.jchromb.2009.09.014 · Cited by 140 · see citing works
Paediatric Cushing's syndrome: epidemiology, investigation and therapeutic advances
Storr, H. L., Chan, L. F., Grossman, A. B., & Savage, M. O. (2007) · Trends in Endocrinology and Metabolism · doi:10.1016/j.tem.2007.03.005 · Cited by 128 · see citing works
Self-citationReference Values for Morning Salivary Cortisol Concentrations in Healthy School-aged Children
Törnhage, C. (2002) · Journal of Pediatric Endocrinology and Metabolism · doi:10.1515/jpem.2002.15.2.197 · Cited by 97 · see citing works
Urine steroid metabolomics as a novel tool for detection of recurrent adrenocortical carcinoma
Chortis, V., Bancos, I., Nijman, T., Gilligan, L. C., Taylor, A. E., Ronchi, C. L., O’Reilly, M. W., Schreiner, J., Asia, M., Riester, A., et al. (2020) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgz141 · Cited by 93 · see citing works
Manetti, L., Rossi, G., Grasso, L., Raffaelli, V., Scattina, I., Del Sarto, S., Cosottini, M., Iannelli, A., Gasperi, M., Bogazzi, F., et al. (2013) · European Journal of Endocrinology · doi:10.1530/eje-12-0685 · Cited by 69 · see citing works
Perogamvros, I., Owen, L. J., Keevil, B. G., Brabant, G., & Trainer, P. J. (2010) · Clinical Endocrinology · doi:10.1111/j.1365-2265.2009.03582.x · Cited by 61 · see citing works
Stratakis, C. A., Mastorakos, G. P., Mitsiades, N., Mitsiades, C. S., & Chrousos, G. P. (1998) · Pediatric Dermatology · doi:10.1046/j.1525-1470.1998.1998015253.x · Cited by 53 · see citing works
Effects of Cushing Disease on Bone Mineral Density in a Pediatric Population
Lodish, M. B., Hsiao, H., Serbis, A., Sinaii, N., Rothenbühler, A., Keil, M. F., Boikos, S. A., Reynolds, J. C., & Stratakis, C. A. (2010) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2009.12.027 · Cited by 47 · see citing works
Episodic ACTH and cortisol secretion in normal children
Wallace, W. H., Crowne, E. C., Shalet, S. M., Moore, C., Gibson, S., Utley, M. D., & White, A. E. (1991) · Clinical Endocrinology · doi:10.1111/j.1365-2265.1991.tb00297.x · Cited by 44 · see citing works
Pediatric Cushing's syndrome: clinical features, diagnosis, and treatment
Chan, L. F., Storr, H. L., Grossman, A. B., & Savage, M. O. (2007) · Arquivos Brasileiros de Endocrinologia & Metabologia · doi:10.1590/s0004-27302007000800012 · Cited by 35 · see citing works
Self-citationKeil, M. F., Graf, J. C., Gokarn, N., & Stratakis, C. A. (2011) · Clinical Nutrition · doi:10.1016/j.clnu.2011.11.007 · Cited by 25 · see citing works
Afshari, A., Ardeshirpour, Y., Lodish, M. B., Gourgari, E., Sinaii, N., Keil, M. F., Belyavskaya, E., Lyssikatos, C., Chowdhry, F. A., Chernomordik, V., et al. (2015) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2015-2497 · Cited by 23 · see citing works
Lodish, M. B., Gourgari, E., Sinaii, N., Hill, S. C., Libuit, L. G., Mastroyannis, S. A., Keil, M. F., Batista, D. L., & Stratakis, C. A. (2014) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2013.11.065 · Cited by 19 · see citing works
The 24-h cortisol secretory pattern in Cushing's syndrome
TOURNIAIRE, J., Chalendar, D., Rebattu, B., Fèvre‐Montange, M., Bajard, L., Mazenod, B., Déchaud, H., Samra, A. B. A., & Cauter, E. V. (1986) · European Journal of Endocrinology · doi:10.1530/acta.0.1120230 · Cited by 13 · see citing works
Flagged first, then by citations
Research works printed but not linked: 1
- [26]Robert Bjerknes OBK, Njølstad PR, Bland JD, Knudtzon J. Utredning ved mistanke om Cushing syndrom. Pediatrisk Endokrinologi 1998; 12: 67- 78.
Cited by
Sorted by citations
Molecular Derangements and the Diagnosis of ACTH-Dependent Cushing’s Syndrome
Nieman, L. K. (2022) · Endocrine Reviews · doi:10.1210/endrev/bnab046 · Cited by 33 · see citing works
Recent developments in wearable & non-wearable point-of-care biosensors for cortisol detection
Kaur, S., Gupta, N., & Malhotra, B. D. (2023) · Expert Review of Molecular Diagnostics · doi:10.1080/14737159.2023.2184260 · Cited by 20 · see citing works
Adrenal Cushing’s syndrome in children
Guarnotta, V., Emanuele, F., Salzillo, R., & Giordano, C. S. D. S. (2023) · Frontiers in Endocrinology · doi:10.3389/fendo.2023.1329082 · Cited by 15 · see citing works
Bäcklund, N., Brattsand, G., Lundstedt, S., Aardal, E., Bartuseviciene, I., Berinder, K., Höybye, C., Burman, P., Edén Engström, B., Isaksson, A., et al. (2023) · Clinical Chemistry and Laboratory Medicine (CCLM) · doi:10.1515/cclm-2023-0141 · Cited by 9 · see citing works
A dilute and shoot method for urinary free cortisol analysis by LC-MS/MS
Shen, Y., Luo, X., Guan, Q., & Cheng, L. (2024) · Journal of Chromatography B · doi:10.1016/j.jchromb.2024.124127 · Cited by 8 · see citing works
Scribante, A., Pellegrini, M., Ghizzoni, M., Pulicari, F., Giannì, A. B., & Spadari, F. (2024) · The Open Dentistry Journal · doi:10.2174/0118742106346940241212104004 · Cited by 8 · see citing works
Ballerini, M. G., Freire, A. V., Rodríguez, M. E., Brenzoni, L., Daga, L., Castro, L., Cau, A. C. A., Testa, G., Gil, M. R., Braslavsky, D. G., et al. (2024) · Hormone Research in Paediatrics · doi:10.1159/000540785 · Cited by 3 · see citing works
Jones, L., Park, J., Dliso, S., Hawcutt, D. B., Shantsila, A., Lip, G. Y. H., & Blair, J. (2025) · American Journal of Medical Genetics Part C Seminars in Medical Genetics · doi:10.1002/ajmg.c.32130 · Cited by 2 · see citing works
Endocrine hypertension in children
Valaiyapathi, B., & Ashraf, A. P. (2023) · Elsevier eBooks · doi:10.1016/b978-0-323-96120-2.00008-x · Cited by 1 · see citing works
Honour, J. W. (2023) · Elsevier eBooks · doi:10.1016/b978-0-12-818124-9.00019-x
Salivary Cortisol Detection Technology: Current Investigations and Challenges
孙, 欣. (2025) · Open Journal of Natural Science · doi:10.12677/ojns.2026.141004
New tools for the diagnosis of hypercortisolism
Zhao, Q., Sima, O.-C., Estapé, M., Casals, G., & Hanzu, F. A. (2026) · Vitamins and hormones · doi:10.1016/bs.vh.2026.02.007
- Authors
- Ueland, G. Å., Kellmann, R., Jørstad Davidsen, M., Viste, K., Husebye, E. S., Almås, B., Storr, H. L., Sagen, J. V., Mellgren, G., Júlíusson, P. B., & Methlie, P.
- Affiliations
- Haukeland University Hospital (NO)
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, 5021 Bergen, Norway
- Queen Mary University of London (GB)
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- Corresponding author
- Ueland, Grethe Å
- ORCID
- Venue
- Journal of the Endocrine Society
- Publisher
- The Endocrine Society
- Published
- 2021-03-04
- Volume
- 5
- Issue
- 5
- Pages
- bvab033-bvab033
- ISSN
- 2472-1972 (ISSN-L)
- PMC
- PMC8064046
- OpenAlex
- W3133974342
- Cited by
- 12
- References
- 25
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 3 · 2023: 5 · 2021: 1
- FWCI
- 1.68
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Journal of the Endocrine Society (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- NORA - Norwegian Open Research Archives (submittedVersion, cc-by-nc-nd)
- NORA - Norwegian Open Research Archives (submittedVersion, other-oa)
- Funders
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Pituitary Gland Disorders and Treatments
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Life Sciences › Neuroscience › Behavioral Neuroscience › Stress Responses and Cortisol
- Keywords
- Cushing's syndrome, salivary cortisone, screening test, children, diagnostic thresholds, 24-hour urine free cortisol, obesity, diurnal cortisol rhythm
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