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Rob Lindsay, MD Adjunct Professor of Pediatrics University of Utah School of Medicine
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10 year old girl with documented autoimmune (Hashimoto) thyroiditis and hypothyroidism. Her initial TSH was > 1000mU/L.
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Type 1 Diabetes Mellitus Down Syndrome Turner’s Syndrome Celiac Disease Klinefelter’s Syndrome
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Serum Free T 4 and TSH are sufficient Serum T 3 levels often misleading If measuring total T 4 also do T 3 resin uptake or thyroid binding protein Antithyroglobulin and antithyroid peroxidase antibodies Thyroid imaging rarely indicated
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NHANES III (1988 – 1994) Adolescents 12-19 years of age 6.3% positive antithyroglobulin 4.8% positive antithyroid peroxidase antibodies 2:1Female:Male
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105 children with positive antibodies and normal TSH followed for 5 years: 65% remained euthyroid 10% developed mild TSH elevation 26% developed TSH twofold above normal
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55 children with positive antibodies and mildly elevated TSH levels: 29% reverted to normal TSH 29% were unchanged 42% developed TSH twofold above normal
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1:3000 to 1:4000 in newborn infants More common in Hispanic and Native American infants at 1:2000 Less common in African American infants at 1:32,000 Consistently 2:1 Female:Male
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85% are sporadic – 15% hereditary 90% permanent – 10% transient
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Only 5% suspected by clinical diagnosis ◦ At time of newborn screen ◦ At 2-3 weeks of age Birth weight and length normal OFC slightly increased Gestational age > 42 weeks in 33%
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Primary T 4 measurement with backup TSH Primary TSH measurement Recall rate (T 4 20 mU/L ◦ Primary T 4 - 0.3% ◦ Primary TSH – 0.05%
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Free T 4 – Upper half of normal range: ◦ 1.4 – 2.3 ng/dl TSH < 10 mU/L ◦ May take one month of treatment
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Before Newborn Screening: ◦ If diagnosed between birth and 3 months IQ = 89 ◦ If diagnosed between 3 and 6 months IQ = 71 ◦ If diagnosed after 6 months IQ = 54
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1 year-old child with undiagnosed/untreated congenital hypothyroidism who was born before national screening programs for this condition. She was treated with replacement thyroid hormone, and 6 months later had a more normal facial appearance but significant developmental delays due to delay in diagnosis and treatment.
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New England Congenital Hypothyroidism Collaborative ◦ Verbal IQ 109 ◦ Performance IQ107 ◦ Full Scale IQ109 At 6 years of age.
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New England Congenital Hypo- thyrodism Collaborative ◦ Inadequate treatment in first 3 years IQ = 87
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A small proportion may have: Language deficits Problems with visual-spatial integration Ataxia Gross and fine motor incoordination Muscle tone abnormalities Short attention span Strabismus 10% will have sensorineural deafness
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Baloch Z, Carayon P, Conte-Devolx B, et al. Laboratory medicine practice guidelines. Laboratory support for the diagnosis and monitoring of thyroid disease. Thyroid 2003; 13:3. Cassio A, Ricci G, Baronio F, et al. Long-term clinical significance of thyroid autoimmunity in children with celiac disease. J Pediatr 2010; 156:292. Chiesa A, Gruñeiro de Papendieck L, Keselman A, et al. Final height in long- term primary hypothyroid children. J Pediatr Endocrinol Metab 1998; 11:51. Chiovato L, Larizza D, Bendinelli G, et al. Autoimmune hypothyroidism and hyperthyroidism in patients with Turner’s syndrome. Eur J Endocrinol 1996; 134-568. de Vries S, Bulvik S, Phillip M. Chronic autoimmune thyroiditis in children and adolescents: at presentation and during long-term follow-up. Arch Dis Child 2009; 94:33 Elmlinger MW, Kühnel W, Lambrecht HG, Ranke MB. Reference intervals from birth to adulthood for serum thyroxine (T 4 ), triiodothyronine (T 3 ), free T 3, free T 4, thyroxine binding globulin (TBG) and thyrotropin (TSH). Clin Chem Lab Med 2001: 39;973.
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Hollowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab 2002; 87:489. Lazar L, Frumkin RB, Battat E, et al. Natural history of thyroid function tests over 5 years in a large pediatric cohort. J Clin Endocrinol Metab 2009; 94:1678. Lindsay AN, Voorhess ML, MacGillivray MH. Multicystic ovaries detected by sonography in children with hypothyroidism. AJDC 1980; 134:588. Lindsay AN, Voorhess ML, MacGillivray MH. Multicystic ovaries in primary hypothyroidism. Obstetrics & Gynecology 1983; 61:433. Lindsay AN, Voorhess ML. Slipped capital femoral epiphysis in hypothyroidism. AJDC 1984; 138:1149. Moore DC. Natural course of ‘subclinical; hypothyroidism in childhood and adolescence. Arch Pediatr Adolesc Med 1996; 150:293. Nelson JC, Clark SJ, Borut DL, et al. Age-related changes in serum free thyroxine during childhood and adolescence. J Pediatr 1993; 123:899.
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Ozer G, Yüksel B, Kozanoġlu M, et al. Growth and development of 290 hypothyroidic patients at diagnosis. Acta Paediatr Jpn 1995; 37:145. Radetti ML, Gottardi E, Bona G, et al. The natural history of euthyroid Hashimoto’s thyroiditis in children. J Pediatr 2006; 149:827. Rallison ML, Dobyns BM, Meikle AW, et al. Natural history of thyroid abnormalities: prevalence, incidence and regression of thyroid diseases in adolescents and young adults. Am J Med 1991; 91:363. Rivkees SA, Bode HH, Crawford JD. Long-term growth in juvenile acquired hypothyroidism: the failure to achieve normal adult stature. N Engl J Med 1988; 318:599. Sattar N, Lazare F, Kacer M, et al. Celiac disease in children, adolescents, and young adults with autoimmune thyroid disease. J Pediatr 2011; 158:272. Sklar CA, Qazi R, David R. Juvenile autoimmune thyroiditis. Hormonal status at presentation and after long-term follow-up. Am J Dis Child 1986; 140:877.
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