Chapters Transcript Video Pediatric Thyroid Disorders in Primary Care All right, thanks for joining us. We're gonna go get started to make sure Doctor Chester has enough time to present to us today. Thank you all for joining us. My name is Maria Bremmer, physician liaison with Benioff children's hospitals. We are thrilled to have Doctor Hannah Chester present our CME lecture to us today on pediatric thyroid disorders and primary care. As always, your evaluation for your CME will populate after the completion of this lecture, please make sure you fill it out or you'll also get an email um with the evaluation also and some if you can submit that by tomorrow for your CME credit would be greatly appreciated. We have some exciting lectures planned for July. If my screen would advance one moment, my computer is freezing one second. Ok. There we go. Obviously, we have no uh webinar next week with Fourth of July, but we do have a good craniofacial facial talk and then a cardiac issues and sports screening for July. Look out in your emails for the registration links for those and as always, your liaison team is here with any issues questions you may have. Please reach out to us over email or cell phone. We're happy to help with anything you may need without further ado, I'd like to introduce doctor Hannah Chester endocrinologist with Bania children's hospitals. Welcome. Thank you. Thanks for the introduction. I'll start sharing my slides. One thing I did forget to add is we will. If you have questions, go ahead and put them in the Q and A and doctor Cheer is gonna answer those at the conclusion of her, of her lecture today. OK. Now I'm seeing a circle, my screen might be freezing, but you can hear me. OK? Yeah, we can hear you. OK. Good, great. All right. So thanks for joining me during your lunch hour. Uh Our talk is gonna be on pediatric thyroid disorders and primary care. Um So I am uh one of the faculty over at U CS FB Children's Hospital Oakland. Um So I know financial disclosures and learning objectives for today are to identify and monitor infants at risk for neonatal graves disease and then describe thyroid, newborn screening and thyroid physiology and neonates, identify and screen for thyroid conditions in Children with trisomy 21 and in Children with obesity and then explain the initial work up and management of pediatric thyroid um conditions and when to refer including how she motor thyroiditis and grave's disease. I'm not gonna cover all pediatric thyroid conditions, but I figured that these were the most common um referrals and questions that we're getting in our pediatric in your current office. So let's start with the case first. So you are seeing a three day old, um term 39 Meaker uh female who was born to a mama Graves disease. The maternal history is initially a little bit difficult to discern. Um, she had had radioactive iob population in the Philippines as a child. Then she was lost to follow up, stopped taking her medication and then actually was restarted by um her ob on thyroid replacement. And um when you are saying mom, she is telling you that she has quote unquote low thyroid and takes thyroid medication daily um with levothyroxine. So questions are, what information do you need from mother's medical record? And then does this infant need thyroid screening? Um So you go back and, and find that there was a T SI. So thyroid stimulating immunoglobulin that was checked in the third trimester of mom's pregnancy. The T SI was mildly positive. It was 100 and 62%. Anything over 100 and 40% is considered positive. And then you astutely um see that um the infant T SI level was actually sent on the first day of life or day of life zero. And then when you are seeing the the baby use in thyroid function testing and it comes back actually showing hyperthyroidism. So the TSH is suppressed less than 0.013 T four is elevated at six. Infant is totally asymptomatic normal heart rate, normal blood pressure feeding. Well, um and you call endocrinology and we were come in starting with them as well. And then a few days later, the T SI for the baby actually comes back being quite positive at 428%. And so for a clinical course, this infant um continued to have a positive T SI until around seven weeks of life. Um And around that time, we were able to lean off the Methimazol and then at our repeat thyroid check. Two weeks later, the thyroid levels were normal. So this all resolved by nine weeks of age. And this is in contrast to another case, I actually saw this case when I was in fellowship. Um This is a one week old male infant who was born at 35 weeks, had a brief three day nick, you stay and then is presenting to your office with poor feeding taca cardia retractions and lethargy you fa send the family to the ed due to concerns for dehydration. Um labs show severe thrombocytopenia, direct hyper billy transit. The babies and cardiac failure is started on pressors in the IC U. Um And then eventually the TFTs do get checked and it shows hyperthyroidism. TSH is suppressed less than 0.013 T four is over seven and the T SI is positive. And this is the, the textbook example of um a baby that has vi thyrotoxicosis due to neonatal graves disease. But this baby looked exactly like this. So you can notice the proptosis, um catic appearance and super hyper reflexic on exam. Um This mom had also had radioactive io dilation when she was a teenager, she's been taking her thyroid replacement since then consistently. So when her ob checked her TFTs in pregnancy, her TSH and three T four were normal, there weren't any follow up questions that were asked and it was just assumed that mom had low thyroid levels. Um So no T si was checked and it was actually missed that the baby was at risk for getting graves. And so we started Methimazol. Um The heart failure did resolve within a week. Transaminitis persisted for a bit um by eight weeks of life. So about two months, the TFTs had normalized and we were able to start decreasing Methimazol and we were able to stop the Methimazol entirely by seven months old. So again, this was a severe presentation, but a transient um manageable problem once we figured out what was going on. So just to start with some thyroid basics, remember, hyperthyroidism um is which would include grave's disease is a low TSH and high three T four. TSH is thyroid simulating hormone going from the brain, talking to the thyroid gland. So you have to think in double negatives um due to the feedback loop and then a hypothyroidism you'll often hear on thyroid replacement. Um that is gonna be a high TSH and a low three T four. And many women do, um get definitive therapy for graves. So they either get a thyroidectomy or radioactive bio dyb. And so when they are pregnant, they, um, may look as if they just have a um hypothyroidism since they're taking a thyroid pill. Um The interesting thing is that the mom's antibodies, so the T si antibodies that are um responsible for Graves disease, they can actually last for a long time. Um even after definitive therapy. So that's why if there's any history at all, we're supposed to check for mom's T SI. Um So we know whether or not to screen baby and then this question tends to come up a lot. Um is what is the risk from maternal thyroid antibodies crossing the placenta? So all thyroid antibodies are gonna cross the placenta because um they are IgG um but the way that the antibodies work is different. So TPO antibodies and thyroglobulin antibodies, those are the ones responsible for hypothyroidism. So, um how she motors thyroiditis, those cause T cell mediated inflammation. So the kind of inflammation is um much slower to actually have any impact on um a child. And the thing is is that it's all the, all of these antibodies are in the bloodstream transiently. So they're out of the bloodstream somewhere between three and six months of age. And so TP A and thyroglobulin don't have time to cause any problems in the baby, whereas T si, which is thyroid stimulating immunoglobulin, which is a subset of Trib tra is TSH re receptor antibody. Those are both um they have a direct effect on the TSH receptors. And so both um the stimulating part of trap, which is T si and the blocking part of trap can have short term effects on the infant. So short term as in the 1st 3 to 6 months of life. Um So why do we prefer uh perform screening for grapes disease at all? Um And the, this question that has come up especially, I would say more from like newborn nursery and nu settings because the prevalence in neonatal hyperthyroidism is super low actually. So only 1.5 to 2.5% of babies born to mom with grapes will go on to develop hyperthyroidism though there is one study that reported up to 20%. Um And the reason is, is because like I was saying, the T SI can persist for years beyond definitive therapy. So T SI levels are high in, in mothers who have active groups disease, but they can also stay elevated. Um And about a third of people uh several years after a thyroidectomy and then 40% of patients after they've had a radioactive bio diab and then this makes sense, the higher the mom's T SI, the higher the chance of the baby getting graves and then put more simply positive cod T si correlates to um, the likelihood of developing hyperthyroidism. But then the reverse is true. The nice thing is, is that if they're, if mom doesn't have the antibodies, there's really no way for her to pass them along to the baby. So there's really negligible risk for a baby going on to develop hyperthyroidism. And I'm not gonna go into fetal hyperthyroidism too much. It's extremely rare because most, um, I would say most mothers um have their thyroid levels managed quite well during pregnancy. But as you can see, neonatal hyperthyroidism, if it's not caught early, can be quite severe. As we saw in the case with the baby who um developed heart failure, the mortality rate is up to 20%. Um and the most likely time for the babies to develop symptoms is within the first two weeks. Um And so that's why screening starting early. So within like three days is super important because a lot of the signs are super subtle until the baby decompensates and needs IC U level care. So it's serious but transient and a manageable problem. Um So the consensus among pediatric neuro CNO is we should test right, we should do the screening. Um And then I just wanted to talk about how the California newborn screen works. So I'll go into this in a bit more detail. Um But our California newborn screening is checking for high TSH levels. And so it is looking for for infants who have hypothyroidism. It's not gonna catch an infant that has a low TSH level, it's not gonna flag it. So you're not gonna catch the one that has scrapes. Um The other thing you know about newborn screening is that the uh um it's interesting. So when a baby is born, when they're exposed to the cold, the cold is uh what triggers a TSH surge. So it's normal for most babies to have a very high TSH level in the 1st 24 hours of life. So we recommend not checking any sort of thyroid function testing within the 1st 24 hours because it's gonna come back showing the TSH is high. Um And we'll just be saying repeat. Um So in an effort to save some blood Popes for the baby. So um the recommendations are to um screen uh moms during pregnancy by checking A T si sometime between 2024 weeks of gestation. So second to third trimester. Um and that's if mom has any history of graves disease in her past. So that requires us asking those questions. However, sometimes the T SI isn't checked. Um And so if, if the T SI is positive or unknown, then we have to do testing in the baby. Whereas if the T SI is negative, we can stop checking altogether. There's really, we can just assume that there's very minimal risk for the baby and we don't need to check any TFTs. Um I'm gonna zoom into this algorithm uh in a, in a second. But um I I, in the ideal world, we could send a cord blood T si um because that really is a proxy to see if the antibodies is being uh transmitted across the placenta. But if we are not able to send a cord blood T si, you want to send in the baby as soon as possible. So, ideally day of life zero and then that's gonna take about a week to come back. So in the meantime, you do have to check TFTs. Um So while you're waiting to see if the baby has a high T SI or not, you are gonna send thyroid function tests to TSH and three T four on day of life, 3 to 5 and then again, again, day of life 10 to 14. And if at any point, the T SI comes back negative, you can stop checking, reassure yourself and the family that the baby is not at risk. But then if at any point, the TFTs come back abnormal, that's when you're gonna be calling us. Um and you can talk to endocrinology and whether or not we should start with them as well. Um And then after that, really, after two weeks, the guidelines say we don't need to check any more TFT SI will say that a lot of times we will be checking maybe again like two weeks later. Um But technically, it's, it's fine to stop checking after two weeks because that's the highest risk window for developing hyperthyroid symptoms. Um And then just clinical pearls as I was pointing out the TP and thyroglobulin antibodies shouldn't um be around in the baby system long enough to cause any problems for baby. Um And so just a reminder, I think this is just a example that it you need, we all should be asking follow up questions in the, um, in new parents and new moms about their thyroid history. Even if someone said is that they take Levy Aine, just ask if they've ever heard of Graves Disease or ask if they've had a thyroid surgery or ask if they've had radioactive iob. Um, and the signs of hyperthyroid in the babies can be really subtle. So the, the signs for watch four would be tachycardia per weight gain, diarrhea, sweating, flushing. But usually I would say most babies are asymptomatic until they're very sick. Um And then the great thing about all this is once the T si is negative, you can reassure yourself and the family and stop testing. So in the end, all the screening that we're recommending actually can save the baby and family a lot of, um, hassled with having to get a lot of blood work done in a stressful time. Ok? So we're gonna shift gears. Um, and talk about another case also related to babies. So you, um, your office is notified that a five day old term infant, um who's new to your practice has a positive newborn screen for congenital hypothyroidism. The TSH on the newborn screen is 40 the abnormal cut-off is over 29. So you see them in your office and you do an exam. There's no, there's no lingual thyroid glands, the baby's feeding, ok. And you obtain confirmatory serum TSH and free T four. The TSH is 17 which is elevated and the free T four is in the normal range. So we've got um high TSH, normal, free T four. And so we will um come back to the interpretation of the next steps for that. So, congenital hypothyroidism is the most common preventable cause of intellectual disability worldwide. Um They can also lead to psychomotor dysfunction and impaired growth. And the incidence of congenital hypothyroidism is about 1 to 2000 to 1 in 4000 newborn infants. The reason for this big range is that um we are detecting more and more congenital hypothyroid with more sensitive newborn screening. And so it's probably closer to one in 2000 infants. And then there are a couple of groups that are higher risk for having ch so um female infants actually have a 1.5 to 2 times increased incidence of thyroid ectopia. Um but then like this hor monogenesis is equal in both sexes. Um try to be 21 higher incidents and then actually multiple gestations. So about double the rate of single gestations. So one in 100 one in 876 in twin births and then one in 575 and higher multiple births. Um And then I found this interesting, I actually didn't know this until creating this presentation that most twin pairs are discordant for ach. So that means if one infant has ch it's not necessarily the case that the other one's gonna have it even if they're homo cy is twins. So, um there is permanent congenital, hypothyroidism and transient hypothyroidism. Typically, we're gonna treat it the same regardless of whether or not it's permanent or transient. So most cases are permanent and that can be from a defect in thyroid gland development. Um A defect in thyroid hormone synthesis or rarely pituitary hypothalamic defects. So that would be central hypothyroidism or TSH deficiency and then cases that could be transient congenital hypothyroidism would be if they're maternal antithyroid antibodies. So that trap antibody I was talking about which is blocking antibody. This is very rare, but it's something we do check for. Um or if there is maternal or fetal iodine deficiency or excess, which can be um seen out somewhere and prematurity. And then regardless if we are gonna start someone on thyroid replacement therapy with Lebo, we typically keep uh Children on live with thyroxine until they're three years old. And the reason is it's just such a critical, critical time for brain development. And also for growth. And then, um, if we're suspecting that it could be a transient case, we could do a trial off around the age of three years old. Um, and going back to this newborn screening, like I was saying, California is a primary TSH screening program. So it's looking for high TSH levels. That means we're gonna miss any baby that has central hypothyroidism, first of all. Um And we're also gonna miss some babies that have a delayed rise in their TSH. And so I wanted to review um all the reasons for either having a false positive or false negative test um for congenital hypothyroidism. So sick and preterm infants are the ones that have the delayed TSH surge. So we often get positive newborn screens uh for prey babies and the nu um and similarly, preterm infants can have a higher risk for iodine deficiency. Um sick infants who need glucocorticoids or dopamine that can increase TSH secretion. So, artificially elevate it and make it look like they have a positive screen. Um and then non thyroid illness can do this too. So, non thyroidal illness is essentially our body's like metabolic response to coping with physiologic illness. Um initially during critical illness or even just like a viral illness, we have low T four and normal to low TSH. But then on the upswing of it, when we're recovering, the TSH can transiently rise above the normal range, usually about 6 to 15. And so um this, this is just a common thing that is coming up if in all Children, not just babies, if we're um checking thyroid levels when someone's sick enough to be in the hospital. So, um I wanted to review some new guidance for clinicians that just came out in January of this year. And the the new guidelines say to do the initial newborn screening between 24 and 72 hours of birth. I believe the prior screening said to or the prior recommendations were to do it after 12 hours. So we have a 24 hour mark because like I was mentioning that TSH surge in the 1st 24 hours of life is super normal because of the exposure to cold in the baby. Um And then now there's a recommendation to do a second newborn screen, which I think it would be fine to do a just a serum TSH and a free T four in infants at risk for hypothyroidism. So those are born prematurely. So less than 34 weeks, very low birth weight or ill enough to be admitted to the nicu monozygotic twins tri to be 21. Um and actually premature infants are supposed to have um actually a third screening. So you're supposed to get one at birth, one at 2 to 4 weeks and then a third, a month later, even if the initial two are normal. So going back to our case, um which was the positive deri screen for congenital hypothyroidism, you have the TSH on serum is 17, elevated and three T four is 1.8. So in the normal zone. And so, um typically, if, if the TSH is elevated and the three T four is low, that's when we universally agree, like let's start treatment, let's call this hypothyroidism. We'll start leave the thyroxine. So that would be a call to endocrinology and then an urgent referral to us. Um But then this is the case we're left with. So this baby has subclinical hypothyroidism. There's an elevated TSH and a normal three T four. And it's really controversial study results on neurodevelopmental outcomes of sub clinical hypothyroidism in young babies. Um The majority of studies point to no difference in developmental outcomes um that are not treated and there are currently no studies demonstrating a beneficial effectively with thyroxine therapy on outcomes in patients with mild congenital hypothyroidism. So with that being said, the guidelines, the new guidelines are suggesting that uh that we do it based off TSH value. So, TSH, over 20 we all agree. Let's start treatment with the Bethy Roine. If TSH is less than 20 it could be reasonable to follow the TFT trend every 1 to 2 weeks without any treatment. Um But that would be you calling us and working with endocrinology. So we can um hear about the uh the birth situation and how the baby is doing clinically. But then if TSH continues to be elevated to a persistent elevation over 10 by a month of life, then we would start treatment we do with Thor. So in this case, the baby with a TSH of 17, I have a feeling that we would be saying, let's repeat again in a week or two and see what the trend is. So if the TSH is turning down, we may not, we may get by without treating and then shifting gears to pediatric cover thyroidism. So, uh low thyroid levels and older kids, um the symptoms are going to be growth, deceleration. You may see delayed puberty or irregular mensies if they've already had their first period decline in school performance, sluggishness, fatigue, cold intolerance, constipation, dry skin um for the dry skin, I I like to ask more about um the hair and nails uh because so many people have dry skin just related to weather changes. So you can ask if someone's hair is brittle or more coarse and texture if it breaks easily or if they're appealing nails, facial puffiness, I like this photo or this cartoon. Um because it shows that there is like some facial puffiness that develops um and maybe some weight gain, but it's actually more related to fluid retention. So in my experience, I it's not, it's not like rapid weight gain. I mean, there, there certainly are people who will gain £20 but it's more like kind of puffiness and holding on to fluids. Um You may have muscle aches and pains and then you may or may not have an enlarged thyroid gland. So, and the most common cause for hypothyroidism in kids is gonna be hashimoto thyroiditis, um which is autoimmune thyroiditis. So, that's the TPO and thyroglobulin antibodies attacking the thyroid lands and chronic, causing chronic lymphocytic thyroiditis. So, just three terms for the same thing. Um and there are, there are populations that are increased risk prior to immune thyroid problems that includes childrens with Down Syndrome. Uh if they're positive antibodies, about 40% of Children with Down Syndrome will develop a thyroid problem. And the incidence of antibodies increase with age, especially after the age of six Turner syndrome. About 30% of patients will develop hypothyroidism if they have positive antibodies and in type one diabetes, um about 25%. So about a quarter if they have positive antibodies and then this also comes up sometimes. So, ultrasound is not routinely done in the US unless we feel a symmetry on exam, a thyroid nodule on exam or if there are other clinical concerns. Um So this the question is like how, how much of our population actually has positive thyroid antibodies. So we don't really know the incidence of thyroid antibodies in the pediatric population. But we do know that in the general population, about 12 to 20% of people have positive thyroid antibodies, they're definitely not 12 to 20% of people that have a thyroid problem. The the rate of antibodies increases with age and over 30% of elderly adults do have thyroid antibodies and the if TSH and three T four are normal. So if thyroid function tests are normal Lebo thyroxine treatment is not indicated just for the antibody tighter alone. Um because the the clinical course really is waxing and waning. You may have antibodies your entire life and may never go on to develop the thyroid problem. Um But about 25% of Children who do have a positive antibody will go on to develop hypothyroidism, which we consider TSH being elevated over 10, requiring treatment with Lexine. Um So I typically, if, if someone is, has had a thyroid antibody checked, that's positive, what we'll do is we'll ask about symptoms, we'll check TFTs if they're normal. Then I say please get your thyroid levels checked once a year or sooner if you develop symptoms of hypothyroidism. And I usually like to say if you have like three or more symptoms of hypothyroidism for more than three weeks at a time because the thing is, is hypothyroidism, symptoms are so nonspecific. So many people have constipation related to diet changes, travel, et cetera. So many people feel fatigued due to sleep problems, et cetera. So I say if you have three symptoms, then that's the time to ask your doctor for a thyroid check and then treatment for Levi Thyroxine pearls in case, um you are asking your patients about medication adherence. So um the half life of live with thyroxine is very long, it's seven days and the absorption can be changed by certain foods. So we ask families to give it on an empty stomach and wait 30 minutes before breakfast. And that's because uh iron, calcium and soy products can change the absorption. So also if someone, for example, is on an iron supplement, you need to make sure to be giving the multivitamin or the iron supplement at a different time of day than they live with their Roine. And once we start treatment, it's usually a lifelong therapy. So it's not something that we're able to wean off. Um But the nice thing is is that after we find a dose, that's right for someone, even as they're growing, we only have to check the thyroid levels once every six months when they're done growing, it's once a year. Um So oftentimes in the family medicine world, hypothyroidism is treated um or is managed by family medicine doctors, not by endocrinologists. And then uh this is all tablet medication. So po and uh little kids, families can crush it and mix it into something or a small amount of liquid. But you'll notice that our dosing is typically based off either full tablets or half tablet doses. Um And then treatment goal is to uh try, we try to get the TSH in the lower half of the reference range. And once you start lexine, you should check, uh, TFTs again about 4 to 6 weeks later. And the reason we don't check more often than that is just because it takes, um, that long for thyroid levels to change since the half life of the medication is so long also because the half life is so long, we are able to say, say if someone forgets a dose on Sunday, it's OK to take two doses on Monday. And that's one of the few medications it's OK to double up on the dose if it's forgotten. Um And then I'm not gonna talk about central hypothyroidism in this talk. But um TSH isn't helpful for guiding treatment and SRO hypothyroidism because that's what's missing. And so we're looking only at the three T four and we're trying to target the upper half of the reference range um when they're treating something, someone with central hypothyroidism. Ok. And then uh thyroid screening for trime 21. So as I was mentioning, there is a higher incidence of congenital hypothyroidism for kids for trime 21 about 1 to 12%. And the theory is that the extra chromosome 21 will result in results in genomic dosage imbalance of genes interfering with thyroid hormone production. And then Children with Down Syndrome also have a higher incidence of acquired hypothyroidism. So, about 24 to 30% will develop a thyroid problem in the pediatric years. And the risk goes up with age. So, um like we have learned from our new guidelines from January 2023 there should be a second newborn screen or at least a serum TSH and free T four done around 2 to 4 weeks of life. And if that's normal, then the recommendation is to check TSH and free T four at six months and then 12 months and then annually. So, um we then the question comes up what to do if someone's TSH is a little bit elevated. So um Children with trime 21 actually have a higher TSH set point. So it's very common to see mildly elevated TSH levels. However, usually the three T four is normal. Um I typically do not start thyroid replacement in the presence of normal range free T four levels unless a patient with trime 21 has a TSH, which would be considered over the 95th percentile. So that's TSH of 9 to 10. And also this is just in patients that don't have a bunch of symptoms of hypothyroidism. And then just because they have a slightly higher TSH to take like a TSH of five, upper limit is for in a positive antibody, that's not gonna change my threshold for starting medication because as we've learned the presence of antibodies is so high in the general population. And then this is also a very common reason for us to be getting referrals and um questions related to TSH and Children who have had TSH checked for obesity screening. So, um I just confirmed this uh as I was making this presentation. So laboratory screening for pediatric obesity is not standardized though TSH is not routinely recommended. I know that many offices do include it in their obesity screening panel. And the reason that TSH is not routinely recommended is that endocrine disorders account for less than 1% of all causes of pediatric obesity. So, endocrine causes for obesity could be Cushing Syndrome, growth hormone deficiency, hypothyroidism or pseudohypoparathyroidism. Um But I, I'm of the mindset that if you see a growth curve like the one on the right, I would not be necessarily checking a TSH or a free T four unless the patient is telling me that they've got multiple symptoms of hypothyroidism. And the reason I wouldn't check is because um first of all, it's not rapid weight gain. The BM I has slowly been increasing. And secondly, it's very common as interest me. 21 it's very common for TSH to be mildly elevated in obesity. And the reason for this. So there can be mild elevation TSH around 5 to 10 in about 10 to 20% of Children with obesity and then still normal three T four values. The theory is is that this is a metabolic compensation. So we know that thyroid is our metabolism hormone and that it um changes in response to our metabolic demands. And so when someone has excess adiposity, our body is trying to increase energy expenditure and that um can activate the Deonna activity which converts T four to T three and T three can help us burn some extra calories. Um The, there's also a theory that adipocyte actually um can have resistance to TSH. So someone's body may have to produce a little extra TSH in order to um have the body see effects of thyroid hormone. Um just to see more tissue responsiveness and then leptin, which is a marker of our central adiposity. Um Leptin actually increases thyrotropin releasing hormone which then increases TSH. So, leptin in and of itself can raise her TSH levels and then inflammation caused by obesity can um increase iodine uptake and small amounts of increased iodine uptake can increase her um her thyroid levels. And so is there is there any uh indication for thyroid medication or weight loss? Essentially, there is not any indication. So, even in patients that we're seeing who are retreating for overt hypothyroidism, they um rarely have significant weight loss. Um there may be a little bit of modest weight loss kind of returning to baseline VM I but not in all patients. And then there have been studies that have shown that learin is not a weight loss medication, it doesn't induce weight loss for youth. I read patients and in pediatric patients with obesity TSH has been shown to normalize with weight loss. So, when I am seeing a patient who is referred to us for a TSH of six, normal, three T four has been um obese for many years and has positive thyroid antibodies. I really emphasize lifestyle modification um and repeating the levels in several months and then just annual TFT screening because of those positive antibodies. And so my suggestion for triaging a patient um who has an abnormal TSH level in either trisomy 21 or obesity is for if the TSH is less than 10 and if three T four is normal, not many symptoms of hypothyroidism, you can recommend a trial of lifestyle modification and repeat TFTs again in about 3 to 4 months, you can also add on antibodies. And then if the TSH is over 10, even if the three T four is normal, it's worth a consult with us with endocrine and we may or may not recommend lexine and you'd refer to us. And like I have been mentioning a few times, positively, antibodies don't necessarily change our treatment decision. Um in these cases. And finally, I uh wanted to talk about older age graves disease. So pediatric grapes disease, this is much less common than hypothyroidism in Children, but the symptoms can be severe. So about one per 5000 Children and adolescents can develop Graves disease. Uh unlike hypothyroidism. So unlike how she the majority of patients will have a goiter. So 95% of patients will have a goiter and that's one of the most prominent things we see. Um, also fatigue, exercise, intolerance, tachycardia, palpitations, hypertension, wide pulls, pressure. This is the dangerous part. Um, and then same, same with sweaty skin and heat intolerance. I typically like just like touching someone's skin, they feel like wet and clammy and just warm to the touch, like kind of all over their skin looks a little bit pink and flushed and as it's not so much, um changes in hair texture, but they'll have hair thinning and then definitely may have weight loss despite increased appetite. Um along with mal absorption and diarrhea because remember this is our metabolism hormone. So everything is getting ramped up and then um any hyperthyroidism can cause stare or lead lag that's due to sympathetic over activity and tightness of the levator, pulpy brain muscle. And then proto is specific to graves disease. And the reason they for their proc tosis is that the TS a antibody actually um can cause inflammation of the eye muscles can so it can push the eye. Um forward resting trim are very common issue as well. Proximal muscle weakness, hyperlexia and mood swings and poor sleep and hyperactive. Um One really good question to ask kids is if they're all of a sudden, are having a hard time sleeping. So having a hard time staying asleep or falling asleep. So, initial treatment is uh with beta blockers to control the symptoms of hyperthyroidism. And in general, hyperthyroidism is gonna be an urgent condition. This is something that uh if you're seeing in the office. Um First of all, getting a good blood pressure checking, good heart rate is gonna be very helpful for us in triage. And then I would recommend calling endocrinology so we can help decide what medications to start before we see them. But I this is an urgent referral to us. We try to see them within two weeks but they need to be on medication before the that two week window. Um So beta blockers for treating the tachycardia blood pressure and stability, we'll use propanolol which blocks the conversion of T four to T three T three is like the active thyroid hormone in our bodies. And propanol is nonselective. It blocks both beta one and beta two and then sometimes um I like a tool because it's once a day, it's easier to remember. Um And it's cardioselective. So just affects the heart propanol we would not be using and someone that has um asthma and then the drug of choice is Methimazol. PTU is contraindicated because I have had toity. Methimazol is a useful medication, but it has a ton of adverse side effects. Rash is the most common side effect in 20% of patients. Most commonly, it's just itchy skin and we can prescribe Zyrtec. But um Steven Johnson syndrome has also been seen and so if they have hives, we cannot restart Methimazol and then um more rare but serious is bone marrow suppression and liver toxicity. And um for that reason, we say if someone is taking Methimazol and they have a fever and a sore throat, we say to stop the medication and get a CBC check to make sure they don't have a granu cytosis. And so before studying methos, all they need to have a baseline CBC and LFTs. Um so after about a year or two on therapy, the remission rate for groups disease is about 20 to 30%. And uh a lot of times we'll keep kids on therapy if they're um for even a little bit longer up to three years. But there is a low chance of going into remission if the thyroid is really large. Uh If the Graves disease is diagnosed at a young age or a more severe presentation, so high fry for a a and so if Methimazol, if medical therapy doesn't work, the, we have to move to definitive therapy. And the reason is, is because Methimazol is pretty toxic, you don't wanna be on it for years and years. Um And it's actually way easier to manage hypothyroidism than it is to manage hyperthyroidism. And so definitive therapy is to remove the thyroid tissue. So you end up with hypothyroidism and options are radioactive iodine ablation or surgery. Um But they would be working with us on that decision. So that is all I have for you all. Um And I'm happy to take any questions related to diet problems. Thank you for spending your lunch time with me. Great. Thank you so much, Doctor Chesser. We're going to give it a minute to see if anybody has any questions for her. Um It takes a little bit I know to type in there so we'll give you guys a minute um for the attendee just a reminder to submit your evaluations when you see it populated after this lecture is ended. And also it will be in your email if that's easier for you to do by tomorrow, we will be sending you the slides. Um If you have wanna look back and reference anything um moving forward also, you'll get that in an email in a couple of days. Let's give it another minute and we'll see if anybody has any questions. Here's one that just came in. The question is recent screening guidelines for thyroid disease for teenagers. I am not aware of new guidelines for screening in teenagers unless there are symptoms of hypothyroidism. I would be curious to know if you're referencing some guidelines that you're worth other questions asking. Do you need to do any screening for a newborn whose mom has hashimoto's thyroiditis in general? No, you don't. And the reason is, is because the um TPO and thyroglobulin antibodies while they do cross the placenta, um they, their t cell mediated inflammation. So by the time it would cause any problems, um the antibodies are gonna be out of the baby's bloodstream. So it's just like slow inflammatory process. So, no, um you don't, you don't need to check any TFTs in the baby. Great. Thank you. Another comment just says, thank you. Great talk. Another question is asking how often would you check? How often would you check TSH and screen when someone does have Throid antibodies? As long as uh someone who has thyroid antibodies does not have multiple symptoms of hypothyroidism, you only need to check the TFTs once a year. So you get a TSH and a free T four for the annual labs. Thank you. So give another minute in case there's any more questions that come in and I was just gonna, going back to the question about thyroid antibodies typically. Um I, I'm not gonna be starting treatment unless the TSH is over 10. So as long as the person is not super symptomatic and their free T four is normal, I, we try to hold off on treating um just because it's like uh it's lifelong therapy once we start. Great. Thank you. It looks like that's it for the questions. 01 more just came in. If the TFH and the T four are normal, why would you get one? Why would one get antibodies? That's a pretty good question. Um I don't, I don't think we should be just getting antibodies. I think sometimes families will ask their doctor for antibodies if someone in the family has a thyroid problem, but I would say it's better not to check. Um, there's no reason really for us to, to know if they're thyroid antibodies because the screening for a thyroid problem should be based off symptoms of hypo theism. Thank you. All right. We'll wrap it up for today unless I see any additional questions coming in. Thank you so much for presenting us today, taking time out of your lunch and thank you all to the attendees for taking time out of your lunch for listening to this CME. We hope you have a good Fourth of July holiday and we hope to see you back for our webinars in July. Have a great day. Everybody take care. Created by Related Presenters Hanna Chesser, MD, FAAP View full profile
