Pediatric Thyroid Disorders: Diagnosis, management ,and treatment
Pediatric Thyroid Disorders: Diagnosis, management, and treatment
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| Pediatric Thyroid Disorders: Diagnosis, management, and treatment |
Alright, just like Mike likes to talk very loud, I like to talk very fast. So if I start talking too fast, just slow me down. So I have no relevant disclosures to this talk.
And so this we're gonna start off with a baby. 18-day-old male recently discharged from NICU, establishing care with their primary care physician. Male was born at six pounds seven ounces after a 39-week gestation. The baby was born with congenital heart disease. Soon the discharge from the NICU, they repeated the newborn's screen 'cause he had surgery. Newborn's screen was positive for congenital hypothyroidism that came to your office, and so what do you do? The newborn screen on the TSH on the newborn screen was 120 which is very abnormal. Less than 11 is normal. And so then you repeat it and the TSH is greater than 100. And the free T4 is quite low. You can't see the mouse in here, okay. Alright, so this baby has congenital hypothyroidism.
The TSH rises really fast and that makes the thyroid start working. And the T4 and the T3 start to go. That's okay. And the T4 is actually very necessary for the first three years of life. It's necessary for all parts of life, but the brain growth is the fastest in the first three years of life, so it's very important to normalize it at that point.
So thankfully, even if the baby has congenital hypothyroidism, 95% of them will come out perfectly normal, because if the mom's thyroid levels are normal, the baby gets the thyroid levels from the mother.
And so they come out with normal weight, normal length. They may have a small open posterior fontanelle, but that's really hard to feel, and the majority of them don't have it. But if they don't get treated, the symptoms of lethargy and macroglossia and hypothermia, umbilical hernia, those all come later. Those are in babies that don't get treated. So thankfully in the US we rarely ever see this unless the baby isn't treated.
So in the newborn screen, the goal is for early detection of primary hypothyroidism, which if not treated promptly results in mental retardation. And that's really important to understand, that's primary hypothyroidism. So primary hypothyroidism means there's something wrong with the thyroid itself. So I always tell families, this is like your furnace.
The TSH is your thermostat. The thermostat makes the furnace work, but it also responds to the hormone that's coming out of the thyroid.
And so you have to know, whatever state you're in, is this a TSH-based scan or a free T4-based screen? In Michigan, we're a TSH-based screen. And so we're really trying to get kids with primary hypothyroidism because that's the majority of them.
So that means a child who has a brain abnormality who does not get the TSH secreted correctly or the secondary hypothyroidism, those kids are gonna fall through our cracks.
So if you have a child that you think has hypothyroidism, it is still important to check. And this screen is based on the newborn screen, and so you have to repeat with serum. And so primary congenital hypothyroid is actually really common if you think about it. The general population is one in 1,300.
And so this we're gonna start off with a baby. 18-day-old male recently discharged from NICU, establishing care with their primary care physician. Male was born at six pounds seven ounces after a 39-week gestation. The baby was born with congenital heart disease. Soon the discharge from the NICU, they repeated the newborn's screen 'cause he had surgery. Newborn's screen was positive for congenital hypothyroidism that came to your office, and so what do you do? The newborn screen on the TSH on the newborn screen was 120 which is very abnormal. Less than 11 is normal. And so then you repeat it and the TSH is greater than 100. And the free T4 is quite low. You can't see the mouse in here, okay. Alright, so this baby has congenital hypothyroidism.
Pediatric Thyroid Disorders: Diagnosis, management, and treatment
So this is the most preventable cause of mental retardation. This is really one of our best modern miracles, medical miracles. So as soon as you clamp the cord, the TSH rises really fast.The TSH rises really fast and that makes the thyroid start working. And the T4 and the T3 start to go. That's okay. And the T4 is actually very necessary for the first three years of life. It's necessary for all parts of life, but the brain growth is the fastest in the first three years of life, so it's very important to normalize it at that point.
So thankfully, even if the baby has congenital hypothyroidism, 95% of them will come out perfectly normal, because if the mom's thyroid levels are normal, the baby gets the thyroid levels from the mother.
And so they come out with normal weight, normal length. They may have a small open posterior fontanelle, but that's really hard to feel, and the majority of them don't have it. But if they don't get treated, the symptoms of lethargy and macroglossia and hypothermia, umbilical hernia, those all come later. Those are in babies that don't get treated. So thankfully in the US we rarely ever see this unless the baby isn't treated.
So in the newborn screen, the goal is for early detection of primary hypothyroidism, which if not treated promptly results in mental retardation. And that's really important to understand, that's primary hypothyroidism. So primary hypothyroidism means there's something wrong with the thyroid itself. So I always tell families, this is like your furnace.
The TSH is your thermostat. The thermostat makes the furnace work, but it also responds to the hormone that's coming out of the thyroid.
And so you have to know, whatever state you're in, is this a TSH-based scan or a free T4-based screen? In Michigan, we're a TSH-based screen. And so we're really trying to get kids with primary hypothyroidism because that's the majority of them.
So that means a child who has a brain abnormality who does not get the TSH secreted correctly or the secondary hypothyroidism, those kids are gonna fall through our cracks.
So if you have a child that you think has hypothyroidism, it is still important to check. And this screen is based on the newborn screen, and so you have to repeat with serum. And so primary congenital hypothyroid is actually really common if you think about it. The general population is one in 1,300.
Pediatric Thyroid Disorders: Diagnosis, management, and treatment
And it varies depending on ethnicity. And this is our data from Michigan in the last five years. This is the letter that you receive in your office. And so what you'll see is, it's important to have the birth date, the collection date, that's the hours, the collection age, the birth order. I still haven't figured out why birth order is important, but for some reason newborn screen wants it, and I'm sure that's probably a statistic. The mother's name because our newborn screen comes by the mother's name on discharge.
So if the baby changes the name, we will not have that name. The weight, gender, and any other important information. And then there are the expected results.
So less than 24 hours is undefined because as soon as the TSH surges, we don't know if it gets to 100 or if it gets to 60. We don't really know how high it gets. And then it has to come down. And these are the data that we have. So this is our newborn screen algorithm.
So less than 24 hours, we suspect it should be less than 44. And 24 to 36 hours should be less than 27. If it's not, then all of a sudden these different things start happening. So just be aware, this is all just on the newborn spot. This is not a serum. The Michigan Department of Community Health does recommend that preterm infants less than 34 weeks gestation get a second one. Same-sex twins get a second one, and that's the idea that there is some fetal blood merging in utero. So repeating it. And then infants with Down syndrome because they have kind of a slower drop in their TSH. And that's the screen of two to four weeks of age.
So 75% of babies with congenital hypothyroidism will be born with thyroid dysgenesis, which is basically either not being born, lingual thyroid, aplasia, ectopy. And then a small subset will have thyroid days hormonogenesis. These are the babies that are born with kind of just slightly abnormal TSH's. They could be like 80, less than 80. And when you try to take them off, later on,
So if the baby changes the name, we will not have that name. The weight, gender, and any other important information. And then there are the expected results.
So less than 24 hours is undefined because as soon as the TSH surges, we don't know if it gets to 100 or if it gets to 60. We don't really know how high it gets. And then it has to come down. And these are the data that we have. So this is our newborn screen algorithm.
So less than 24 hours, we suspect it should be less than 44. And 24 to 36 hours should be less than 27. If it's not, then all of a sudden these different things start happening. So just be aware, this is all just on the newborn spot. This is not a serum. The Michigan Department of Community Health does recommend that preterm infants less than 34 weeks gestation get a second one. Same-sex twins get a second one, and that's the idea that there is some fetal blood merging in utero. So repeating it. And then infants with Down syndrome because they have kind of a slower drop in their TSH. And that's the screen of two to four weeks of age.
So 75% of babies with congenital hypothyroidism will be born with thyroid dysgenesis, which is basically either not being born, lingual thyroid, aplasia, ectopy. And then a small subset will have thyroid days hormonogenesis. These are the babies that are born with kind of just slightly abnormal TSH's. They could be like 80, less than 80. And when you try to take them off, later on,
they don't come off. They just have slightly abnormal levels. And you may see siblings with this one because it is autosomal recessive. This is the ones that we can't screen for in the newborn screen unless we screen for free T4. This is the hypothalamic-pituitary deficiency. And you'll see that in midline defects. And then there is a small subset that will have transient hypothyroidism due to really maternal issues or neonatal issues. And then if mom has Graves' disease, you could actually see the antithyroid drugs cross the placenta.
So our state's goal is to start treatment by two weeks of age. And if we are testing the kids and these thyroid levels just don't normalize, sometimes we just bite the bullet and say we're gonna treat. It's not worth sometimes kind of continuing to check and losing time, and so we will treat these kids for subclinical hypothyroidism for the first three years of life and then try to take them off.
So the goals of therapy. We try to aim for a free T4 in the upper range of normal, and a TSH with a normal range, and that's usually around three. And we use three because the normal range is like .35 to 5.5. We use that in the range just so that we have legal room as they grow. Treatment is Synthroid DAW. The reason we want that is that if they go to Myer's or Walgreens, they'll get the same formulation versus if they went to Myer, they might have different generic. We do tablets, we crush it and put it in a small amount of breast milk or formula.
So these babies do not have to have it on an empty stomach like you hear us talk about with older kids. And then we start, as a rule of thumb is 50 micrograms for full-term infants, and 37.5 for preterm or small infants. But if their free T4 is quite low, we might do kind of a loading dose for just a short period of time to get the free T4 back up.
So early treatment is really critical for the normal neurological outcome, and if we do this, the babies do fine.
So this is a 15-year-old girl with a one-month history of diarrhea and weight loss. She complains occasionally of shortness of breath, difficulty sleeping, moodiness, irregular menses, no past medical history, none. Medications, albuterol is needed. And mom has type one diabetes and celiac disease.
So before that, that's pretty much a lot of your patients, right?
So on your exam though. She is anxious, she's fidgety, but she's not really in acute distress. Her eyes are bulging a little bit. When she tries to close her eyes, her eyes definitely have kind of a slow decrease, and her eyes can tremor eyelids tremor. And her goiter is quite large. And if you listen you can hear bruit, but no nodules. And then when you have her stick out her arms, you can see her shake, and she otherwise looks OK.
So you get labs and her TSH is suppressed and her free T4 is quite high, as well as her T3. And so those are kind of the beginning labs. I always also caution just to get a CBC and liver function test at the same time because that actually helps us decide what medications we can use.
So this girl has hypothyroid, obviously. And she has very similar symptoms as you would see in adults. They can have problems sleeping, they can be fatigued, they can tremor, heart tachycardia, their periods become irregular and they can lose weight. Although weight loss is not always consistent. But in kids, a lot of times what you see is their behavior deteriorates. They're having problems in school. They can't sit still. A lot of kids will get evaluated for ADHD during this time period because parents and the teachers think there's something just happened that's different. And thyroid is also a growth hormone. It makes the kids grow really fast. And so you could actually see them starting to jump percentiles. So then the kids do look really skinny because they've kind of stretched out.
So part of our evaluation is if we wanted to do imaging, we could do a thyroid scan, and this is just a picture. It just tells us if there are any nodules and kind of the size of the thyroid.
If we wanted to actually get the function of the thyroid, we do radioactive iodine. And so what happens if you give them a small dose of iodine and it goes right to the thyroid.
So if the thyroid is actively making thyroid hormone, it gets incorporated into it, and so you see the thyroid light up. If the thyroid is not actively working, the iodine just goes through the patient, and they just urinate it out.
And so this is just kind of a function test to see how fast the thyroid is working. And ultrasound again gives us an idea if there are any cysts. And then if there are cysts, we can do a fine needle aspiration.
So when I think of hypothyroidism I like to divide it into three kinds of big categories. One is hyperfunction, one is destruction, and one is like other, which is like ingestion or administration of thyroid hormone. And within the hyperfunction, I think of Graves' disease, and then autonomously functioning thyroid nodules. Within the destruction, you have subacute thyroiditis and then Hashimoto's. And then ingestion is something that iatrogenic, what we do, or something that's happened without our knowledge or parents' knowledge.
So within the hyperfunction, the most common one we see is Graves' disease.
This is an autoimmune disease that either happens through the receptor or through the TSH. And then 60% of them will have some family history of thyroid problems, not necessarily Graves' disease, but they could have Hashimoto's or some other autoimmune disorder. And the majority of the kids are gonna come in early puberty around the 10 to 15 years of age 'cause this is autoimmune disease kind of peak in pediatrics there on puberty. And it happens more in females than males just because of the autoimmune factor. And on lab work, you'll see a positive TSI or thyroid-stimulating immunoglobulin. Another hyperfunction is a toxic adenoma. This is the hot nodules that you might hear us talking about. You can see cancer that's hyperfunctioning. And then in some syndromes such as McCune-Albright syndrome they can also have hyperfunctioning thyroid cells. And so the classic McCune-Albright triad is the cafe-au-lait spots, the fibrous dysplasia, and the precocious puberty.
Subacute thyroiditis is also destruction. So basically, you have the hyperfunction. Now we're destroying the thyroid so the thyroid releases the thyroid hormone and causes hypothyroidism. And so this is self-limited. It comes usually with an infection.
So the thyroid gets sick is what I tell families. And it happens equally in males and females because this is not autoimmune. The clinical presentation is that you'll see a patient come in with a fever. They can have pain from the thyroid. They can refer to the jaw, and their thyroid will be tender.
Sometimes families can't quite figure out where the pain is coming from. They just don't feel right. They will have all the signs and symptoms of hypothyroid.
So in this situation, if you did the testing, you'll see the increased T3 and the T4 and the suppression of TSH. The radioactive iodine will below.
So our state's goal is to start treatment by two weeks of age. And if we are testing the kids and these thyroid levels just don't normalize, sometimes we just bite the bullet and say we're gonna treat. It's not worth sometimes kind of continuing to check and losing time, and so we will treat these kids for subclinical hypothyroidism for the first three years of life and then try to take them off.
So the goals of therapy. We try to aim for a free T4 in the upper range of normal, and a TSH with a normal range, and that's usually around three. And we use three because the normal range is like .35 to 5.5. We use that in the range just so that we have legal room as they grow. Treatment is Synthroid DAW. The reason we want that is that if they go to Myer's or Walgreens, they'll get the same formulation versus if they went to Myer, they might have different generic. We do tablets, we crush it and put it in a small amount of breast milk or formula.
So these babies do not have to have it on an empty stomach like you hear us talk about with older kids. And then we start, as a rule of thumb is 50 micrograms for full-term infants, and 37.5 for preterm or small infants. But if their free T4 is quite low, we might do kind of a loading dose for just a short period of time to get the free T4 back up.
So early treatment is really critical for the normal neurological outcome, and if we do this, the babies do fine.
Pediatric Thyroid Disorders: Diagnosis, management, and treatment
I have plenty of honor students who have congenital hypothyroidism who are just doing wonderfully. But if they're not treated adequately for whatever reason, they will have lower IQs, they have a gross and fine motor impairment, language deficits and poor visual-spatial abilities. So we're gonna move now into the next kind of case.So this is a 15-year-old girl with a one-month history of diarrhea and weight loss. She complains occasionally of shortness of breath, difficulty sleeping, moodiness, irregular menses, no past medical history, none. Medications, albuterol is needed. And mom has type one diabetes and celiac disease.
So before that, that's pretty much a lot of your patients, right?
So on your exam though. She is anxious, she's fidgety, but she's not really in acute distress. Her eyes are bulging a little bit. When she tries to close her eyes, her eyes definitely have kind of a slow decrease, and her eyes can tremor eyelids tremor. And her goiter is quite large. And if you listen you can hear bruit, but no nodules. And then when you have her stick out her arms, you can see her shake, and she otherwise looks OK.
So you get labs and her TSH is suppressed and her free T4 is quite high, as well as her T3. And so those are kind of the beginning labs. I always also caution just to get a CBC and liver function test at the same time because that actually helps us decide what medications we can use.
So this girl has hypothyroid, obviously. And she has very similar symptoms as you would see in adults. They can have problems sleeping, they can be fatigued, they can tremor, heart tachycardia, their periods become irregular and they can lose weight. Although weight loss is not always consistent. But in kids, a lot of times what you see is their behavior deteriorates. They're having problems in school. They can't sit still. A lot of kids will get evaluated for ADHD during this time period because parents and the teachers think there's something just happened that's different. And thyroid is also a growth hormone. It makes the kids grow really fast. And so you could actually see them starting to jump percentiles. So then the kids do look really skinny because they've kind of stretched out.
So part of our evaluation is if we wanted to do imaging, we could do a thyroid scan, and this is just a picture. It just tells us if there are any nodules and kind of the size of the thyroid.
If we wanted to actually get the function of the thyroid, we do radioactive iodine. And so what happens if you give them a small dose of iodine and it goes right to the thyroid.
So if the thyroid is actively making thyroid hormone, it gets incorporated into it, and so you see the thyroid light up. If the thyroid is not actively working, the iodine just goes through the patient, and they just urinate it out.
And so this is just kind of a function test to see how fast the thyroid is working. And ultrasound again gives us an idea if there are any cysts. And then if there are cysts, we can do a fine needle aspiration.
So when I think of hypothyroidism I like to divide it into three kinds of big categories. One is hyperfunction, one is destruction, and one is like other, which is like ingestion or administration of thyroid hormone. And within the hyperfunction, I think of Graves' disease, and then autonomously functioning thyroid nodules. Within the destruction, you have subacute thyroiditis and then Hashimoto's. And then ingestion is something that iatrogenic, what we do, or something that's happened without our knowledge or parents' knowledge.
So within the hyperfunction, the most common one we see is Graves' disease.
This is an autoimmune disease that either happens through the receptor or through the TSH. And then 60% of them will have some family history of thyroid problems, not necessarily Graves' disease, but they could have Hashimoto's or some other autoimmune disorder. And the majority of the kids are gonna come in early puberty around the 10 to 15 years of age 'cause this is autoimmune disease kind of peak in pediatrics there on puberty. And it happens more in females than males just because of the autoimmune factor. And on lab work, you'll see a positive TSI or thyroid-stimulating immunoglobulin. Another hyperfunction is a toxic adenoma. This is the hot nodules that you might hear us talking about. You can see cancer that's hyperfunctioning. And then in some syndromes such as McCune-Albright syndrome they can also have hyperfunctioning thyroid cells. And so the classic McCune-Albright triad is the cafe-au-lait spots, the fibrous dysplasia, and the precocious puberty.
Subacute thyroiditis is also destruction. So basically, you have the hyperfunction. Now we're destroying the thyroid so the thyroid releases the thyroid hormone and causes hypothyroidism. And so this is self-limited. It comes usually with an infection.
So the thyroid gets sick is what I tell families. And it happens equally in males and females because this is not autoimmune. The clinical presentation is that you'll see a patient come in with a fever. They can have pain from the thyroid. They can refer to the jaw, and their thyroid will be tender.
Sometimes families can't quite figure out where the pain is coming from. They just don't feel right. They will have all the signs and symptoms of hypothyroid.
So in this situation, if you did the testing, you'll see the increased T3 and the T4 and the suppression of TSH. The radioactive iodine will below.
The uptake will be low because this is not a hyperfunctioning thing. This is destruction. So basically, if you give them iodine, they're just gonna urinate it out. So it will not just light up on the scan. And there'll be no thyroid antibodies. So thankfully, this is self-limiting.
So one to three weeks, one to four weeks, the thyroid will totally empty out, and then they'll go into a hypothyroid phase where the thyroid has to kind of recover.
So the whole time is somewhere between two to nine months, and they will get back to normal thyroid function tests.
If the child is really uncomfortable, you could do anti-inflammatory drugs or you could do corticosteroids. But most of the time you just have to wait it out. "Hashimoto's thyroiditis is the most well-known reason for hypothyroidism." It is also autoimmune, and you'll hear people call it chronic lymphocytic based on what you would see on the ultrasound, or autoimmune. You will see thyroid antibodies in greater than 80%, and it's associated with other autoimmune disorders. In five to 10% of them who have Hashimoto's, they have a thyrotoxic phase, and that's basically, again, the emptying of the thyroid.
So one to three weeks, one to four weeks, the thyroid will totally empty out, and then they'll go into a hypothyroid phase where the thyroid has to kind of recover.
So the whole time is somewhere between two to nine months, and they will get back to normal thyroid function tests.
If the child is really uncomfortable, you could do anti-inflammatory drugs or you could do corticosteroids. But most of the time you just have to wait it out. "Hashimoto's thyroiditis is the most well-known reason for hypothyroidism." It is also autoimmune, and you'll hear people call it chronic lymphocytic based on what you would see on the ultrasound, or autoimmune. You will see thyroid antibodies in greater than 80%, and it's associated with other autoimmune disorders. In five to 10% of them who have Hashimoto's, they have a thyrotoxic phase, and that's basically, again, the emptying of the thyroid.
The thyroid can be tender, so it can look like subacute thyroiditis. But they will have positive thyroid antibodies. And if you also did the radioactive iodine uptake, it's also lower absent, and the treatment, again, in this situation is symptomatic. The majority of the time by the time we see them, they have gone through that hypothyroid phase and they're already hypothyroid.
And so their thyroid might have actually atrophied at that point. So the third class is kind of the ingestion or the administration of thyroid hormone.
So it could be iatrogenic, meaning that some patients will try to take thyroid support with thyroid medications. You can get these at any health food store, and it's basically to help your metabolism. Of course, you could put yourself into heart failure, but you will lose weight.
So this is something we have to ask about now, especially now in this day and age where things are really happening with people are going and doing all these different types of health food stores.
It could be accidental. There are kids who can get into their parents' Synthroid. There was a couple decades ago, I think there was a situation where a beef farmer didn't take the thyroids out of the cow's meat, a lot of meat had thyroid tissue in it. So all of a sudden they had a group of people that became hypothyroid. That's pretty unusual, and I think nowadays you shouldn't see that, but it can happen. And then certain medications have iodine, especially one that our cardiologists love to use,
And so their thyroid might have actually atrophied at that point. So the third class is kind of the ingestion or the administration of thyroid hormone.
So it could be iatrogenic, meaning that some patients will try to take thyroid support with thyroid medications. You can get these at any health food store, and it's basically to help your metabolism. Of course, you could put yourself into heart failure, but you will lose weight.
So this is something we have to ask about now, especially now in this day and age where things are really happening with people are going and doing all these different types of health food stores.
It could be accidental. There are kids who can get into their parents' Synthroid. There was a couple decades ago, I think there was a situation where a beef farmer didn't take the thyroids out of the cow's meat, a lot of meat had thyroid tissue in it. So all of a sudden they had a group of people that became hypothyroid. That's pretty unusual, and I think nowadays you shouldn't see that, but it can happen. And then certain medications have iodine, especially one that our cardiologists love to use,
which is amiodarone.
That has 35% iodine content. And so again, kind of watching and looking at the medication list to see what's happening. Most of our patients that come for amiodarone know that risk. So back to our case.
So the TSH is suppressed. The free T4 obviously is high, the T3 is high. This child actually has both Hashimoto's and Graves'. That can happen very often.
So it's two autoimmune disorders that come in the same family. And so I usually say, when you have Graves' disease, that one wins because you have to make the thyroid to stop working, and then Hashimoto's, it will stop working eventually, but the Hashimoto's won't have a chance to do anything until the thyroid kind of burns out. And so the first thing that they need to do before they walk out of your office is cardioprotection.
So you have to do either propranolol or atenolol. We prefer the propranolol. It actually does slow down the conversion of T3, sorry, T4 to T3, and T3 is the active hormone. But if a child has asthma, then we have to go with atenolol.
So just making sure that they get started appropriately. And then they have two choices or three choices. The first choice is the blockade of thyroid hormone synthesis. This is a time buyer. This is a medication we can use to basically block at the thyroid level. And it says the statistics are 60 to 70% successful, although I find if you keep pushing the dose up, you will eventually suppress the child.
The other one in the same class is PTU, which we don't use very much because it has been associated with liver failure. With methimazole, we do have to make sure that we watch the liver functions very closely because they can have abnormal liver functions with the methimazole. And if that happens we have to talk about whether or not this medication is appropriate for them.
Other side effects include granulocytopenia, agranulocytosis, and a rash which can look almost like Stevens-Johnson.
So not a benign medication, and we could use it for about two to five years with the idea that some of these kids might go into remission, and the remission may not be long-lasting. So they can go into remission, and then it could come back later on.
So I usually tell families we can try this medication for two to five years to buy time for either definitive treatment or to see if we can actually not do anything right now. If we are going to definitive treatment, your two choices are radioactive iodine therapy or surgery.
So radioactive iodine, you give a large dose of iodine, it goes right to the thyroid, and it actually just destroys the thyroid right there. It doesn't go to anywhere else in the body because no other body parts need iodine like this.
And it results in permanent hypothyroidism. It's been used for decades, and long-term safety seems very positive. It is the most unexciting treatment. People think that they're gonna glow. They don't glow. But you do have to keep them away from developing thyroids.
So the nuclear medicine doctor will tell them to stay away from like pregnant women and babies and young children, and so there are some different type of activities that they have to do. If they do not want to do radioactive iodine or if it's not an option for them, another choice is surgery.
And so surgery is really used for those who have those who failed initial therapy with radioactive iodine, if they have a severe eye disease, or if the family chooses. And we're really lucky at the University of Michigan. We have a great thyroid surgeon,
That has 35% iodine content. And so again, kind of watching and looking at the medication list to see what's happening. Most of our patients that come for amiodarone know that risk. So back to our case.
So the TSH is suppressed. The free T4 obviously is high, the T3 is high. This child actually has both Hashimoto's and Graves'. That can happen very often.
So it's two autoimmune disorders that come in the same family. And so I usually say, when you have Graves' disease, that one wins because you have to make the thyroid to stop working, and then Hashimoto's, it will stop working eventually, but the Hashimoto's won't have a chance to do anything until the thyroid kind of burns out. And so the first thing that they need to do before they walk out of your office is cardioprotection.
So you have to do either propranolol or atenolol. We prefer the propranolol. It actually does slow down the conversion of T3, sorry, T4 to T3, and T3 is the active hormone. But if a child has asthma, then we have to go with atenolol.
So just making sure that they get started appropriately. And then they have two choices or three choices. The first choice is the blockade of thyroid hormone synthesis. This is a time buyer. This is a medication we can use to basically block at the thyroid level. And it says the statistics are 60 to 70% successful, although I find if you keep pushing the dose up, you will eventually suppress the child.
The other one in the same class is PTU, which we don't use very much because it has been associated with liver failure. With methimazole, we do have to make sure that we watch the liver functions very closely because they can have abnormal liver functions with the methimazole. And if that happens we have to talk about whether or not this medication is appropriate for them.
Other side effects include granulocytopenia, agranulocytosis, and a rash which can look almost like Stevens-Johnson.
So not a benign medication, and we could use it for about two to five years with the idea that some of these kids might go into remission, and the remission may not be long-lasting. So they can go into remission, and then it could come back later on.
So I usually tell families we can try this medication for two to five years to buy time for either definitive treatment or to see if we can actually not do anything right now. If we are going to definitive treatment, your two choices are radioactive iodine therapy or surgery.
So radioactive iodine, you give a large dose of iodine, it goes right to the thyroid, and it actually just destroys the thyroid right there. It doesn't go to anywhere else in the body because no other body parts need iodine like this.
And it results in permanent hypothyroidism. It's been used for decades, and long-term safety seems very positive. It is the most unexciting treatment. People think that they're gonna glow. They don't glow. But you do have to keep them away from developing thyroids.
So the nuclear medicine doctor will tell them to stay away from like pregnant women and babies and young children, and so there are some different type of activities that they have to do. If they do not want to do radioactive iodine or if it's not an option for them, another choice is surgery.
And so surgery is really used for those who have those who failed initial therapy with radioactive iodine, if they have a severe eye disease, or if the family chooses. And we're really lucky at the University of Michigan. We have a great thyroid surgeon,
and so you really do want someone who has a lot of experience, and we have one surgeon, Dr. Bruch, who does a lot of these for us. But surgery is never easy to decide. There are definitely complications that can occur in the two classic board questions are hypoparathyroidism and recurrent laryngeal nerve damage.
So he will counsel them, these are the two choices. There are things that he is doing now to kind of prevent or reduce the chances of them having it, but these, unfortunately, still do occur sometimes.
Alright. So my last case. A 13-year-old girl with no known medical issues. Mom was actually training to be an ultrasonographer, so she was testing it out on her child just like we all tested a lot of things out on our kids. And she detected a nodule in her thyroid.
So she went to see her pediatrician. I'm sure that was a fun conversation. And the exam was totally normal.
So the mom did have hypothyroidism, and so the pediatrician repeated the ultrasound by a person who's already accredited, and there was a thyroid nodule.
So it was .7 x .7 x .7, which is kind of less than we always talk about the one-centimeter remark. But in this situation, there were coarse internal calcifications, which is one of those things that you have to kind of be aware of that are not good to see.
So thyroid nodules are thankfully very rare. In kids, it's .2 to 1.8%,
So he will counsel them, these are the two choices. There are things that he is doing now to kind of prevent or reduce the chances of them having it, but these, unfortunately, still do occur sometimes.
Alright. So my last case. A 13-year-old girl with no known medical issues. Mom was actually training to be an ultrasonographer, so she was testing it out on her child just like we all tested a lot of things out on our kids. And she detected a nodule in her thyroid.
So she went to see her pediatrician. I'm sure that was a fun conversation. And the exam was totally normal.
So the mom did have hypothyroidism, and so the pediatrician repeated the ultrasound by a person who's already accredited, and there was a thyroid nodule.
So it was .7 x .7 x .7, which is kind of less than we always talk about the one-centimeter remark. But in this situation, there were coarse internal calcifications, which is one of those things that you have to kind of be aware of that are not good to see.
So thyroid nodules are thankfully very rare. In kids, it's .2 to 1.8%,
and probably 1/5 to 1/4 of these kids, they are gonna be malignant. Now it is common. Malignancy is not as much in adults, but it's a lot bigger number in pediatrics.
And so we usually classify the nodules either as benign or malignant. And you can see the different types of thyroid cancers that are listed.
So the factors that are associated with malignancy is if a patient has head and neck irradiation if they've had treatment for cancer before and if there's a family history of medullary carcinoma.
So I'm gonna detour to talk about the multiple endocrine neoplasias.
So as you can see, the medullary thyroid carcinoma is known to be in medullary MEN 2A and 2B. And depending on when you find out about this, if this is a family history, there are time periods where you have to take the thyroid out because it's almost 100% that they're gonna get medullary thyroid carcinoma.
And so we usually classify the nodules either as benign or malignant. And you can see the different types of thyroid cancers that are listed.
So the factors that are associated with malignancy is if a patient has head and neck irradiation if they've had treatment for cancer before and if there's a family history of medullary carcinoma.
So I'm gonna detour to talk about the multiple endocrine neoplasias.
So as you can see, the medullary thyroid carcinoma is known to be in medullary MEN 2A and 2B. And depending on when you find out about this, if this is a family history, there are time periods where you have to take the thyroid out because it's almost 100% that they're gonna get medullary thyroid carcinoma.
And so usually in the MEN 2B and A, the goal is actually to take out the thyroid by six months. If it's MEN 2A, it has a less pathogenic version. They can get them out by like early teenagers or age five depending on what their mutation is. And they could have other diseases such as pheochromocytoma. And then the pituitary adenoma. If the nodule is growing really fast, if it's firm, if it's adjacent to other structures, if you have also a child that has vocal cord paralysis, that's something to be worried about. Enlargement of regional lymph nodes. Evidence of distant metastases. Those are all things that we would want to be more worried about.
So we do recommend getting thyroid function tests first even if you have a large thyroid nodule just to make sure that we know what we are dealing with. If the TSH is suppressed, it's usually good news,
So we do recommend getting thyroid function tests first even if you have a large thyroid nodule just to make sure that we know what we are dealing with. If the TSH is suppressed, it's usually good news,
it's probably a hot nodule. And those have less likelihood of cancer. If it's elevated, it could be Hashimoto thyroiditis, also has fewer chances of cancer.
So in Hashimoto's, the recommendations are that it's not to get a routine ultrasound unless you feel a nodule, and most people can feel a nodule when it gets to be above one centimeter. But if you have a nodule, making sure that the patient doesn't have Hashimoto's is really important because that kind of helps us guide our direction.
So in Hashimoto's, the recommendations are that it's not to get a routine ultrasound unless you feel a nodule, and most people can feel a nodule when it gets to be above one centimeter. But if you have a nodule, making sure that the patient doesn't have Hashimoto's is really important because that kind of helps us guide our direction.
We will get an ultrasound, and we'll do a fine needle aspiration if we find solid material. If it's cystic, it's most likely just colloid and it's not something we can really need to do anything about.
So referral to surgery is anything that's concerning for malignancy, any positive or suspicious FNA's, or any cystic lesions. Just again, to kind of talk to the family about what we need to do next, and then we send them to nuclear medicine for radioiodine therapy if they have cancer. I just want to take a second to kind of go about our new pathway for taking care of thyroid nodules.
So before this, you guys would refer to ped endo, we would see them in the clinic, we were doing screen labs, we refer to ped surge, they would be seen in ped surge, repeat neck ultrasound then, they would see radiology appointment for FNA, and then they would go to the ped surgery clinic to discuss the therapy options.
So that would take a long time, and families would get very frustrated. And really, it took about six to nine months to get them to the final endpoint, which is a thyroidectomy. And so one of the things that we decided to do is actually start a multidisciplinary pediatric endocrine surgery clinic, and this started in May 2013.
So this is an example. This is actually the case of the girl
So referral to surgery is anything that's concerning for malignancy, any positive or suspicious FNA's, or any cystic lesions. Just again, to kind of talk to the family about what we need to do next, and then we send them to nuclear medicine for radioiodine therapy if they have cancer. I just want to take a second to kind of go about our new pathway for taking care of thyroid nodules.
So before this, you guys would refer to ped endo, we would see them in the clinic, we were doing screen labs, we refer to ped surge, they would be seen in ped surge, repeat neck ultrasound then, they would see radiology appointment for FNA, and then they would go to the ped surgery clinic to discuss the therapy options.
So that would take a long time, and families would get very frustrated. And really, it took about six to nine months to get them to the final endpoint, which is a thyroidectomy. And so one of the things that we decided to do is actually start a multidisciplinary pediatric endocrine surgery clinic, and this started in May 2013.
So this is an example. This is actually the case of the girl
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| Pediatric Thyroid Disorders: Diagnosis, management, and treatment |
who came in with the mom that has the ultrasonographer.
So she was referred to us in August. She was seen in our clinic on September 3rd, and what happens in that clinic is it's Dr. Bruch, and then either Dr. Menon and I, we're the endocrinologists there.
So they come in, they get an ultrasound right before they see us, there's a radiologist there, he reads the ultrasound, and he actually pages Dr. Bruch and tells him the results.
So before we walk in to see the patient, we actually know the results of the ultrasound. If we have the suspicion that this child needs an FNA,
So she was referred to us in August. She was seen in our clinic on September 3rd, and what happens in that clinic is it's Dr. Bruch, and then either Dr. Menon and I, we're the endocrinologists there.
So they come in, they get an ultrasound right before they see us, there's a radiologist there, he reads the ultrasound, and he actually pages Dr. Bruch and tells him the results.
So before we walk in to see the patient, we actually know the results of the ultrasound. If we have the suspicion that this child needs an FNA,
we actually get it set up beforehand. We tell the families don't eat, and then they have an appointment scheduled.
And so they get the FNA in the afternoon. We tell them within one or two days what the results are, and then they get the thyroidectomy if needed.
So we've really managed to get everything done much faster. So this is our new referral process. So you still send them to us,
And so they get the FNA in the afternoon. We tell them within one or two days what the results are, and then they get the thyroidectomy if needed.
So we've really managed to get everything done much faster. So this is our new referral process. So you still send them to us,
but just be aware that you might not need to send them to ped surgery too. We might actually be able to get this done much faster now. And families are really happy because we're actually in the room together talking about it.
And I think I finished just in time too. Thank you.
And I think I finished just in time too. Thank you.
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