Pediatric Hypothyroidism Treatment & Management

  • Author: Robert J Ferry Jr, MD; Chief Editor: Stephen Kemp, MD, PhD   more...
 
Updated: Aug 12, 2010
 

Medical Care

In congenital hypothyroidism, treatment should be initiated as soon as the diagnosis is suggested, immediately after obtaining blood for confirmatory tests. Delaying treatment after 6 weeks of life is associated with a substantial risk of delayed cognitive development. Newborns with elevated TSH should be treated empirically with thyroid hormone replacement until they are aged 2 years to eliminate any possibility of permanent cognitive deficits caused by hypothyroidism.

  • Once treatment is initiated for congenital hypothyroidism, serum total T4 and TSH concentrations should be assessed monthly until the total or free T4 levels normalize, then every 3 months until the patient is aged 3 years. Thereafter, total T4 and TSH should be measured every 6 months.
    • In patients with thyroid agenesis, serum TSH levels may remain slightly elevated (15-25 mcIU/mL) despite adequate thyroid hormone replacement, as indicated by serum total or serum free T4 levels and clinical assessment.
    • This phenomenon has been termed a reset thyrostat and reflects initial transient unresponsiveness of the hypothalamic-pituitary axis (hypertrophied thyrotrophs) to thyroid hormone replacement. The higher the initial serum TSH, the more likely one is to observe persistent mild elevation despite adequate replacement. If appropriate thyroid hormone replacement therapy is given, the thyrostat typically resets to a normal value within a few months.
  • Initial evaluation and follow-up can be conducted on an outpatient basis.
  • Bone age may confirm the diagnosis of congenital hypothyroidism or can be used to assess excessive thyroid hormone replacement.
  • Therapeutic goals are normalization of thyroid function test results and elimination of all signs and symptoms of hypothyroidism.
  • Therapy should correct growth, pseudoprecocious puberty, and galactorrhea. Goiter may be reduced; however, replacement therapy often does not result in complete normalization of size.
  • When indicated by an elevated serum TSH, dosage adjustments of 0.0125 mg levothyroxine are usually sufficient. Because the half-life of T4 in the serum is about 6 days, approximately 3.5 weeks are required for serum T4 values to reach a new steady state. Depending on the degree of hypothyroidism and the time spent in the hypothyroid state, suppression of elevated TSH levels may take longer; therefore, repeat measurements of total T4 and TSH should be obtained no sooner than 1 month after any dosage adjustment or change in brand of thyroid hormone.
  • Levothyroxine tablets are easily crushed and can be given in a spoon with a small amount of water, formula, or cereal. Suspensions are not commercially available and are not recommended because maintaining a consistent concentration of levothyroxine in solution is difficult.
  • Approximately 20% of children with CLT recover to the euthyroid state and do not require lifelong thyroid hormone replacement. After treatment beyond the completion of puberty, a 6-month trial off thyroid hormone replacement therapy should be considered, with monitoring of serum TSH and total T4 levels every 3 months. If serum TSH levels rise above the reference range, levothyroxine treatment should be resumed and continued for life. Patients with CLT should undergo at least yearly monitoring of thyroid function with serum total T4 and TSH assessment to assure adequate treatment and maintenance of euthyroidism.
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Surgical Care

Rarely, a massive goiter may require surgical resection for cosmetic indications. Generally, surgical therapy has no role in the treatment of hypothyroidism. Case reports have documented surgical resection of an enlarged pituitary gland, which subsequently demonstrated physiologic thyrotroph hypertrophy related to primary hypothyroidism. This condition is best treated by adequate T4 replacement.

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Consultations

Consultation with a nuclear medicine physician is indicated for performance of radioiodine scan. Surgical consultation is advised during evaluation of a single cold nodule in the adolescent or young adult.

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Diet

No dietary restrictions are necessary. However, soy-based formulas have been recognized to reduce the absorption of levothyroxine. Thus, these infants may require a slightly higher replacement dose to achieve euthyroidism.

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Activity

Children with large pericardial effusions secondary to hypothyroidism should not participate in vigorous sports activities, until the effusion has resolved with T4 replacement. Such pericardial effusions from myxedema typically resolve within a month of attaining euthyroidism. No restriction of activity is required for patients with hypothyroidism who are euthyroid on replacement therapy.

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Contributor Information and Disclosures
Author

Robert J Ferry Jr, MD  Chief, Division of Pediatric Endocrinology and Metabolism, Le Bonheur Children's Hospital; Professor, Department of Pediatrics, University of Tennessee Health Science Center at Memphis; St. Jude Children's Research Hospital, Memphis, TN; Brigade Surgeon, 36th Sustainment Brigade, U.S. Army; Adjunct Professor, Pediatric Surgery Department, King Saud University, Riyadh, Saudi Arabia

Robert J Ferry Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Diabetes Association, American Medical Association, Endocrine Society, Lawson-Wilkins Pediatric Endocrine Society, Society for Pediatric Research, and Texas Pediatric Society

Disclosure: Nutropin Speakers Bureau Honoraria Speaking and teaching; Genotropin Speakers Bureau Honoraria Speaking and teaching; Eli Lilly & Co. Grant/research funds Independent contractor; MacroGenics, Inc. Grant/research funds Independent contractor; Ipsen, S.A. (formerly Tercica, Inc.) Grant/research funds Independent contractor; NovoNordisk SA Grant/research funds Independent contractor; Diamyd Independent contractor

Coauthor(s)

Andrew J Bauer, MD  Program Director, Pediatric Endocrinology Fellowship, Uniformed Services University of the Health Sciences; Chief, Pediatric Endocrinology, Walter Reed Army Medical Center/National Naval Medical Center

Andrew J Bauer, MD is a member of the following medical societies: American Academy of Pediatrics, American Thyroid Association, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Thomas A Wilson, MD  Professor of Clinical Pediatrics, Director of Pediatric Endocrinology, Department of Pediatrics, The School of Medicine at Stony Brook University Medical Center

Thomas A Wilson, MD is a member of the following medical societies: Endocrine Society, Lawson-Wilkins Pediatric Endocrine Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London)  Professor and Chair, First Department of Pediatrics, Athens University Medical School, Aghia Sophia Children's Hospital, Greece; UNESCO Chair on Adolescent Health Care, University of Athens, Athens, Greece

George P Chrousos, MD, FAAP, MACP, MACE, FRCP(London) is a member of the following medical societies: American Academy of Pediatrics, American College of Endocrinology, American College of Physicians, American Pediatric Society, American Society for Clinical Investigation, Association of American Physicians, Endocrine Society, Lawson-Wilkins Pediatric Endocrine Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Merrily P M Poth, MD  Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences

Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kemp, MD, PhD  Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas and Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

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