thyroid disorders in children diagnosis and treatment .pptx

thyroid disorders in children diagnosis and treatment .

1. Field of Medicine Medicine Program Lecture : (thyroid gland disordres in children ) Date : 24/2 /2025 Dr : (Marwa Elsayed )

2. Thyroid gland Location: Located close to thyroid cartilage. Has two lateral lobes connected by thyroid isthmus medially. Development: first endocrine gland to appear during development. Develops from endodermal floor of early pharynx

3. Thyroid gland • Thyroid gland is composed of over a million cluster of follicles • Follicles are spherical & consists of epithelial cells surrounding a central mass (colloid) • Thyroglobulin is a storage room • Two main hormones: – Tetraiodothyronine (Thyroxin) = T4 – Triiodothyronine = T3

4. Foetal brain & skeletal maturation • Increase in basal metabolic rate • Inotropic & chronotropic effects on heart • Increases sensitivity to catecholamines • Stimulates gut motility • Increase bone turnover • Increase in serum glucose Decrease in serum cholesterol • Conversion of carotene to vitamin A • Play role in thermal regulation Effects of thyroid hormones

5. • Congenital • Acquired – Primary – Secondary – Tertiary Thyroid disorders: Aetiolog y

6. Causes of hypothyroidism Congenital Autoimmune (Hashimoto) Iodine deficiency Subacute thyroiditis Drugs (amiodarone) Irradiation Thyroid surgery Central hypothyroidism (radiotherapy, surgery, tumor) .

7. Agenesis (No goiter) or dysgenesis (aplasia, hypoplasia, ectopic gland) are the commonest causes …..85% Dyshormonogenesis (10%) and a goiter will be present. Pendred syndrome with sensorineural deafness is the commonest (often euthyroid). Transplacental maternal TSH receptor blocking Abs (TRBAb) account for 5% of cases. Pituitary failure and maternal ingestion of goitrogens are other causes Congenital hypothyroidism

8. One of the most common treatable causes of Mental retardation CH Screening is the most cost effective program Almost all affected Newborns have no S/S at birth Congenital Anomalies increased by 10% (cardiac) It is permanent in more than 90% of the cases The earlier diagnosis the better IQ

9. Newborn Screening

10. . Clinical Features of Congenital Hypothyroidism Finding % Lethargy 96% Constipation 92% Feeding problems 83% Respiratory problems 76% Dry skin 76% Thick tongue 67% Hoarse cry 67% Umbilical hernia 67% Prolonged jaundice 12% Goiter 8%

11. Clinical features of Acquired hypothyroidism Weight gain Goitre Short sature Fatigue Constipation Dry skin Cold Intolerance Hoarseness Sinus Bradycardia .

12. A. Delayed epiphyseal appearance B. epiphyseal dysgensis

13. . suspect Clinical Confirm Rx & FU Biochemical (screening) Lab ( TSH & FT4 ) T scan B age Optional Thyroxine Congenital Hypothyroidism X Growth & D TSH & FT4

14. Neonatal screening for congenital hypothyroidism • Routine in most countries worldwide • Filter paper blood spot measuring TSH • Why ?? • Clinical manifestations at birth, usually are subtle or even absent (passive transplacental maternal thyroxin) • At birth, surge of TSH (stress of delivery) up to 30 -40 µu/ml • Early detection will prevent mental retardation or decreasing IQ of affected neonates • Thyroxin is important for CNS development from birth till 3 years of life • Screening program will miss 2ry/tertiary cases • The program is hampered by a high rate of false positive results Neonatal screening for congenital hypothyroidism

15. Newborn Screening

16. • Documentation – Free T4, TSH , Maternal investigations: TFT and Abs • Thyroid scan, ultrasound (optional) • Treatment (normal size full term) – start L-thyroxin at 10-15 mcg/Kg daily – Monitor TSH every 2-3 months during first 2 years of life. Management of congenital hypothyroidism

17. . Clinical Outcome Pre-screening data: Mean IQ = 76 Post-screening data: Children screened & treated by age 25 days Mean IQ = 104 Age of Diagnosis % with IQ > 85 3 months 78% 6 months 19% > 7 months 0%

18. • More common than hyperthyroidism • 99% is primary (< 1% due to TSH deficiency) • Hashimoto ’ s Most common cause of hypothyroidism Autoimmune lymphocytic thyroiditis Antithyroid antibodies: Thyroglobulin Ab Microsomal Ab TSH-R Ab (block) Females > Males Runs in Families • Iatrogenic Hypothyroidism from radioactive iodine therapy Acquired hypothyroidism

19. Symptoms – General Slowing Down – Lethargy/somnolence – Depression – Modest Weight Gain – Cold Intolerance – Hoarseness – Dry skin – Constipation (↓ peristaltic activity) – General Aches/Pains – Arthralgias or myalgias (worsened by cold temps) – Brittle Hair – Menstrual irregularities – Excessive bleeding – Failure of ovulation – ↓ Libido Symptoms

20. • Dry, pale, course skin with yellowish tinge • Periorbital edema • Puffy face and extremities • Sinus Bradycardia • Diastolic HTN • ↓ Body temperature • Delayed relaxation of reflexes • Megacolon (↓ peristaltic activity) • Pericardial/ pleural effusions • Congestive heart failure • Non-pitting edema • Hoarse voice • Myopathy Examination

21. Subacute (de Quervain’s) Thyroiditis Preceding viral infection Infiltration of the gland with granulomas Painful goitre Hyperthyroid phase  Hypothyroid phase

22. Acquired Hypothyroidism • TSH • fT4 • Thyroid antibodies • Thyroid ultrasound • TSH: low in secondary hypothyroidism -high in primary hypothyroidism • TRH test: to differentiate between secondary & Tertiary hypothyroidism Diagnosis

23. Treatment Most people with Hashimoto's disease take medication to treat hypothyroidism. If you have mild hypothyroidism, you may have no treatment but get regular TSH tests to monitor thyroid hormone levels. T-4 hormone replacement therapy The treatment goal is to restore and maintain adequate T-4 hormone levels and improve symptoms of hypothyroidism. You will need this treatment for the rest of your life. Monitoring the dosage Your heath care provider will determine a dosage of levothyroxine that's appropriate for your age, weight, current thyroid production, other medical conditions and other factors. Your provider will retest your TSH levels about 6 to 10 weeks later and adjust the dosage as necessary. Once the best dosage is determined, you will continue to take the medication once a day. You'll need follow-up tests once a year to monitor TSH levels or any time after your provider changes your dosage.

24. Definition • Excessive secretion of T3 & T4 • Affects metabolic processes in all body organs • Hyperthyroidism is 4-10 times more prevalent in women Hyperthyroidism(Thyrotoxicosis)

25. Graves ’ Disease Most common cause of hyperthyroidism Goiter, proptosis TSH-R antibody (stimulating) = TRAB 40-70% relapse after 2 years of treatment

26. Hyperthyroidism S&S Heat intolerance Hyperactivity, irritability Weight loss (normal to increased appetite) Diarrhea Tremor, Palpitations Diaphoresis (sweating) Lid retraction & Lid Lag (thyroid stare) Proptosis Menstrual irregularity Goiter Tachycardia

27. A 15 years old female with classic Graves disease

28. Diagnosis • TSH level usually < 0.05 µu / ml • 95 % of cases, high FT4 & FT3 • In 5% high FT3 with normal T4 (T3 Thyrotoxicosis) • Thyroid receptor (TRAB) are usually elevated at diagnosis • Antibodies against thyroglobulin, peroxidase or both are present in the majority of patients

29. Diagnosis TSH, free T3&T4 Thyroid antibodies (TSH receptors antibodies) Radionucleotide thyroid scan (inceased uptake)

30. Treatment Medical: Beta -blockers Carbimazole or Methimazole PTU (propylthiouracil) Other modalities (definitive treatment) Radioactive iodine surgery 40-70% relapse after 2 years of treatment

31. Quiz What is the obvious abnormality of this 14 years old girl? What are the most likely causes? How do you investigate? How do you treat?

32. Causes of goiter Physiological (puberty) Iodine deficiency Hashimoto thyroiditis Graves disease Tumor Congenital (maternal antithyroid drugs, maternal hyperthyroidism, dyshormonogenesis) .

33. Quiz 16 year 7 month Growth failure x 1 1/2 years Labs : TSH: 1008 µIU/ ml (0.3-5.0) T4: <1.0 µg/dl (4-12) Antithyro Ab. 232 U/ml (0-1) A- perox Ab. 592 IU/ml (<0.3) Prolactin : 29 ng /ml (2-18) patient asked about prognosis what you tell?