77

centrations exceeded the normal upper limit (8 /1 units

per ml.) and returned to normal after recovery.
Serum total T3 and total T4 concentrations were
measured in thirty-three patients. In general, concentrations tended to be comparatively normal, high, or
low. In threepatients, however, total T3 was increased when total T4 was normal. One of these
three patients was overtly hyperthyroid, the other two
were clinically euthyroid, although serum-total-T3
exceeded the normal upper limit of 150 ng. per dl.

Thyroglobulin-antibody Titres
Forty-six patients were tested serially.

In eight,
titres increased over pre-treatment values (1/64 or
less) after iodine-1255 treatment. Post-treatment
values reached 1/128-1/4096.
However, in five
patients, titres before treatment of 1/64-1/2048 fell
after treatment to less than 1/32.

Discussion
The number of

patients treated in each dose-ratio

deliberately kept small because of the high
group
of
frequency persistent hyperthyroidism and concern
over the frequency of transient hypothyroidism.
Injury of the thyroid-cell nucleus without destruction
could possibly later lead to thyroid cancer.
To use the dose ratio of iodine-125/iodine-131to
calculate doses of iodine-125, the customary doses of
iodine-131 used in a particular clinic must be known.
Doses in mCi or ju.Ci per estimated g. thyroid gland
would vary according to this variable. In our clinic,
iodine-131 has always been given in low doses (mean
4 mCi since its first usel,10). (Despite this low iodine131 dosage schedule, the frequency of late hypothyroidism progressively increasesy.14)
The occurrence of hypothyroidism with the lowest
doses, or dose ratios, of iodine-125 given, and of persistent hyperthyroidism despite the highest doses or
dose ratios, reveals the same variability in biological
sensitivity to radiation observed with iodine-131. In
addition, a wide spread of radiation doses has been
calculated to be delivered to the gland with both
was

125 could provide several real advantages. Moreover,

the response of some patients with sensitive glands
to even the smallest doses of iodine-125 suggests
that iodine-125 could be given in a single dose to
screen out the responders.
Surgery or iodine-131
could then be used to bring about remission in the

non-responders.
We thank the National Pituitary Agency for human T.S.H.
and antiserum, and Dr R. Bangham for the human T.S.H.
standard. This work was aided by grants from the Institute
of Arthritis and Metabolism, National Institutes of Health.

Requests for reprints should be addressed to S. C. W., 640

West 168th Street, New York, N.Y. 10032, U.S.A.
REFERENCES
1. Werner, S. C., Coelho, B., Quimby, E. H., Day, M. Mc. Bull.
N.Y. Acad. Med., 1957, 33, 783.
2. Beling, U., Einhorn, J. Acta radiol. 1961, 56, 275.
3. Nofal, M. M., Beierwaltes, W. H., Patno, M. E. J. Am. med. Ass.
1966, 197, 605.
4. Werner, S. C., Johnson, P. M., Goodwin, P. N., Wiener, J. D.,
Lindeboom, G. A. Lancet, 1970, ii, 681.
5. Gillespie, F. C., Orr, J. S., Greig, W. R. Br. J. Radiol. 1970, 43, 40.
6. Ben-Porath, M., Feige, Y., Lubin, E., Levitus, Z. J. nucl. Med.
1970, 11, 300.
7. Lancet, 1973, ii, 426.
8. Bremner, W. F., McDougall, I. R., Greig, W. R. ibid. p. 281.
9. Werner, S. C., Acebedo, G. A., Radichevich, I. J. clin. Endocr. Metab.
1974, 38, 493.
10. Werner, S. C., Quimby, E. H., Schmidt, C. Am. J. Roentg. 1948,
51, 564.
11. Werner, S. C. The Thyroid (edited by S. C. Werner and S. H.
Ingbar); p. 697. New York, 1971.
12. Werner, S. C., Johnson, P. M. Lancet, 1971, ii, 492.
13. Werner, S. C. J. clin. Endocr. Metab. 1969, 29, 982.
14. Cevallos, J. L., Hagen, G. A., Maloof, F., Chapman, E. M. New
Engl. J. Med. 1974, 290, 141.
15. Sterling, K., Brenner, M. A., Newman, E. S., Odell W. D.,
Bellabarba, D. J. clin. Endocr. Metab. 1971, 33, 729.

therapies.4,lO
As with iodine-131, 15 total T3 concentrations may
become increased in patients becoming euthyroid
after iodine-1253 administration, despite total T4
values which are low or slightly below normal. In
contrast to iodine-131, transient hypothyroidism is
common with iodine-125 treatment and permanent
hypothyroidism is rare. Also, antithyroglobulin titres
are often increased in the first year after iodine-131
therapy,15 but not after iodine-125 treatment.
Iodine-131 therapy 11 may be followed by progression of eye changes into classes 2-6. The number of
patients is too small, however, to establish whether
such a progression can be expected after iodine-125
therapy. However, an increase in proptosis of 2 to
4 mm. has been observed in about a quarter of our
patients treated with iodine-125.
The several differences between iodine-131 and
iodine-125 results tend to suggest that iodine-125
therapy might justifiably be further investigated,
rather than stopped.s Despite the theoretical possibility of later development of thyroid cancer, iodine-

SUCCESSFUL LABORATORY SCREENING

FOR CONGENITAL HYPOTHYROIDISM
ALAN H. KLEIN
THOMAS P.

AMELIA V. AGUSTIN

FOLEY, JR.

Department of Pediatrics, University of Pittsburgh School

of Medicine, Childrens Hospital of Pittsburgh,
125 DeSoto Street, Pittsburgh, Pennsylvania 15213,
U.S.A.

An infant with subclinical

congenital
hypothyroidism
successfully
detected by a screening test which measured thyroidstimulating hormone (T.S.H.) in umbilical cord serum.
The frequency of congenital hypothyroidism is
approximately 1 in 8500. The diagnosis of hypothyroidism and initiation of replacement therapy within
the first three weeks of life through a screening programme should significantly reduce the number of
patients with irreversible mental retardation caused
by untreated congenital hypothyroidism. The
measurement of T.S.H. in cord serum or on day three
of life should provide a simple, accurate technique
of rapid screening for congenital hypothyroidism.
Summary

was

Introduction
THE clinical

during

diagnosis of congenital hypothyroidism

period is difficult and often

the neonatal

78
missed. The possible benefit of a screening test to
detect hypothyroidism in the newborn and the subsequent early treatment of identified infants is
indicated by evidence that optimum intellectual
attainment occurs when thyroid-replacement therapy
is begun before three months of age 1·a
We report our initial success with a screening
programme for newborn infants, involving the
determination of thyroid-stimulating hormone (T.s.H.)
in samples of cord blood. Cord blood was selected
because it is available at birth and easy to collect.
Serum-T.s.H. is the most sensitive test for primary
hypothyroidism, and it is raised in mild hypothyroidism when serum-thyroxine (T4) is still within
the normal range .3,4 Improved techniques for the
measurement of serum-T.s.H. make this determination in cord blood suitable as a screening test for

when it became apparent that the normal range of

T.S.H. values exceeded 20 t-tu per ml., the screening
cut-off point increased progressively to 50 t-tu per
ml. A representative sample consisting of 552 normal
cord serum-T.s.H. concentrations measured during a
four-week period in the screening assay (see
accompanying figure) demonstrated that serum-T.s.H.
levels were less than 20 t-tu per ml. in 85%, while
concentrations higher than 60 t-tu per ml. occurred
in only 0-4 %.
All infants with cord serum-T.s.H.

hypothyroidism.
Methods

delivery and ligation of the umbilical cord,

approximately 1 to 5 ml. of venous blood was withdrawn
with a syringe from the placental side of the cord and
stored at 4°C.
A modification of previously reported
methods was used for the immunoassay of T.S.H.5.6 After
centrifugation, samples were pipetted with an automatic
pipette (Micromedic Systems) which diluted 100 11-1. of
serum with 600 1. of 0-01 M phosphate buffer in 014 M
saline solution (P.B.s.) (pH 76) with 0-1% bovine serumalbumin (Sigma Chemical) (B.S.A.).
For the standardcurve specimens, 100 µl. of bovine serum was added to
500 jul. of P.B.S./B.S.A. and 100 1. of human T.S.H.
standard. To this mixture, 200 jul. of rabbit anti-T.s.H.
antisera
(initial dilution 1/60,000; final dilution
1/300,000) in P.B.S./B.S.A. with 1% normal rabbit serum,
human chorionic gonadotrophin (10 i.u. per sample), and
edetic acid 001 M were added and the samples incubated at
4°C overnight, after which 100 jul. of 125I-T.S.H. in 0-1%
B.S.A./P.B.S. was added, and assay tubes were incubated
at 4°C for forty-eight hours. Sheep anti-rabbit y-globulin
in an amount sufficient for maximum precipitation was
added. After overnight incubation at 4°C, the supernatantwas removed and the precipitate counted in an automatic
Assay results were
gamma counter (Nuclear Chicago).
analysed, using the Radass computer program adapted
for the DEC system-10 computer of the University of
Pittsburgh. T4 and serum-triiodothyronine (T3) were
measured by radioimmunoassay as previously described 6
unless otherwise indicated.
After

made weekly in lots of 100 to 150. With

preliminary methods, the maximum time
between the collection of a cord specimen and the availability of results is two weeks. Infants with increased
cord T.S.H. have blood drawn to estimate serum T4 and
Runs

our

are

current

T.S.H.

again.

Distribution of 552 cord serum-T.S.H. determinations.

levels between 20 and 50 uu per ml. who were retested

were clinically euthyroid on re-evaluation and had
normal serum T.S.H. and T4 concentrations.
2 of the infants studied had thyroid disorders. 1
infant with goitre secondary to maternal iodide ingestion had a cord serum-T.s.H. value of 60 Mu per
ml. and a cord T4 of 9.3 f.J.u per 100 ml. by competitivebinding assay 0 Tetra-Tab, Nuclear Medical
Laboratories). The second infant, described in the
following case-report, had a cord serum-T.s.H. level
in the screening assay of >100
iku per ml. We are
not aware of any infants with a cord serum-T.s.H.
less than 50 ,u per ml. in whom congenital hypothyroidism has subsequently been diagnosed.

Case-report
A 3670 g. White female had an uncomplicated fortytwo-week gestation and vaginal vertex delivery. The mother
received medroxyprogesterone during the first trimester
for vaginal bleeding; otherwise the mother received no
other medication during her pregnancy. There was no

family history of thyroid disease. Hypothyroidism

the

Results
Between August 13, 1973, and March 13, 1974,
3686 infants were delivered at Magee Womens Hos-

pital. Cord-blood samples were obtained and tested

in 3577 (97%). 1 infant with congenital hypothyroidism has been diagnosed by this screening programme.
In a pilot study of 30 full-term normal infants, the
concentration for cord serum-T.s.H. was 8.5
ttu per ml., and no value exceeded 16.6 nu per ml.6
Initially infants with cord serum-T.s.H. concentrations
that exceeded 20 jnu per ml. were retested. Later,

mean

was

not

the infants nursery stay, and review of

and nurses notes gave no clue to the diag-

suspected during
physicians

nosis retrospectively.
After discharge from the nursery, her parents believed
that she

was

completely normal, although they

were con.

cerned about the infrequency of. bowel movements from

the seventeenth day of life. At three weeks of age some
puffiness of the face, a slightly protruding tongue, a
hoarse cry, and dry skin were noted.
Screening assay of the cord blood revealed a T.S.H.
level greater than 100 ill per ml., which measured 302
ill per ml. after dilution. The cord serum-T4 was 56 g
per 100 ml. and the serum-T3 was 29 ng. per 100 ml.
At twenty days of age, serum-T4 was 19 .g. per 100 ml.

79
and the T3 was 86 ng. per 100 ml. In our pilot study6
the mean cord serum-T4 was 10-9 g. per 100 ml. and
our lowest value in normal infants found during a sixweek follow-up was 69 µ.g. per 100 ml. The mean
cord T3 was 48 ng. per 100 ml. and our lowest normal
value was 11 ng. per 100 ml. At six weeks of age the
lowest normal value for T4 was 78 fJ.g. per 100 ml.

The uptake of radioactive iodine

was

less than

at

twenty-four hours

03%.

At twenty-two days of age she was started on 25 jug.

of T3 by mouth once daily for seven days and then
switched to 125 jug. T3 plus one tablet containing 50 ju.g.
T4 and 125 jug. T3 by mouth once daily for another
After fourteen days of therapy the T3 by
seven days.
itself was discontinued and the patient was continued on
the T4 and T3 combination tablet. The patient has subsequently grown at a normal rate and at three months of
age was normally developed:

Discussion
For a screening programme to be appropriate and
worth while, it should meet several important criteria.
The disease for which screening is instituted must
be serious and have some general importance to the
community. The importance of congenital hypothyroidism is indicated by both the frequency of the
disease and the subsequent development of irreversible
mental retardation among untreated infants. The
frequency of congenital hypothyroidism has been
estimated at between approximately 1/5000 to 1/10,000
live birthsDuring the years 1970-1973, there were
25,450 liveborn infants delivered at Magee Womens
Hospital. We are aware of three infants with congenital hypothyroidism (not including the patient
reported here) born during this period, making the
minimum frequency approximately 1 in 8500. This
compares with a national frequency for phenylketonuria of 1 in 14,300,8 for which there is a mandatory
screening test in the U.S.A.
An appropriate screening test must be able to
differentiate between affected and non-affected individuals with ease. In congenital hypothyroidism,
affected individuals have a low serum-T4 and a high
serum-T.s.H. After fetal thyroidectomy in sheep, fetal
serum-T.s.H. levels in utero are markedly increased
to 350-1500 /u per m1.9 In an infant with congenital
hypothyroidism studied before this screening programme, serum-T.s.H. concentration at five hours of
age was 300 ju.u per ml. (serum-T4=0.8 jnu per ml.
and maternal T.S.H.=105 ju.u per ml. at ten days post
partum). Unfortunately no cord specimen was collected by the referring hospital. The raised serumT.S.H. levels reported from the study in sheep and the
patients described in the present report suggest a
considerable discrepancy between the cord serum1.S.H. concentrations in normal and affected infants.
That the T4 concentration in cord serum was 5.6 ju,u
per 100 ml., but only 1.9 Au per 100 ml. at three
weeks of age in an infant with athyreosis suggests
that maternal to fetal placental passage of thyroxine
took place. The cord T4 and T3 values were higher
than expected, and this would argue against their
measurement as a screening test for congenital hypo-

thyroidism.
For screening

to

be useful, there

must

be

period

when the disease can be detected by a screening test,

but it is not readily apparent clinically. Congenital
hypothyroidism often goes undiagnosed for several
months. It seems reasonable to assume that adequate
treatment will improve the prognosis when therapy
is started during the asymptomatic period, since the
final outcome in this disease depends upon beginning
treatment as early as possible. Currently, early treatment often is not started because diagnosis is

delayed.
patients reported previously,! congenital hypothyroidism was diagnosed at less than
three months of age in only 9 infants (29%). The
mean Stanford-Binet i.Q. for the 9 infants receiving
adequate thyroid therapy before three months of age
was 89, whereas the mean i.Q. for 22 patients treated
In

group of 31

three months of age or older was 66.

Finally, the cost of a screening test must be
sufficiently low to warrant its use. The exact cost
per test in the present programme is difficult to
determine. A radioimmunoassay kit for determination
of serum-T.s.H. is commercially available (Twin 100
HTSH Kit, Beckman Instruments), with a cost on
a large volume order of about$1.00 plus labour perpatient in duplicate. This kit produces the results
in less than forty-eight hours, and needs only 25 pl.
of serum per tube. Our experience with this commercial T.S.H. kit is limited, but with minor changes
in technique it seems to have sensitivity, specificity,
and precision comparable to our method.
at

potential merits of a programme to detect

congenital hypothyroidism would be the institution
of early treatment and reduction of the mental retardation caused by this disease. Further study and
The

refinement of the present programme is needed to

evaluate the feasibility of this method and to define
more accurately the frequency of congenital hypothyroidism before its general use can be advocated.
We thank Dr P. R. Larsen for measuring serum T4 and T3
in the affected infant; Ms Anita Perricelli, Ms Sandra Terrill,
Ms Hedy Gruenebaum, and Ms Barbara Foley for technical
assistance; the nursing and obstetrical staff of Magee Womens
Hospital for cooperation; and Ms Carleen Peppler for valuable
secretarial assistance. The immunological materials used to
measure T.S.H. were supplied by the National Pituitary Agency.
M.R.C. Research Standard A was supplied by the W.H.O.,
London. This study was supported by the Renziehausen Fund,
United States Public Health Service research grant HD 07220,
training grant HD 00227 (A. H. K.), general research support
grant 3501-RR-05507, and grant 2M01-RR-00084 for the
General Clinic Research Center. A. V. A. is a Renziehausen
Fellow.

Requests for reprints should be addressed

to

T. P. F.

REFERENCES
1.
2.
3.

Klein, A. H., Meltzer, S., Kenny, F. M. J. Pediat. 1972, 81, 912.

Raiti, S., Newns, G. H. Archs Dis. Childh. 1971, 46, 692.
Hershman, J. M., Pittman, J. A., Jr. New Engl. J. Med. 1971, 285,

977.
4. Hayek, A., Maloof, F., Crawford, J. D. Pediat. Res. 1973, 7, 28.
5. Patel, Y. C., Burger, H. G., Hudson, B. J. clin. Endocr. Metab.

1971, 33, 768.

Abuid, J., Klein, A. H., Foley, T. P., Jr., Larsen, P. R. J. clin.
Endocr. Metab. (in the press).
7. Frankenburg, W. K. Adv. Pediat., 1973, 20, 149.
8. Hsia, D. Y. Birth Defects, Atlas and Compendium (edited by D.
Bergsma); p. 725. Baltimore, 1973.
9. Erenberg, A., Omori, K., Oh, W., Fisher, D. A. Pediat. Res. 1973,
7, 870.
6.