Hypothyroidism

by:
Judhaimah Mardhiah bt Mat Tari
0810544
case : A BABY WITH SLOW METABOLIC RATE

A 3 month old baby, presented with failure to

thrive. The facial features were rather coarse
and the skin was dry. The tongue tended to
protrude and there was an umbilical hernia.
There was a tinge jaundice. The baby seemed
apathethic and was not smilling or interacting
with the parents. Blood testing showed a low
thyroxine but very high TSH levels.
 Outline
• Thyroid synthesis and function
• Definition
• Epidemiology
• Classification
• Clinical Manifestation
• Diagnosis
• Management :
-Treatment
-Follow-up
 Function of thyroid hormone
Central nervous system -Brain maturation (esp.in
the 1st 2-3 yrs of life)
-Myelination and
sympathetic development

Musculoskeletal system -Bone growth and

potentiate GH effect

Cardiovascular system -Increase number and

affinity of β2-
adrenoceptor in the heart
 cont’..

Gastrointestinal tract -Increase gastric

motility

Reproductive system -Normal menses

 Definition
• A clinical condition that resulted from
decreased production of thyroid hormone or
defect in thyroid receptor activity

Epidemiology
• Incidence – 1/2500-4000 live births world
wide
• Lower in black Americans (1/32 000)
• Higher in Hispanics and Native Americans
(1/2000)
• Twice as many girls as boys are affected
• In Malaysia – 1/4000-5000
 Classification

Divided into:
Primary (disease of the thyroid gland)
Secondary (abnormality of pituitary gland)
Tertiary (abnormality of hypothalamus)

It can be due to congenital or acquired

CONGENITAL HYPOTHYROIDISM
 causes :CONGENITAL HYPOTHYROIDISM
Iodine deficiency -commonest worldwide
-prevented by iodination of
salt in maternal diet

Maldescent of thyroid and -can be either completely or

athyrosis partially not develop
-normally, thyroid migrates
from a position at the base of
the tongue (sublingual) to its
normal site below larynx
-if this is not occur
(1) remains as lingual mass
(2) thyroglossal cyst
 cont’..

Dyshormonogenesis -inborn error of thyroid

hormone synthesis
-common in consanguineous
marriage
TSH deficiency -usually associated with
panhypothyroidism
*growth hormone
* ACTH
-isolated TSH deficiencydeficiency
is rare
(<1%)
 CLINICAL MANIFESTATION

• Clinical manifestation in the immediate

newborn period is usually subtle, it only
becomes evident after weeks or months later.

• Therefore, newborn screening is crucial for

early diagnosis and initiate therapy by younger
than 1month of age in the absence of
definitive signs.
 CONGENITAL HYPOTHYROIDISM
Symptoms Signs
General General
-failure to thrive -pale, cold and mottled dry skin
-feeding problems -hypothermia
-delayed development
GIT
-prolonged jaundice Head and Neck
-constipation -large anterior frontanelle
-coarse facies
-large tongue
-goiter (occasionally)

Abdomen
-umbilical hernia
 DIAGNOSIS

• Thyroid Function Test

1.TSH measurement
=can differentiate between hyper-or hypo
thyrodism
2. Serum free T4 test
3. TRH test
=to check for hypothalamus dysfunction
 ACQUIRED HYPOTHYROIDISM

• Common condition – prevalence of 0.1-0.2%

in population.
• Incidence in girls is 5 to 10 times greater than
boys.
 ACQUIRED HYPOTHYROIDISM
Primary hypothyroidism -Autoimmune
-Iodine deficiency
-Subacute thyroiditis
-Drugs
-Post-irradiation thyroid
-Post-ablative

Central hypothyroidism -Intracranial tumors/masses

-Post cranial
radiotherapy/surgery
-Development pituitary defect,
isolated TSH deficiency,
multiple pituitary hormone
deficiency
 ACQUIRED HYPOTHYROIDISM
Symptoms Signs
General General
-weight gain -short stature/growth failure
-cold intolerance -dry skin
-tiredness and lethargy -obesity (BMI>30)
-delayed puberty
-learning difficulties Hands
-deterioration in school work -cold peripheries
-changes in voices (husky and coarse) -bradycardia
GIT Head and Neck
-constipation -thin dry hair
-pale, puffy eyes with loss of eyebrows
Reproductive system -goiter (usually present)
-menorrhagia
-oligomenorrhagia/amenorrhoea Musculoskeletal
-infertility -slipped femoral epiphysis
-slow-relaxing reflex
 DIAGNOSIS

• Diagnosis may be confirmed by serum anti-

thyroid peroxidase and anti-thyroglobulin
antibodies.
• Neither biopsy, nor thyroid scan is indicated in
hashimoto’s thyroiditis
 MANAGEMENT
• Treatment should begin immediately after
diagnosis is established.
• If features of hypothyroidism are present,
treatment is started urgently pending
T4/TSH results.
• It is lifelong except in children suspected of
having transient hypothyroidism where re-
evaluation is done at 2-3 years of age.
• ONLY T4 tablet should be used.(crushed and
mixed with breast milk, formula or water
and fed the baby)
• General doses of L-tyroxine by age :
Age mg/kg/dose, daily

0-3 months 10-15

3-6 months 8-10

6-12 months 6-8

1-5 years 5-6

6-12 years 4-5

>12 years 2-3

• Follow-up :
(1)Monitor T4/TSH at regular interval :
recommendation by The American Academy of
Paediatrics
•At 2 and 4 weeks after initiation of T4 treatment.
•Every 1 to 2 months during 1st year of life.
•Every 2 to 3 months between 1 to 3 years of age.
•Every 3-12 months threafter until growth is
complete.
•Two weeks after any change in dosage
•At more frequent intervals when compliance is
questioned
(2)Monitor or abnormal
growth results are obtained.
(weight/height/OFC)
(3)Development assesment
 REFERENCES

• Pocket Essential of Paediatrics, Saunders Elsevier

• Paediatric Protocols For Malaysian Hospitals 2nd
edition
• Nelson Essentials of Pediatrics 5th edition
• Illustrated Textbook of Paediatric 3rd Edition
• Nelson Textbook, 12th Edition
• Oxford Handbook of Paediatric
• http://www.buzzle.com/articles/congenital-hyp
othyroidism-symptoms-causes-and-treatment.ht
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