Pediatric Hypothyroidism Treatment & Management

Updated: Dec 20, 2016
  • Author: Sunil Kumar Sinha, MD; Chief Editor: Sasigarn A Bowden, MD  more...
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Treatment

Medical Care

In congenital hypothyroidism, treatment should be initiated as soon as the diagnosis is suggested preferably before 2 weeks of life, immediately after obtaining blood for confirmatory tests. Delaying treatment after 6 weeks of life is associated with a substantial risk of delayed cognitive development. Recommended starting dose of levothyroxine for congenital hypothyroidism is 10 to 15 μg/kg/day. [6]  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.

  • In the case of concomitant hypopituitarism with corticotropin deficiency or any other causes of suspected adrenal insufficiency, glucocorticoid replacement should always precede thyroid hormone replacement. This reduces the risk of adrenal crisis resulting from increased demands from enhanced metabolism from thyroid hormone replacement.

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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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