M. Hashemipour Professor of Pediatric Endocrinology Isfahan university of medical sciences
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M. HashemipourProfessor of Pediatric Endocrinology Isfahan university of medical sciences
Newborn Thyroid Function Tests
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Increase in congenital hypothyroidism in New York State and
in the United States Incidence• Between1978 -2005 48.3 per100000 • 2005 70.7 per100000Asians have a 65% higher incidence than
the average of all infants 98.4/100,000 vs. 59.5/100,000
Mol Genet Metab. 2007 Jul;91(3)
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incidence rates of CHHarris and Pass 2007• increase in the incidence rates of CH overthe past 2 decades• New York 1 in 3378 to 1 in 1414 births • United States 1 in 4098 to 1 in 2370 births• Molecular Genetics and Metabolism 2007
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ترم 20نوزاد فول تحت= 70TSHروزهگرفته قرار درمان
چگونه دارو مصرف زمان و دوزاست؟
سطح مناسب درمان صورت درطبیعی T4,TSHسرمي زمانی چه در
؟ شد خواهدسرمي سطح حداكثر و و T4حداقل
TSH چه درمان از پس نوزاد اين درباشد؟ باید میزان
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Low T4 &Elevated TSH
• Any Infant With A Low T4 Level And Elevated TSH Is Considered To Have
Primary HypothyroidismTSH>10 two weeks Abnormal
• AAP2006
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Treatment
The Goal Of Treatment To Ensure Normal Growth &Development
T4 10 To 16 Ug/dlTSH 0/5-2Miu/L
• PEDIATRIC RESEARCH 2009
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TreatmentGood prognosis • T4 normalizes in 3 days.• TSH returns to the target range by 2 weeks of
therapy.
with 12–17 µg/kg levothyroxin
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صورتيكه زمان TSHو T4در درچه نرسيد مناسب حد به معين
است؟ مطرح هائي تشخيص
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Failure of increase T4TBG DeficiencyPreparation of L-thyroxin Is Not
Appropriately ActiveAbsorption of L-thyroxin Is IncompleteChild Is Not Receiving The MedicationDrug exposure to high temperature
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Failure of increase T4• Malabsorption• increased degradation (anticonvulsants)• large hemangiomas with high deiodinase
activity
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Interfere With The Absorption
Soy Formulas (within an hour ) Ferrous Sulfate Aluminum Hydroxide Bile Acid Sequestrants Calcium
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هائيمي يادآوري چه مادر به كنيد؟
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از که صورتی در فوق بیمار پیشاگهیبار چهار سالگی دو تا TSHششماهگی
است 5باالی چگونه باشد داشته
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prognosis
During The First Year Of Life, Infants WithT4 <10 mcg/dlAccompanied By TSH > 15 Mu/L
Have Lower IQ Values Than infantsAAP2006
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prognosis• T4 <10 ug/dl in the first year of life was
associated with an 18-point lower IQ compared with T4 above 10u g/d
• J Clin Endocrinol Metab, 2011
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Prognosis
Infant With Initial T4 Level < 5 µg/dl Delay Skeletal Maturation at Birth. May have Permanent Intellectual Sequelae
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Prognosis
• If Treatment Is Delayed (after 2 weeks) OR• A Lower Dose Is Used A 20 Point Deficit In Both Mental And
Psychomotor Development Is Observed
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Prognosis
• Delay in normalizing serum T4 and TSH by more than 2 wk after starting treatment
resulted 10 point lower IQJ Clin Endocrinol Metab, 2011
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Prognosisinfants diagnosed by 3 months of age Mean IQ of 89• Between 3 and 6 months Mean IQ of 71 • More than 6 months of age Mean IQ fell to 34J Clin Endocrinol Metab, 2011
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درمان شروع از پس ماه شش TSH=0.01 T4=12
تصمیم؟
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پسازدرمان سال 10دوT4=18,TSH =
مشکل این برای علتی چهدارد وجود
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سه سن در صورت چه درنمی قطع وی درمان سالگی
شود
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Permanent congenital hypothyroidism
TSH> 10 mU/L after the first year of life during treatment
initial thyroid scan shows ectopic/absent gland confirmed by ultrasonographic examination
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با ترم فول درمان TSH=25نوزاد تحتبا لووتیروکسین 25قرار گرم میکرو
ماهگی سه سن در است گرفته قرارTSH=0.1
T4=18 تصمیم؟
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با 14نوزاد • کرده T4=3و TSH=28روزه مراجعهاست.
دارد؟ ضرورت وی در اسکن صورت چه در
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Thyroid Radionuclide Uptake
Recommend Routinely In Infants With
TSH>50mu/L
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با 14نوزاد =mIU/L 11 TSHروزهT4=10 ug/dl
به توجه با معالج پزشك كرده، مراجعهT4 درمان را Bوي گرفته تصميم طبيعي
پيگيري. باشد صحيح وي اقدام اگر نكنداست چگونه نوزاد اين
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if serum TSH is elevated 9–25 mU/liter• Recheck a serum TSH and free T4 in 1 wk. we recommend treating• If the serum TSH has not normalized by 3–4
wk of age OR
• initial TSH is greater than 25 mU/liter• J Clin Endocrinol Metab, 2011
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وزن 14نوزاد • با گرم 1300روزه•T4= 4 µg/dl TSH=8mu/L به • توجه و T4با تشخيص TSHپائين معالج پزشك باال
. ؟ چيست شما نظر داد هيپوتيروئيدي
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VLBW & Thyroid functionAn Average Age For TSH Rise
Is 30 Days (range, 11–176)
>1500GR
• All VLBW Infants Should Be Rescreened At 2, 6,and 10• Weeks of Age
• .
• AAP99• Current Opinion in Endocrinology & Diabetes 2005, .
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Current Opinion in Endocrinology & Diabetes 2005, 12:36–41
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Premature• Currently the evidence base does not indicate
cognitive benefit from thyroid therapy of hypothyroxinemia of prematurity in the absence of TSH elevation.
• AAP2006
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Premature• It Would Seem Reasonable At The Present
Time To Treat Any Premature Infant With
A Low T4 And Elevated TSH
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Normal Values For T4 Level By Weight
Weight T4(ug/dl)± SD<1000 5.6± 31000-1500 7.7± 2.71500-2000 9.6± 2.72000-2500 11.2± 2.4>2500 12± 2
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Normal Values For TSHAge TSH (mU/L) 2–20wk 1.7–9.1 5–24 mo 0.8–8.2 2–7 yr 0.7–6.2
AAP2003
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خوار به 1/5شیر طبیعی قد و وزن با ای ماههتیروئید تست بار دو حال به تا کرده مراجعه شما
شده TSH=3 ,T4 =5
T4= 3ug/dl, TSH= 1mU/L وی درمان و تشخیص تایید مورد در شما نظر
چیست؟کاهش باعث است ممکن عللی ؟بشوند T4چه
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• T3RU• FT4
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Low T4 &Normal TSH Anticonvulsants preterm infants NTITBG deficiency Central hypothyroidBirth asphyxia
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Low T4 &Normal TSH• primary hypothyroidism and delayed TSH
elevation • High-dose glucocorticoids
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سابقه با ماهه هشت خوار شیرمبتال فعال شده کنترل هیپوتیروئیدی
مورد در شما نظر است تشنج بهچیست؟ وی درمان
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سابقه 3/5کودک با سالهقطع وی درمان فعال هیپوتیروئیدی
دارد = TSH 8و T4=10شده وی پیگیری مورد در شما تصمیم
است ؟چگونه
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سابقه با ای ساله سه کودکقطع وی درمان گذرا هیپوتیروئیدیقطع از پس ازمایشات و است شده
در شما نظر است طبیعی درمان؟ است چگونه وی پیگیری ؟مورد
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• it is still high TSH(over 30%) in late childhood.• Children that maintain euthyroidism in late
childhood have higher TSH value• J Clin Endocrin Metab 2008
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به 9نوزاد مبتال مادر از روزهدرمان تحت تیروئیدی هیپر
فعال و شده TSH=15متولدچیست؟ شما تصمیم دارد
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• Newborn whose mother is receiving anantithyroid drug. T4 and TSH values return to normal
within 1 to 3 weeks
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در دان سندرم به مبتال نوزادازمایش باید هائی زمان چهشود انجام ها این در تیروئید
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اسکرین هفتگی دو ماهگی دو سالگی 12-6هر سه تا ماه
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بزرگ همانژیم با نوزادزمان چه در شده متولد
ازمایش باید هائیانجام ها این در تیروئید
شود
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است • تیروئید تست به نیاز ماهیانه سالگی یک تا
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علت 18نوزادی به مناسب وزن افزایش با روزهشده داده ارجاع ذیل تیروئید تست با قراری بی
• T4==18ug/100• TSH=0/5• T3=250ng/ml
را • درمان هیپرتیروئیدی تشخیص با معالج پزشکچیست؟ شما نظر کرده شروع
T4==18ug/100TSH=0/5miu/lT3=250ng/ml
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Follow-upCHD fourfold higher than controlHearing ScreeningKidney disease GI• The Journal of Pediatrics2008
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Assessing 0f permanence of CH
At 3 Years Of Age Discontinue Treatment And Retest Serum T4/TSH After 4 Weeks especially
If the serum TSH value has not increased
Infant is normal
Almost 100% Of Children With True CH Have Elevated TSH Levels After 4 Weeks Off Of Treatment.
AAP2006
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Assessing permanence of CH
Permanence of hypothyroidism is confirmed.
TSH> 10 mU/L
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Assessing permanence of CH
• Serum TSH> 10 mU/L after the first year of life
• AAP1993
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طور 12دختر • به که ای توده احساس علت به ای سالهشده مشاهده گردن قدامی قسمت در اتفاقی
. است کرده مراجعهمادر و مادر در را تیروئید کاری پر فامیلی حال شرح
. میدهد بزرگ. دارد طبیعی نسبتا وزن و قد اولیه معاینات در
عملکرد و قرینه غیر ، سفت نسبتا تیروئید ینه معا در. دارد طبیعی
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؟ • کنید می ارسال آزمایشاتی چه؟ • کنید می تجویز را درمانی چهخواهد • عوارضی چه شدن وبزرگتر درمان عدم درصورت
؟ داشتصورت • چه ؟ FNAدر دارد الزمشود؟ • می انجام جراحی درمان صورت چه درایجاد • کشیده گواترطول دنبال به است ممکن عوارضی چه
شود؟؟ • است چگونه درمان مدت طول؟ • کنید می پیگیری را بیمار چگونه
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Goiter
• Goiter = Chronic enlargement of the thyroid gland not due to neoplasm
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Investigation of Goiter
• TFT• Thyroid Abs
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Complications of Goitre
• Dysphagia• Dyspnea• Hoarseness• Malignancy 1-10%• Toxic goiter %30• micro or macronodularity
Without treatment
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FNA
• Asymmetric goiter• prominent nodule• smaller nodule that enlarges during follow-
up
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Surgical Care
• Large goiters with compression
• Malignancy • Ineffective treatment• Cosmetic• Rapid enlargement
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Complications
• Hyperthyroidism• Lymphoma• Malignancy
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Treatment
• The size of goiter reduced with levothyroxine )suppressive therapy(
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Levothyroxin
• Reduced TSH secretion
• Subside the effect of TSH on thyroid
TSH should be kept between 0.1-0.5 mu/l
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Duration of Treatment
• It probably is best to continue treatment until growth and pubertal development are complete.
• Some children treated for several years have persistently normal thyroid function after T4 treatment is discontinued.
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Follow up
• Thyroid function test 6 wk after initiation.
• Assessment for Growth and sexual development TSH measurement : • Every 4–6 mo in the growing child.
• yearly once final height has been attained.
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به . 16دختر • او است کرده مراجعه سالیانه معاینه جهت ای سالهبزرگ . کمی تیروئید معاینه در ندارد مشکلی یبوست جز
است . : ذیل شرح به وی تیروئید تست است
•TSH = 7.5 mU/ ml (0.5-5) •Free T4 = 1.1 ng (0.8-1.8) • ؟ • است چگونه وی پیگیری و درمان
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Subclinical Hypothyroidism
Risk of conversion to HYPOthyroidism:
• If TSH raised and Antibodies raised ; 50%• If TSH raised and Ab negative ; 33%• If TSH normal and Ab positive ; 25%
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Subclinical Hypothyroidism
• vigorous analysis indicates that subjects with TSH in the 4.5–10 mU/L range, no benefit was seen
• If there is a goiter or the TSH is >10 mU/L, treatment is indicate
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Subclinical Hypothyroidism
If there is no goiter And TSH is <10 Repeated test is suggested in 6–12 months.• Repeating the tests within a month, as is often done,
usually results in A TSH similar to the initial one And provide no new information International Journal of Pediatric Endocrinology2010
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Subclinical Hypothyroidism
By waiting 6–12 months one allows time for Either normalization of TSH or progression to
OH. • It may be more helpful to measure thyroidantibodies with the second free T4 and TSH than
as a screening test.International Journal of Pediatric Endocrinology2010
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Subclinical Hypothyroidism
If ab are negative it would provide reassurance that is not AIT And decrease the need for subsequent testing• while strongly positive antibody levels would
signal the need for closer monitoring of thyroid tests.
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Conclusions
• It is proposed that TSH be rechecked periodically for 2 years
longer if There is a goiterstrongly positive antibodiesInternational Journal of Pediatric Endocrinology2010
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Conclusions
• If the TSH remains in the 5–10 mU/L • The child considered to have a stable mild TSH
elevation and not require repeat testing unless
A goiter appearsThere are new symptoms suggestive of OHInternational Journal of Pediatric Endocrinology2010
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Subclinical Hypothyroidism
Since a child with TSH 5–10 mU/L, no goiter, and negative antibodies is unlikely to progress to OH
it is difficult to justify treatment. Even though an occasional child in this group will develop symptomatic OH during follow-up
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Subclinical Hypothyroidism
• when free T4 is normal but TSH is 10–15, progression to OH is more likely, particularly if there is evidence of AIT.
• Treating such patients seems reasonable, but periodic monitoring off therapy should also be an option
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