Clues to Spotting Thyroid Issues in Kids

A new review article covers the presentation, evaluation, and treatment of thyroid disorders in children and teens. It was published online August 29 in JAMA Pediatrics.

The article is intended to be a one-stop evidence-based review of pediatric thyroid diseases commonly seen in primary care. It covers hypothyroidism, hyperthyroidism, thyroid nodules, and thyroid cancer and provides tools for evaluating these disorders.

"The primary care physician plays a critical role in identifying children and adolescents with thyroid disease," lead author Andrew Bauer, MD, from Children's Hospital of Philadelphia, Pennsylvania, commented to Medscape Medical News.

Dr Bauer formerly practiced general pediatrics before completing an endocrinology fellowship and said he was sensitive to the demands and time pressures of frontline healthcare providers.
He emphasized the importance of early identification and treatment of thyroid disorders, which can affect growth and neurocognitive development.

"An understanding of the risk factors, signs and symptoms, as well as the evaluation and treatment of hypothyroidism and hyperthyroidism, is associated with earlier diagnosis, earlier initiation of treatment, and reduced morbidity from disease," he stressed.

The authors included information from 83 articles identified through a literature search and published between January 2010 and December 2015, along with some earlier articles of historical interest.
It covers basic pathophysiology, clinical presentation, diagnosis (including laboratory and radiologic assessment), and treatment of congenital hypothyroidism, acquired hypothyroidism, hyperthyroidism, and thyroid nodules. The article also lists criteria for selecting which patients should have definitive treatment for Graves disease.

The review points out a key feature in differentiating hypo- and hyperthyroidism from thyroid nodules: The former are often symptomatic at presentation, while the latter often do not have symptoms and are diagnosed incidentally on physical exam.
"Signs and symptoms of acquired thyroid disease include altered growth, goiter, and/or change in behavior or school performance. Patients with thyroid nodules and thyroid cancer are typically asymptomatic at the time of diagnosis," Dr Bauer explained.

Acquired hypothyroidism is most commonly due to an autoimmune disorder (Hashimoto thyroiditis), with a 1% to 2% prevalence in childhood and a 4:1 female-to-male ratio.
Congenital hypothyroidism affects about 1:1500 to 1:3000 infants diagnosed through universal screening as part of the newborn exam. Affected infants are often asymptomatic at birth but may develop symptoms after the first 48 hours of life.
Meanwhile, hyperthyroidism accounts for about 15% of pediatric thyroid disorders, mostly due to autoimmune hyperthyroidism (Graves disease). Hyperthyroidism has a peak incidence at ages 10 to 15 years.

The incidence of thyroid nodules has increased over the past few decades. Most nodules are benign, but those diagnosed before age 19 years have a higher rate of malignancy than those in older patients.
Because children and teens often have enlarged lymph nodes, a working knowledge of the common location of reactive compared with pathologic lymph nodes is important, according to Dr Bauer. Papillary thyroid cancer, the most common form of thyroid cancer, commonly metastasizes to the cervical and lateral neck lymph nodes. Therefore, the authors provide a diagram showing the location of lymph nodes in the neck and which ones to suspect in thyroid cancer.

Dr Bauer also emphasized the importance of a complete thyroid and lymph node exam, which can be conducted in 1 to 2 minutes as part of a well-care visit. He and his coauthors have developed a YouTube video on how to perform a complete thyroid exam in different types of patients, including those with a normal thyroid.

"For patients with persistent lymphadenopathy, thyroid cancer must be included in the differential diagnosis. If a malignancy is being considered, a thyroid and neck ultrasound should be performed prior to referral for diagnostic, excisional lymph node biopsy," he explained.
When possible, patients should be referred to a pediatric thyroid center experienced in pediatric thyroid nodules and cancer, Dr Bauer added.
Because most patients will need long-term or lifelong medical therapy and follow-up, the authors stressed the importance of communication between primary care providers and subspecialists.

NONINVASIVE STRATEGY FOR OBTAIN A CLEAN-CATCH URINE SAMPLE IN INFANTS

NONINVASIVE STRATEGY FOR  OBTAIN A CLEAN-CATCH URINE SAMPLE IN INFANTS

By MEGAN BROOKS- source from Medscape Nurses

NEW YORK (Reuters Health) - A bladder stimulation technique is a quick and effective noninvasive way to obtain a clean-catch urine sample in infants, a new study confirms.
Obtaining a urine sample for diagnostic studies in infants can be time-consuming and require uncomfortable invasive procedures (urethral catheterization or suprapubic aspiration).

In 2013, researchers described success with a noninvasive technique of bladder and lumbar stimulation for obtaining clean catch urine (CCU) in infants < 30 days (http://bit.ly/2bqDtKI), but questions remain regarding bacterial contamination as well as usefulness in older children. A study in Pediatrics online August 19 addresses the contamination potential and assesses the technique in infants up to six months of age.

The CCU technique involves letting the infant breastfeed or bottle-feed for 20 minutes. After genital cleaning, the infant is held under their armpits by a nurse or parent, legs dangling in boys and hip flexed in girls.

The nurse then begins to stimulate the bladder by gently tapping the suprapubic area at a frequency of 100 taps or blows per minute for 30 seconds. They then stimulate the lumbar paravertebral zone in the lower back with a light circular massage for 30 seconds. The two stimulation maneuvers are repeated until micturition begins (or for a maximum of 300 seconds) and a midstream urine sample is caught in a sterile container.

The new study by Dr. Jocelyn Gravel of CHU Sainte-Justine in Montreal, Quebec, Canada, and colleagues was conducted at a pediatric emergency department and involved 126 infants (64 boys, median age 55 days) needing a urine sample. The most common indication for urine collection was fever of unknown origin. Urinary tract infection was diagnosed in 11 children (9%).

Within five minutes of stimulation, 66 (52%) infants provided a urine sample. However, four samples were considered a failure because of insufficient urine quantity or the presence of stool in the sample, leaving 62 (49%) successful CCU procedures with a median time of 45 seconds.
This proportion increased to 61% in infants < 30 days and to 58% in those < 90 days. The success rate in children 91 to 180 days old was 26%. Age < 90 days was a "strong predictor" for success, Dr. Gravel and colleagues report, while gender, low oral intake, and having urinated within the hour were not predictors of success.

To allow comparison for bacterial contamination, an invasive method (either urethral catheterization or suprapubic aspiration) was performed after CCU procedures in the case of either a positive urinalysis, decision to prescribe antibiotics, or unsuccessful CCU sampling.
The contamination proportion was 16% in the CCU group, which was not statistically different relative to the invasive method group (6%), the researchers report. In addition, the contamination proportion with CCU maneuvers was similar to that reported in the literature for urethral catheterization (12%-14%) and lower than for those reported for collection bag specimens (44%-46%), they say.

These findings "support the use of the CCU standardized stimulation technique as an alternative to invasive methods to obtain a urine specimen," Dr. Gravel and colleagues conclude.
Dr. Gravel told Reuters Health by email, "The technique is ready for use in the ED but nurses have to be trained to use it. We are now using it in our ED but it is not all the nurses who have been trained to use it. We are aware of other EDs who have trained their nurse to use it in their setting."
She added, "Parents are never happy to hear that we will do a urethral catheterism to their young baby. They are happy to see that we are trying to avoid it using new techniques. Babies cry sometime while doing the procedure because they are held by strangers but the families and the medical staff believe that it is less invasive to use the stimulated clean-catch technique."
The researchers suggest using the CCU procedure as a first attempt in well-appearing children aged two to six months to rule out UTI, noting that a child with a negative urinalysis has a < 1% chance of having a UTI.

It would also be useful as a first attempt in children aged zero to six months who merely need a urinalysis and for whom urine specimens are usually obtained by a noninvasive method (including febrile infants in a low-risk group for having UTI, they advise.
The study had no commercial funding and the authors have disclosed no conflicts of interest.

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