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.
