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Practice Essentials
Congenital hypothyroidism is inadequate thyroid hormone production in newborn infants. It can occur
because of an anatomic defect in the gland, an inborn error of thyroid metabolism, or iodine deficiency.
See the image below.
Decreased activity
Large anterior fontanelle
Poor feeding and weight gain
Small stature or poor growth
Jaundice
Decreased stooling or constipation
Hypotonia
Hoarse cry
Often, affected infants are described as "good babies" because they rarely cry and they sleep most of the
time.
The physical findings of hypothyroidism may or may not be present at birth. Signs include the following:
The pills can be crushed in a spoon; dissolved with a small amount of breast milk, water, or other
liquid immediately before administration; and administered to the child with a syringe or dropper
cretinism was determined to be iodine deficiency. In the 1920s, adequate dietary intake of iodine was
found to prevent endemic goiter and cretinism. [13] Endemic goiter and cretinism are still observed in some
areas, such as regions of Bangladesh, Chad, China, Indonesia, Nepal, Peru, and Zaire.
The term sporadic cretinism was initially used to describe the random occurrence of cretinism in
nonendemic areas. The cause of these abnormalities was identified as nonfunctioning or absent thyroid
glands. This led to replacement of the descriptive term sporadic cretinism with the etiologic term
congenital hypothyroidism. Treatment with thyroid replacement therapy was found to elicit some
improvement in these infants (see the images below), although many remained impaired.
radioimmunoassay for TSH and thyroxine (T4) from blood spots on filter paper, obtained for neonatal
screening tests.[17, 18]
Pathophysiology
The thyroid gland develops from the buccopharyngeal cavity between 4 and 10 weeks' gestation. The
thyroid arises from the fourth branchial pouches and ultimately ends up as a bilobed organ in the neck.
Errors in the formation or migration of thyroid tissue can result in thyroid aplasia, dysplasia, or ectopy.
By 10-11 weeks' gestation, the fetal thyroid is capable of producing thyroid hormone. By 18-20 weeks'
gestation, blood levels of T4 have reached term levels. The fetal pituitary-thyroid axis is believed to
function independently of the maternal pituitary-thyroid axis.
The thyroid gland uses tyrosine and iodine to manufacture T4 and triiodothyronine (T3). Iodide is taken
into the thyroid follicular cells by an active transport system and then oxidized to iodine by thyroid
peroxidase. Organification occurs when iodine is attached to tyrosine molecules attached to thyroglobulin,
forming monoiodotyrosine (MIT) and diiodotyrosine (DIT). The coupling of 2 molecules of DIT forms
tetraiodothyronine (ie, T4). The coupling of one molecule of MIT and one molecule of DIT forms T3.
Thyroglobulin, with T4 and T3 attached, is stored in the follicular lumen. TSH activates the enzymes
needed to cleave T4 and T3 from thyroglobulin. In most situations, T4 is the primary hormone produced
by and released from the thyroid gland.
Inborn errors of thyroid metabolism can result in congenital hypothyroidism in children with anatomically
normal thyroid glands.
T4 is the primary thyronine produced by the thyroid gland. Only 10-40% of circulating T3 is released
from the thyroid gland. The remainder is produced by monodeiodination of T4 in peripheral tissues. T3 is
the primary mediator of the biologic effects of thyroid hormone and does so by interacting with a specific
nuclear receptor. Receptor abnormalities can result in thyroid hormone resistance.
The major carrier proteins for circulating thyroid hormones are thyroid-binding globulin (TBG), thyroidbinding prealbumin (TBPA), and albumin. Unbound, or free, T4 accounts for only about 0.03% of
circulating T4 and is the portion that is metabolically active. Infants born with low levels of TBG, as in
congenital TBG deficiency, have low total T4 levels but are physiologically normal. Familial congenital
TBG deficiency can occur as an X-linked recessive or autosomal recessive condition.
The contributions of maternal thyroid hormone levels to the fetus are thought to be minimal, but maternal
thyroid disease can have a substantial influence on fetal and neonatal thyroid function. Immunoglobulin G
(IgG) autoantibodies, as observed in autoimmune thyroiditis, can cross the placenta and inhibit thyroid
function. Thioamides used to treat maternal hyperthyroidism can also block fetal thyroid hormone
synthesis. Most of these effects are transient. Radioactive iodine administered to a pregnant woman can
ablate the fetus's thyroid gland permanently.
The importance of thyroid hormone to brain growth and development is demonstrated by comparing
treated and untreated children with congenital hypothyroidism. Thyroid hormone is necessary for normal
brain growth and myelination and for normal neuronal connections. The most critical period for the effect
of thyroid hormone on brain development is the first few months of life.[14]
Frequency
United States
The incidence of congenital hypothyroidism, as detected through newborn screening, is approximately 1
per 4000 births.[19] An increase in the diagnosis of primary congenital hypothyroidism has been reported in
New York.[20] This trend has also been observed in some other states, [21] although not all. Possible
explanations include changing demographics of the birth population, including changes in race, ethnicity,
and the incidence of low birth weight.[21] Changes in laboratory and screening methodology may also play
a role in this reported rise in incidence.[22] Some infants identified as having primary congenital
hypothyroidism may have transient disease and not permanent congenital hypothyroidism.[5]
Twins
An increased incidence of congenital hypothyroidism is observed in twins. [23, 24, 25] Twin births are
approximately 12 times as likely to have congenital hypothyroidism as singletons. [26] Usually, only one
twin is hypothyroid, but a common in-utero exposure can cause hypothyroidism in both. [27]
International
In central Africa, where iodine deficiency occurs along with excess dietary cyanate from cassava
(Manihot esculenta),[28] as many as 10% of newborns may have both low cord blood T4 concentration and
TSH concentrations over 100 mU/L.[29]
Data from most countries with well-established newborn screening programs indicate an incidence of
congenital hypothyroidism of about 1 per 3000-4000.[30, 31] Some of the highest incidences (1 in 1400 to 1
in 2000) have been reported from various locations in the Middle East. [32]
Although percentages of specific etiologies vary from country to country, ranges are as follows:
In regions of iodide deficiency and a known prevalence of endemic cretinism, the diagnosis may be
straightforward.
Infants with congenital hypothyroidism are usually born at term or after term.
Symptoms and signs include the following:
Decreased activity
Large anterior fontanelle
Poor feeding and weight gain
Small stature or poor growth
Jaundice
Decreased stooling or constipation
Hypotonia
Hoarse cry
Often, they are described as "good babies" because they rarely cry and sleep most of the time.
Family history should be carefully reviewed for information about similarly affected infants or family
members with unexplained mental retardation.
Maternal history of a thyroid disorder and mode of treatment, whether before or during pregnancy, can
occasionally provide the etiology of the infant's problem.
Congenital hypothyroidism is more common in infants with birthweights less than 2,000 g or more than
4,500 g.[36, 24]
Congenital hypothyroidism is more common in multiple births, with a low concordance rate. [26]
Physical
The physical findings of hypothyroidism may or may not be present at birth (see the image below).
Infants with congenital hypothyroidism are usually identified within the first 2-3 weeks of life.
These infants should be carefully examined for signs of hypothyroidism, and the diagnosis should
be confirmed by repeat testing.
Beckwith-Wiedemann Syndrome
Goiter
Iodine Deficiency
Panhypopituitarism
Pediatric Hypopituitarism
Ultrasonography may be a reasonable alternative or addition to scintigraphy but may fail to reveal some
ectopic glands.[6, 57]
A lateral radiograph of the knee may be obtained to look for the distal femoral epiphysis. This ossification
center appears at about 36 weeks' gestation. Its absence in a term or postterm infant indicates prenatal
effects of hypothyroidism, and prior to the introduction of hormone measurements, was used as a
diagnostic test for congenital hypothyroidism. [7]
Early studies of outcome suggested that infants without a distal femoral epiphysis did less well than those
with one, although both groups had results in the normal range. [58] The author of this study was later
unable to demonstrate an effect of bone age at diagnosis on outcome. [59] Another study was unable to
demonstrate any difference in outcome in infants with or without a distal femoral epiphysis. [60]
Other Tests
Neonatal hypothyroidism screening, using TSH levels, has proven helpful in countries with mild to no
iodine deficiency. It has not been found useful in countries with moderate-to-severe levels of iodine
deficiency disorders (IDD) because resources are insufficient to deal with the problem, and efforts here
should be made to supply sufficient iodine to the population as a whole.
In infants with suspected dyshormonogenesis, radioactive iodine uptake (iodine-123) and perchlorate
flush testing (KCIO2) can be performed to determine the presence of an iodide uptake or organification
defect.
Medical Care
The mainstay in the treatment of congenital hypothyroidism is early diagnosis and thyroid hormone
replacement. Optimal care may includes diagnosis before age 10-13 days and normalization of thyroid
hormone blood levels by age 3 weeks.[8, 9, 61]
Consultations
The treatment of hypothyroidism is straightforward. However, because of the potential for serious
morbidity with inadequate treatment or overtreatment, primary physicians should consult a pediatric
endocrinologist. Appropriate psychological, developmental, and educational evaluations should also be
considered.
Diet
Dietary iodide supplementation in iodine-deficient areas can prevent endemic cretinism but does not have
a major effect on sporadic congenital hypothyroidism. Dietary iodine deficiency is the most common
preventable cause of brain damage worldwide.[62]
Soy-based formulas may decrease the absorption of levothyroxine. [63] This is not a contraindication to
their use, even in infants with congenital hypothyroidism. Switching an infant from a milk-based formula
to a soy-based formula may increase the dose of thyroid hormone needed to maintain a euthyroid status.
[64]
Activity
Activity should be encouraged in children with congenital hypothyroidism, because activity should be
encouraged in all children.
Medication Summary
Only levothyroxine is recommended for treatment. [10] It has been established as safe, effective,
inexpensive, easily administered, and easily monitored. Some authors suggest that generic forms may be
just as effective as branded medications,[65] but others diasagree.[66]
No liquid preparations are commercially available in the United States, but they are licensed elsewhere.
[67]
Pharmacies should be discouraged from dispensing suspensions prepared in-house by crushing tablets
and mixing with various agents. The T4 in these preparations is very difficult to keep in suspension, and
the delivery of drug is inconsistent.
Parents should be provided the hormone in pill form and taught proper administration. The pills can be
crushed in a spoon; dissolved with a small amount of breast milk, water, or other liquid immediately
before administration, and administered to the child with a syringe or dropper. The pills should not be
mixed in a full bottle of formula. Toddlers readily chew the tablets without problems or complaints.
Optimum dosage regimens and follow-up laboratory monitoring have not yet been determined. [68, 69,
70]
Initial dosages of 10-15 mcg/kg/d, equivalent to a starting dose of 50 mcg in many newborns, have been
recommended.[11] Equally good developmental results, but with higher thyroid-stimulating hormone
(TSH) levels, have been reported with half this starting dose (25 mcg/d). [12]
Thyroid Hormones
Class Summary
These agents are administered to supplement thyroid hormone in patients with hypothyroidism.
Levothyroxine is the preferred form of thyroid hormone replacement in all patients with hypothyroidism.
[71]
Desiccated thyroid is an obsolete medication made from pooled animal tissue. Desiccated thyroid
should not be used.
View full drug information
Levothyroxine (Levothroid, Levoxyl, Synthroid)
Also known as L-thyroxine, T4, and thyroxine. A thyroid hormone with proven record of safety, efficacy,
and ease of use. In active form, influences growth and maturation of tissues. Involved in normal growth,
metabolism, and development.
200mcg/vial
500mcg/vial
Hypothyroidism
Age 1-3 months
10-15 mcg/kg/day PO
5-7.5 mcg/kg/day IV/IM
Use lower starting dose (25 mcg/day) if patient at risk of cardiac failure; if initial serum T4 lower
than 5 mcg/dL begin treatment at higher dose (50 mcg/day)
Age 3-6 months
8-10 mcg/kg/day PO, OR
25-50 mcg/day PO
4-7.5 mcg/kg/day IV/IM
Age 6-12 months
6-8 mcg/kg/day PO, OR
50-75 mcg/day PO
3-6 mcg/kg/day IV/IM
Age 1-5 years
5-6 mcg/kg/day PO, OR
75-100 mcg/day PO
2.5-4.5 mcg/kg/day IV/IM
Age 6-12 years
4-5 mcg/kg/day PO, OR
100-125 mcg/day PO
2-3.75 mcg/kg/day IV/IM
>12 years
2-3 mcg/kg/day PO, OR
150 mcg/day PO
1-2.25 mcg/kg/day IV/IM
Dosing considerations
Check for bioequivalence if switching brands/generics
May minimize hyperactivity in older children by initiating dose at 1/4 of recommended dose;
increase by that amount each week until full dose achieved
Start children with severe or chronic hypothyroidism at 25 mcg/day; adjust dose by 25 mcg
qweek
Administration
Take tabs with full glass of water before breakfast on empty stomach
Do not use foods that decrease absorption (soybean infant formula) for administering levothyroxine
Administer oral levothyroxine >4 hr apart from drugs known to interfere with absorption
IV/IM 50-75% of PO
Patients unable to swallow intact tabs/caps
Tablets: Crush appropriate dose and place in 5-10 mL of water; administer resultant suspension
by spoon or dropper immediately, do NOT store
Peak effect: 24 hr
Distribution
Protein bound: 99%
Vd: 9-10 L
Metabolism
Deiodinated in blood and then 50% converted to active metabolite, triiodothyronine (T3), also by liver
Metabolites: T3 (active)
Elimination
Half-life: 9-10 days (hypothyroid); 3-4 days (hyperthyroid); 6-7 days (euthyroid)
Total body clearance: 0.8-1.4 L/day
Once euthyroid, infants with congenital hypothyroidism should be observed every 3 months until
they are aged 3 years. Thereafter, these children can be evaluated every 6 months.
Inpatient & Outpatient Medications
See the list below:
Levothyroxine is the appropriate replacement therapy for all clinically significant forms of
hypothyroidism (see Medical Care).
Deterrence/Prevention
See the list below:
The etiology of adverse clinical outcomes is multifactorial. Even with optimal therapy, some
children with congenital hypothyroidism display intelligence quotient values lower than would be
expected on the basis of genetic potential. Factors associated with this adverse outcome include a
markedly low T4 value at birth, a markedly delayed bone age at diagnosis, delay in treatment, and low
serum T4 levels during the first year of therapy.
Prognosis
See the list below:
The prognosis for patients with congenital hypothyroidism that is appropriately treated within 6
weeks of birth is excellent.
Children with acquired hypothyroidism who receive adequate treatment at least 5 years before the
onset of puberty typically achieve a final adult height consistent with their genetic potential.
Overtreating with thyroid hormone does not enhance catch-up growth and may compromise final adult
height by advancing osseous maturation.