Don't Miss Thyroid Disease in Kids

Laurie Scudder, DNP, NP; Andrew Bauer, MD

Disclosures

December 05, 2016

Editorial Collaboration

Medscape &

In This Article

Who Should Be Screened for Thyroid Disease?

Medscape: In your review, you emphasize that a large percentage of children, from infants to adolescents, with thyroid disorders are asymptomatic. However universal screening is recommended only in the newborn period. Should there be screening in older kids?

Dr Bauer: There is a line between testing too much, with potential overdiagnosis, and not testing enough and missing kids who are truly hypothyroid. It's a balance.

We probably test more kids for thyroid disease than many other countries. Some of it is because we are always trying to find easy explanations for signs and symptoms that are increasingly common. The two things that come to mind are overweight and tiredness or fatigue. These are nonspecific symptoms that are often due to everyday life but have crossover with hypothyroidism. So, in an effort to identify a potentially fixable medical explanation, we test even when there are clear issues with the person's activity schedule or diet—and no evidence of thyroid disease on the basis of the physical examination.

 
Thyroid screening is easy to do, and it would an awesome answer to explain gaining 10 pounds. However, most of the time the explanation is based on a poor diet and decreased exercise, and the difficult issue that some patients and families have a metabolism that increases the likelihood of storing calories
 

As it turns out, most overweight kids have normal thyroid function, and the explanation is that foods that are high in calories are less expensive than healthier, fresh foods with lower calories. Thyroid screening is easy to do, and it would an awesome answer to explain gaining 10 pounds. However, most of the time the explanation is based on a poor diet and decreased exercise, and the difficult issue that some patients and families have a metabolism that increases the likelihood of storing calories compared with others, despite the same diet and activity.

So, it's hard to provide strict guidelines for screening that wouldn't put some kids at risk of being missed. If we said, don't test kids who are overweight or don't test kids who are tired, of course you'll miss somebody. It comes down to clinical acumen—to pursuing a thoughtful approach to figure out whether testing is appropriate on the basis of the individual patient, their story, and their family history.

One advantage we have in children and adolescents is that the thyroid is important for normal growth and puberty. So, thyroid testing should be considered in all patients who are not achieving a normal linear growth rate (ie, not following their percentile on the height curve) and/or have abnormal onset or progression through puberty. If a child is maintaining or gaining weight but not growing the expected number of inches or centimeters a year, that's a definite red flag for an endocrine problem.

Medscape: Autoimmune Hashimoto thyroiditis is the most common cause of acquired hypothyroidism in all ages. These children are not as likely to be asymptomatic, correct? Can you describe the typical presentation for this condition? When suspected, what is the most appropriate diagnostic approach in the primary care setting?

Dr Bauer: I practiced general pediatrics for 3 years before going back and doing my endocrine fellowship, so I have lived with trying to figure out who should be screened while not testing everybody. You have to look at the whole person, including the chief complaint that led to this visit. Are there any signs or symptoms that would potentially, either individually or cumulatively, increase the likelihood that thyroid disease should be in the differential diagnosis? Then add the patient's family history, asking whether there is any history of thyroid disease—especially other autoimmune disease, such as type 1 diabetes, celiac disease, rheumatoid arthritis, multiple sclerosis, and others.

Finally, take a look at the child's growth and development and their thyroid. [Editor's note: A video showing the thyroid exam is available online. Observe the child with the chin in neutral position and in neck extension, both with and without swallowing, to see whether the thyroid gland is visible—a sensitive sign of potential thyroid disease.

Combining these things provides a thoughtful approach to determining whether laboratory screening is warranted. Even with all of this information, decisions may not be easy, but at least this comprehensive approach increases the likelihood of an accurate interpretation of laboratory results in a patient with signs and symptoms that are often nonspecific, such as fatigue and overweight.

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