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M. Hashemipour Professor of Pediatric Endocrinology Isfahan university of medical sciences Newborn Thyroid Function Tests 1.

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Presentation on theme: "M. Hashemipour Professor of Pediatric Endocrinology Isfahan university of medical sciences Newborn Thyroid Function Tests 1."— Presentation transcript:

1 M. Hashemipour Professor of Pediatric Endocrinology Isfahan university of medical sciences Newborn Thyroid Function Tests 1

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4 Increase in congenital hypothyroidism in New York State and in the United States Incidence Between per per Asians have a 65% higher incidence than the average of all infants 98.4/100,000 vs. 59.5/100,000 Mol Genet Metab Jul;91(3)

5 incidence rates of CH Harris and Pass 2007 increase in the incidence rates of CH over the 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 Molecular Genetics and Metabolism

6 نوزاد 20 روزه فول ترم 70TSH= تحت درمان قرار گرفته دوز و زمان مصرف دارو چگونه است؟ در صورت درمان مناسب سطح سرمي T4,TSH در چه زمانی طبیعی خواهد شد ؟ حداقل و حداكثر سطح سرمي T4 و TSH در اين نوزاد پس از درمان چه میزان باید باشد؟

7 Low T4 &Elevated TSH Any Infant With A Low T4 Level And Elevated TSH Is Considered To Have Primary Hypothyroidism TSH>10 two weeks Abnormal AAP2006

8 Treatment The Goal Of Treatment To Ensure Normal Growth &Development  T4 10 To 16 Ug/dl  TSH 0/5-2Miu/L PEDIATRIC RESEARCH 2009

9 Treatment Good prognosis T4 normalizes in 3 days. TSH returns to the target range by 2 weeks of therapy. with 12–17 µg/kg levothyroxin 9

10 در صورتيكه T4 و TSH در زمان معين به حد مناسب نرسيد چه تشخيص هائي مطرح است؟

11 Failure of increase T4  TBG Deficiency  Preparation of L-thyroxin Is Not Appropriately Active  Absorption of L-thyroxin Is Incomplete  Child Is Not Receiving The Medication  Drug exposure to high temperature

12 Failure of increase T4 Malabsorption increased degradation (anticonvulsants) large hemangiomas with high deiodinase activity

13 Interfere With The Absorption  Soy Formulas ( within an hour )  Ferrous Sulfate  Aluminum Hydroxide  Bile Acid Sequestrants  Calcium

14 به مادر چه يادآوري هائي مي كنيد؟

15 پیش اگهی بیمار فوق در صورتی که از شش ماهگی تا دو سالگی چهار بار TSH بالای 5 داشته باشد چگونه است

16 prognosis During The First Year Of Life, Infants With  T4 <10 mcg/dl  Accompanied By TSH > 15 Mu/L Have Lower IQ Values Than infants AAP2006

17 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

18 Prognosis Infant With  Initial T4 Level < 5 µg/dl  Delay Skeletal Maturation at Birth. May have Permanent Intellectual Sequelae

19 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

20 Prognosis Delay in normalizing serum T4 and TSH by more than 2 wk after starting treatment resulted 10 point lower IQ J Clin Endocrinol Metab, 2011

21 Prognosis infants 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 34 J Clin Endocrinol Metab, 2011

22 شش ماه پس از شروع درمان TSH=0.01 T4=12 تصمیم؟

23 دو سال پس ازدرمان 10 T4=18,TSH= چه علتی برای این مشکل وجود دارد

24 در چه صورت در سن سه سالگی درمان وی قطع نمی شود

25 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

26 نوزاد فول ترم با TSH=25 تحت درمان قرار با 25 میکرو گرم لووتیروکسین قرار گرفته است در سن سه ماهگی TSH=0.1 T4=18 تصمیم؟

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28 Thyroid Radionuclide Uptake Recommend Routinely In Infants With TSH>50mu/L

29 نوزاد 14 روزه با mIU/L 11 TSH = T4=10 ug/dl مراجعه كرده، پزشك معالج با توجه به T4 طبيعي تصميم گرفته وي را درمان نكند. اگر اقدام وي صحيح باشد پيگيري اين نوزاد چگونه است

30 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

31 نوزاد 14 روزه با وزن 1300 گرم T4= 4 µg/dl TSH=8mu/L با توجه به T4 پائين و TSH بالا پزشك معالج تشخيص هيپوتيروئيدي داد. نظر شما چيست ؟ 31

32 VLBW & Thyroid function An 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,.

33 Current Opinion in Endocrinology & Diabetes 2005, 12:36–41

34 Premature Currently the evidence base does not indicate cognitive benefit from thyroid therapy of hypothyroxinemia of prematurity in the absence of TSH elevation. AAP2006

35 Premature It Would Seem Reasonable At The Present Time To Treat Any Premature Infant With A Low T4 And Elevated TSH

36 Normal Values For T4 Level By Weight WeightT4(ug/dl)± SD < ± ± ± ± 2.4 >250012± 2

37 Normal Values For TSH AgeTSH (mU/L) 2–20wk1.7–9.1 5–24 mo0.8–8.2 2–7 yr0.7–6.2 AAP2003

38 شیر خوار 1/5 ماهه ای با وزن و قد طبیعی به شما مراجعه کرده تا به حال دو بار تست تیروئید شده TSH=3,T4 =5 T4= 3ug/dl, TSH= 1mU/L نظر شما در مورد تایید تشخیص و درمان وی چیست؟ چه عللی ممکن است باعث کاهش T4 بشوند؟

39 T3RU FT4 39

40 Low T4 &Normal TSH  Anticonvulsants  preterm infants  NTI  TBG deficiency  Central hypothyroid  Birth asphyxia

41 Low T4 &Normal TSH primary hypothyroidism and delayed TSH elevation High-dose glucocorticoids

42 شیر خوار هشت ماهه با سابقه هیپوتیروئیدی کنترل شده فعلا مبتلا به تشنج است نظر شما در مورد درمان وی چیست؟

43 کودک 3/5 ساله با سابقه هیپوتیروئیدی فعلا درمان وی قطع شده T4=10 و 8 TSH = دارد تصمیم شما در مورد پیگیری وی چگونه است؟

44 کودک سه ساله ای با سابقه هیپوتیروئیدی گذرا درمان وی قطع شده است و ازمایشات پس از قطع درمان طبیعی است نظر شما در مورد پیگیری وی چگونه است ؟ ؟

45 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

46 نوزاد 9 روزه از مادر مبتلا به هیپر تیروئیدی تحت درمان متولد شده و فعلا TSH=15 دارد تصمیم شما چیست؟

47 Newborn whose mother is receiving an antithyroid drug. T4 and TSH values return to normal within 1 to 3 weeks

48 نوزاد مبتلا به سندرم دان در چه زمان هائی باید ازمایش تیروئید در این ها انجام شود

49  اسکرین  دو هفتگی  دو ماهگی  هر 6-12 ماه تا سه سالگی

50 نوزاد با همانژیم بزرگ متولد شده در چه زمان هائی باید ازمایش تیروئید در این ها انجام شود

51 تا یک سالگی ماهیانه نیاز به تست تیروئید است

52 نوزادی 18 روزه با افزایش وزن مناسب به علت بی قراری با تست تیروئید ذیل ارجاع داده شده T4==18ug/100 TSH=0/5 T3=250ng/ml پزشک معالج با تشخیص هیپرتیروئیدی درمان را شروع کرده نظر شما چیست؟ T4==18ug/100 TSH=0/5miu/l T3=250ng/ml

53 Follow-up  CHD fourfold higher than control  Hearing Screening  Kidney disease  GI The Journal of Pediatrics2008 The Journal of Pediatrics

54 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

55 Assessing permanence of CH Permanence of hypothyroidism is confirmed. TSH> 10 mU/L

56 Assessing permanence of CH Serum TSH> 10 mU/L after the first year of life AAP1993

57 دختر 12 ساله ای به علت احساس توده ای که به طور اتفاقی در قسمت قدامی گردن مشاهده شده مراجعه کرده است. شرح حال فامیلی پر کاری تیروئید را در مادر و مادر بزرگ میدهد. در معاینات اولیه قد و وزن نسبتا طبیعی دارد. در معا ینه تیروئید نسبتا سفت ، غیر قرینه و عملکرد طبیعی دارد.

58 چه آزمایشاتی ارسال می کنید ؟ چه درمانی را تجویز می کنید ؟ درصورت عدم درمان وبزرگتر شدن چه عوارضی خواهد داشت ؟ در چه صورت FNA لازم دارد ؟ در چه صورت درمان جراحی انجام می شود؟ چه عوارضی ممکن است به دنبال گواترطول کشیده ایجاد شود؟ طول مدت درمان چگونه است ؟ چگونه بیمار را پیگیری می کنید ؟

59 Goiter Goiter = Chronic enlargement of the thyroid gland not due to neoplasm 59

60 Investigation of Goiter TFT Thyroid Abs

61 Complications of Goitre Dysphagia Dyspnea Hoarseness Malignancy 1-10% Toxic goiter %30 micro or macronodularity Without treatment 61

62 FNA Asymmetric goiter prominent nodule smaller nodule that enlarges during follow-up 62

63 Surgical Care Large goiters with compression Malignancy Ineffective treatment Cosmetic Rapid enlargement 63

64 Complications Hyperthyroidism Lymphoma Malignancy 64

65 Treatment The size of goiter reduced with levothyroxine )suppressive therapy(

66 Levothyroxin Reduced TSH secretion Subside the effect of TSH on thyroid TSH should be kept between mu/l

67 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. 67

68 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. 68

69 دختر 16 ساله ای جهت معاینه سالیانه مراجعه کرده است. او به جز یبوست مشکلی ندارد. در معاینه تیروئید کمی بزرگ است. تست تیروئید وی به شرح ذیل است : TSH = 7.5 mU/ ml (0.5-5) Free T4 = 1.1 ng ( ) درمان و پیگیری وی چگونه است ؟

70 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% 70

71 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

72 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

73 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 thyroid antibodies with the second free T4 and TSH than as a screening test. International Journal of Pediatric Endocrinology2010

74 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.

75 Conclusions It is proposed that TSH be rechecked periodically for 2 years longer if  There is a goiter  strongly positive antibodies International Journal of Pediatric Endocrinology2010

76 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 appears  There are new symptoms suggestive of OH International Journal of Pediatric Endocrinology2010

77 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

78 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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