Points
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Uncommon presenting complaints associated with hypothyroidism include slipped capital femoral epiphysis, early puberty without pubic hair, pericardial effusion, chronic urticaria, and ovarian torsion. Check thyroid function in patients with these complaints, particularly if the patient has Down syndrome, McCune-Albright syndrome, Turner syndrome, or a personal or family history of thyroid or autoimmune diseases.
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Hypothyroidism may produce constipation, but this is rarely the only symptom and is usually a late sign.
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As commencement of thyroxine supplementation in hypothyroidism is not an emergent requirement, discussion with a pediatric endocrinologist and expedited referral is recommended.
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Although incredibly rare in children, suspect myxedema coma in patients presenting with altered level of consciousness, cardiovascular instability, hypothermia, nonpitting edema, or generalized puffiness associated with hypothyroidism. Consider sending electrolytes, urea, creatinine, creatine kinase, lactate dehydrogenase, blood gases, serum cortisol, and blood and urine cultures, and order an ECG.
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Avoid hypotonic fluids in patients with myxedema coma, due to the risk of worsening hyponatremia. Hypoglycemia, dehydration, prerenal insufficiency, elevation of muscle enzymes, acidosis, and hypoxia may also occur.
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Thyroid storm should be recognized and treated quickly, as multiorgan dysfunction can occur, with a high fatality rate. Essentials for diagnosis are elevated T3/T4 levels, decreased TSH level, and suspicion of thyroid disease or triggering factors in patients with previously diagnosed hyperthyroidism.
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Thyroid storm frequently leads to poor tissue oxygenation and ischemia; intubation may be required.
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In patients with thyroid storm, elevated bilirubin has been found to be associated with high mortality, acting as a marker of hepatic dysfunction. Check markers of organ dysfunction and an ECG for arrhythmias, and plan to admit the patient to the hospital.
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Give propranolol for patients with thyroid storm to decrease receptor binding and decrease conversion of T4 to T3. Then, give medications to reduce thyroid hormone function and release (eg, propylthiouracil and methimazole). Treatment is expected to reduce metabolic demand and improve vital signs; however, it may take 24 to 48 hours for thyroid hormone levels to return to normal.
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Patients with unintentional ingestion of levothyroxine are typically asymptomatic but develop symptoms of hyperthyroidism days later. Treat these patients with supportive care and propranolol, if needed, until resolution of symptoms.
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Order an ultrasound as the first imaging test in patients with thyroid nodules. Pediatric patients with thyroid nodules are more likely than adults to have malignant change within nodules.
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The thyroid can bleed heavily when injured, resulting in external blood loss or in swelling that can compress the airway. Trauma to the thyroid gland, especially in individuals with pre-existing thyroid disease may lead to massive release of hormones and acute thyrotoxicosis.
Pearls
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As thyroid disease can present with nonspecific symptoms, consider testing thyroid function in patients with vague complaints, especially if the complaints are behavioral or cardiac.
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For patients with thyroid storm, do not administer salicylates, as they may displace thyroid hormone from binding sites and worsen symptoms.
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Although calcitonin has been used to stratify risk of thyroid malignancy in adults, this is not established in children.
Table 1. Manifestations of Hypothyroidism and Hyperthyroidism12,76
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Clinical Pathway for the Management of Suspected Hypothyroidism
Clinical Pathway for the Management of Suspected Hyperthyroidism
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