Guidelines for the treatment of childhood-onset Graves' disease in Japan, 2016

Perioperative Care of a Child With Hyperthyroidism

In pediatric-aged patients, hyperthyroidism generally results from the autoimmune disorder, Graves' disease (GD). Excessive levels of thyroid hormones (triiodothyronine and thyroxine) result in irritability, emotional lability, nervousness, tremors, palpitations, tachycardia, and arrhythmias. The risk of morbidity and mortality is increased when surgical intervention is required in patients with hyperthyroidism due to the potential for the development of thyroid storm (TS). A 3-year, 1-month-old child with a past medical history of GD presented for total thyroidectomy when pharmacologic control with methimazole was not feasible due to intolerance following development of a serum sickness-like illness. Prior to surgery, his thyrotoxicosis symptoms worsened with fever, tachycardia, diaphoresis, and hypertension. He subsequently developed TS and was admitted to the pediatric intensive care unit where management included hydrocortisone, potassium iodide, and β-adrenergic blockade with esmolol and propranolol. Thyroid studies improved prior to surgery, and a total thyroidectomy was successfully completed. Corticosteroid therapy was slowly tapered as an outpatient, and he was discharged home on hospital day 9. Following discharge, his signs and symptoms of thyrotoxicosis resolved, and he was started on oral levothyroxine replacement therapy. The remainder of his postoperative and post-discharge course were unremarkable. Only two case reports of perioperative pediatric TS have been published in the past 20 years. Our case serves as an important reminder of the signs of TS in children and to outline the treatment options in a pediatric patient, especially in those unable to tolerate first-line pharmacologic therapies such as methimazole or propylthiouracil.

Association of autoimmune thyroid disease with type 1 diabetes mellitus and its ultrasonic diagnosis and management

As a common hyperglycemic disease, type 1 diabetes mellitus (T1DM) is a complicated disorder that requires a lifelong insulin supply due to the immune-mediated destruction of pancreatic β cells. Although it is an organ-specific autoimmune disorder, T1DM is often associated with multiple other autoimmune disorders. The most prevalent concomitant autoimmune disorder occurring in T1DM is autoimmune thyroid disease (AITD), which mainly exhibits two extremes of phenotypes: hyperthyroidism [Graves' disease (GD)] and hypo-thyroidism [Hashimoto's thyroiditis, (HT)]. However, the presence of comorbid AITD may negatively affect metabolic management in T1DM patients and thereby may increase the risk for potential diabetes-related complications. Thus, routine screening of thyroid function has been recommended when T1DM is diagnosed. Here, first, we summarize current knowledge regarding the etiology and pathogenesis mechanisms of both diseases. Subsequently, an updated review of the association between T1DM and AITD is offered. Finally, we provide a relatively detailed review focusing on the application of thyroid ultrasonography in diagnosing and managing HT and GD, suggesting its critical role in the timely and accurate diagnosis of AITD in T1DM.

Different doses of methimazole treatment of children and adolescents with graves' disease: a clinical study based on 161 cases of outpatients

OBJECTIVE

This study aimed to evaluate the association between the initial dose of MMI and the clinical course, as well as adverse effects on young people with GD.

METHODS

One hundred and sixty-one children and adolescents with newly diagnosed GD were enrolled for this study and categorized into four groups based on initial serum-free T3 and T4 levels and daily MMI doses: Group A (mild, 0.3-0.5 mg/kg/day, n = 78), Group B (moderate, 0.6-0.8 mg/kg/day, n = 37), Group C (severe, 0.6-0.8 mg/kg/day, n = 24), and Group D (severe, 0.8-1.0 mg/kg/day, n = 22). The thyroid function, blood cell analysis and liver function were examined before treatment and at 4, 8 and 12 weeks after treatment. Outcome of long-term follow-up were also observed.

RESULTS

After 12 weeks of treatment, 91.0% of the patients in group A and 90.9% of the patients in group D recovered to normalization of FT3, which was slightly higher than the other two groups; 70.8% of the patients in group C recovered to normalization of FT4, which was slightly lower than that in the other three groups. The incidence of minor adverse effects was 12.8% in group A, 13.5% in group B, 16.7% in group C and 40.9% in group D (P < 0.01). Remission was achieved in 38 patients (23.6%).

CONCLUSIONS

Lower doses of MMI (0.3-0.5 mg/kg/day) are suitable for mild GD, and higher doses of MMI (0.6-0.8 mg/kg/day) are advisable for moderate or severe GD. Much higher doses of MMI (0.8-1.0 mg/kg/day) are harmful for initial use in children and adolescents with GD patients.

Thyroid storm in pediatrics: a systematic review

OBJECTIVES

Thyroid storm (TS) is an uncommon but severe manifestation of hyperthyroidism and an endocrine emergency, as it is fatal if it goes unrecognized. In pediatrics, the current literature is limited to case reports and case series. Current knowledge is extrapolated from adult data. This systematic review aims to present the epidemiology, most common etiologies, clinical presentation, and most accepted standard of care of TS in children. We aim to raise awareness of hyperthyroidism in the pediatric community.

CONTENT

The databases used were PubMed, google scholar, and LILACS, with the search terms "thyroid storm" AND "pediatrics". Studies included case reports and case series in English and Spanish from patients between the ages of 0-21 years with clinical features consistent with a diagnosis of TS based on ATA 2016, with or without reported scale scores, published between 2000 and 2022. Variables such as ethnicity, etiology, possible triggers, clinical features, and management components were analyzed and presented.

SUMMARY

We analyzed data from 45 patients. Their mean age was 11.25 years. The majority of them were from Asia (26%). The most common clinical features were sinus tachycardia (86.7%) and fever (64%), followed by altered mental status (46%) and diarrhea (31%). Graves' disease was the most common underlying condition, and infection the most common precipitant. Thirty one percent of patients received treatment with four components; however morbidity and mortality were not clinically significant with those who did not. TS has a heterogeneous presentation with multisystemic involvement. The most common symptoms in this review were fever, tachycardia, diarrhea, and altered mental status.

OUTLOOK

Further studies may be needed to best standardize the diagnosis and management of TS in children. Qualitative studies are needed to best assess the delay in diagnosis of hyperthyroidism and how this may impact prognosis in case patients were to develop TS.

The characteristics of Grave's disease in children and adolescent patients in Al-Madinah Al-Munawwarah: A retrospective chart review

OBJECTIVES

To determine the characteristics of Graves' disease in children and adolescents in Medina, the Kingdom of Saudi Arabia, and compare them to those observed in other countries.

METHODS

This is a retrospective chart review of children and adolescents diagnosed with Graves' disease between January 2010 and May 2021.

RESULTS

Fifty-eight patients aged 12.02 ± 4.85 years were identified, of which 44 (75.9%) were females. Exophthalmos (63.8%), neck swelling (60.3%), palpitations (46.6%), and tremors (29.3%) were the most common manifestations. Vitiligo (1.72%) and alopecia (1.72%) were the only autoimmune diseases observed in our patients. The median (IQR) value was 0.01 (0.36) (ulU/mL) for thyroid-stimulating hormone (TSH) and 24.89 (29.50) (pmol/L) for FT4. In terms of treatment modalities, 55 (94.8%) received antithyroid medication, 6 (10.3%) underwent thyroidectomy and one patient (1.72%) was treated with radioactive iodine.

CONCLUSION

In general, Graves' disease is more common in females. Neck swelling, palpitation, and tremors were the main manifestations. Compared with other countries, there was a higher frequency of exophthalmos and a lower frequency of associated autoimmune conditions. The primary treatment was antithyroid drugs; thyroidectomy and radioactive iodine were used less frequently.

Diagnostic role of thyroid elastography in pediatric patients with Hashimoto's thyroiditis and Graves' disease: A prospective controlled study

OBJECTIVE

Hashimoto's thyroiditis and Graves' disease are autoimmune diseases of the thyroid gland, and both diseases are diagnosed with ultrasound findings and autoantibody height. However, ultrasound (US) findings may be normal in both diseases rarely. In some pediatric studies, it was reported that shear wave velocity values in autoimmune thyroiditis were significantly higher than normal thyroid parenchyma and it was recommended to be used as a diagnostic method. Our study will address the evaluation of patients with Hashimoto's thyroiditis and Graves' disease by thyroid elastography and the role of this method in diagnosis.

MATERIALS AND METHODS

28 patients with Hashimoto's thyroiditis, 20 patients with Graves' disease and 40 healthy controls were enrolled in our study prospectively. Thyroid Elastography and US were applied to all patients.

RESULTS

In US, Hashimoto's thyroiditis had a hypoechoic echo pattern compared to graves' disease (p < 0.05). When shear wave velocity (SWV) value of children with Hashimoto's thyroiditis and Graves' disease were compared with the control group, thyroid tissue showed more stiffness in both disease groups (p = 0.001). When SWV values were compared between Hashimoto's thyroiditis and Graves' disease, there was no statistically significant difference (p = 0.73).

CONCLUCION

SWV values were found to be higher in children with Hashimoto's thyroiditis and Graves' disease compared to the control group and contributes to the diagnosis of these diseases. However, the elastography technique alone is not sufficient to differentiate. Hashimoto's thyroiditis and Graves' disease.

Clinically practical pharmacometrics computer model to evaluate and personalize pharmacotherapy in pediatric rare diseases: application to Graves' disease

Objectives

Graves' disease (GD) with onset in childhood or adolescence is a rare disease (ORPHA:525731). Current pharmacotherapeutic approaches use antithyroid drugs, such as carbimazole, as monotherapy or in combination with thyroxine hormone substitutes, such as levothyroxine, as block-and-replace therapy to normalize thyroid function and improve patients' quality of life. However, in the context of fluctuating disease activity, especially during puberty, a considerable proportion of pediatric patients with GD is suffering from thyroid hormone concentrations outside the therapeutic reference ranges. Our main goal was to develop a clinically practical pharmacometrics computer model that characterizes and predicts individual disease activity in children with various severity of GD under pharmacotherapy.

Methods

Retrospectively collected clinical data from children and adolescents with GD under up to two years of treatment at four different pediatric hospitals in Switzerland were analyzed. Development of the pharmacometrics computer model is based on the non-linear mixed effects approach accounting for inter-individual variability and incorporating individual patient characteristics. Disease severity groups were defined based on free thyroxine (FT4) measurements at diagnosis.

Results

Data from 44 children with GD (75% female, median age 11 years, 62% receiving monotherapy) were analyzed. FT4 measurements were collected in 13, 15, and 16 pediatric patients with mild, moderate, or severe GD, with a median FT4 at diagnosis of 59.9 pmol/l (IQR 48.4, 76.8), and a total of 494 FT4 measurements during a median follow-up of 1.89 years (IQR 1.69, 1.97). We observed no notable difference between severity groups in terms of patient characteristics, daily carbimazole starting doses, and patient years. The final pharmacometrics computer model was developed based on FT4 measurements and on carbimazole or on carbimazole and levothyroxine doses involving two clinically relevant covariate effects: age at diagnosis and disease severity.

Discussion

We present a tailored pharmacometrics computer model that is able to describe individual FT4 dynamics under both, carbimazole monotherapy and carbimazole/levothyroxine block-and-replace therapy accounting for inter-individual disease progression and treatment response in children and adolescents with GD. Such clinically practical and predictive computer model has the potential to facilitate and enhance personalized pharmacotherapy in pediatric GD, reducing over- and underdosing and avoiding negative short- and long-term consequences. Prospective randomized validation trials are warranted to further validate and fine-tune computer-supported personalized dosing in pediatric GD and other rare pediatric diseases.

Long-term outcomes of anti-thyroid drug treatment in childhood-onset Graves' disease

OBJECTIVE

Outcomes of childhood-onset Graves' disease (GD) and suggested duration of anti-thyroid drug (ATD) therapy have been controversial. This study aimed to determine long-term outcomes following ATD therapy, including remission and relapse rates.

DESIGN, PATIENTS AND MEASUREMENTS

A retrospective study of 265 paediatric patients with GD who were initially treated with ATD was conducted. Long-term outcomes were analysed.

RESULTS

Median (IQR) age at diagnosis was 11.5 (9.4, 13.7) years. Duration of ATD treatment was 4.3 (2.3, 6.7) years and time since diagnosis to the enrolment was 7.1 (3.8, 10.9) years. There were 77, 93 and 95 patients who underwent definitive treatment, had ATD discontinuation, and were still being treated with ATD, respectively. The remission rate was 21% (56 out of 265 patients) and relapse rate was 40% (37 out of 93 patients). Cumulative incidence of first remission increased with the duration of ATD treatment with maximum remission rate at 5.3 years following ATD therapy. Among patients who experienced relapse, approximately 50% had disease relapse which occurred within 1 year after ATD discontinuation. Patients with goitre size of less than 3.5 cm, thyroid-stimulating hormone receptor antibody of less than 10 IU/L, no ophthalmopathy at diagnosis and methimazole dose requirement of less than 0.25 mg/kg/day at 1 year after treatment were more likely to achieve remission.

CONCLUSIONS

Remission rate of childhood-onset GD was relatively low following ATD treatment. Longer-term ATD therapy was associated with increased remission rate. Approximately 50% of patients with relapse had disease relapse within 1 year following ATD discontinuation.

Remission in pediatric Graves' disease treated with antithyroid drug and the risk factors associated with relapse

PURPOSE

To evaluate the characteristics and frequency of remission in pediatric patients with Graves' disease (GD) treated with antithyroid drug (ATD) and to identify factors that may be associated with relapse.

METHODS

Medical records of patients younger than 19 years who presented to the Department of Pediatrics of Queen Elizabeth Hospital Hong Kong with newly diagnosed GD from 1st January 2007 to 31st December 2017 were retrospectively reviewed. Remission was defined as euthyroidism for 12 months or more after discontinuation of ATD treatment and no relapses during the follow-up period. Patients who successfully achieved remission were compared to those who suffered relapse. Factors that may predict occurrence of relapse after ATD treatments were studied, and their odds ratios (ORs) were calculated.

RESULTS

A total of 101 patients was included in this study. Eighty-one patients completed one course of ATD. Eighteen patients (17.8%) successfully achieved remission, and 58 patients (57.4%) experienced relapse after discontinuation of ATD. The remission group received a significantly longer course of ATD therapy than the relapse group (median, 28 months; interquartile range [IQR], 18-48 months in remission group vs. median, 21 months; IQR, 17-26; p=0.024). The OR for relapse was 0.971 (95% confidence interval [CI], 0.946-0.997) in univariate analysis and remained significant after adjustments in the multivariate regression model (OR, 0.961; 95% CI, 0.933-0.989; p=0.008).

CONCLUSION

The remission rate in pediatric patients with GD treated with ATD was low. A longer ATD course was associated with a greater chance of remission in this population.

Approach to the Patient: Management and the Long-term Consequences of Graves' Disease in Children

In children, Graves' disease (GD) is the most common cause of hyperthyroidism. Most pediatric patients with GD will not go into lasting remission, even following many years of antidrug therapy. Thus, most pediatric patients will require radioactive iodine (RAI) or surgery. When antithyroid drugs are used, methimazole is the drug of choice. When methimazole is used in children, up to 20% will have minor adverse reactions and serious adverse events occur in up to 1%. RAI is an effective form of therapy when the thyroid size is less than 80 g. Because of concerns of whole-body radiation exposure, it is recommended that RAI be avoided in children under 5 years of age, and dosages less than 10 mCi be used between 5 and 10 years of age. Surgery is an effective treatment in children if performed by a high-volume thyroid surgeon. Because of the scarcity of high-volume pediatric thyroid surgeons, a multidisciplinary approach using pediatric surgeons and endocrine surgeons can be considered. Whereas there is a trend toward long-term antithyroid drug therapy in adults, for several reasons, this approach may not be practical for children. Determining the optimal treatment for the pediatric patient with GD, requires consideration of the risks and benefits relating to age and likelihood of remission.

Wearable Technology Leads to Initial Workup of Graves' Disease in an Adolescent Female

Graves' disease is the most common form of hyperthyroidism in the pediatric population. While the most prevalent symptoms seen in children with Graves' disease include goiter and excessive sweating (Minamitani et al., 2017), diagnosis is frequently delayed due to presentation with non-specific symptoms (Léger et al., 2018). This case report is of a 12-year-old female who presented to her pediatrician with a one month history of episodes of tachycardia both with physical exertion and at rest. Notably, these episodes were discovered on her electronic smartwatch by its heart rate monitoring feature. Further pertinent positives elicited in the patient's review of systems included increasing anxiety, diaphoresis, intermittent hand tremors, and recent weight loss. These findings led to further workup that included thyroid studies, culminating in a diagnosis of Graves' disease. Indeed, this patient's smartwatch aided in her initial presentation to her physician and allowed for prompt workup and diagnosis. There exist limited studies to date on the use of smartwatches to detect cardiac-related conditions in children, which may be due to the absence of Food and Drug Administration approval for certain cardiac-related smartwatch features in this patient population.

Predictive effect of antithyroid antibody for relapse of Graves' disease

BACKGROUND

The remission rate in children with Graves' disease (GD) after 2-6 years of antithyroid drug (ATD) treatment is 40-50%. It has been reported that it is difficult to predict the GD prognosis based on the thryroid stimulating hormone (TSH) receptor antibody (TRAb) level at the cessation of ATD treatment. We studied whether the persistence of negative TRAb at ATD treatment cessation increased the remission rate in pediatric patients with GD.

METHODS

We included 22 patients diagnosed with GD who discontinued ATD treatment after confirmation of negative TRAb on two or more consecutive tests. Remission was defined as the maintenance of normal thyroid function, including serum TSH level, with negative TRAb more than 2 years after ATD discontinuation.

RESULTS

Of the 22 patients, 12 achieved remission (remission rate 54.5%), with no significant between-group difference in the median duration of ATD treatment in the remission and relapse groups (4.4 vs 3.9 years). Of the 10 patients who relapsed, four (40.0%) relapsed within 2 years after ATD discontinuation, and 4 (40.0%) relapsed more than 5 years after ATD discontinuation.

CONCLUSIONS

The persistence of negative TRAb at ATD treatment cessation might indicate prolonged duration of remission but does not increase the final remission rate in patients with childhood-onset GD.

Methimazole plus levothyroxine for treating hyperthyroidism in children: a systematic review and meta-analysis

BACKGROUND

Hyperthyroidism is a disease of excessive synthesis and secretion of thyroid hormones, and there is a lack of studies that have systematically evaluated the efficacy of the combination in treating hyperthyroidism. This study aimed to systematically evaluate the effectiveness and safety of methimazole combined with levothyroxine for treating hyperthyroidism in children.

METHODS

We searched PubMed, CNKI, Wanfang Database, EMBASE, Web of Science, and other online electronic databases to find correlation studies of methimazole combined with levothyroxine in treating hyperthyroidism in children from 2010 to 2021. Meta-analysis was performed using Stata 16 software.

RESULTS

Finally, 15 relevant articles were included comprising 1,718 pediatric patients. Meta-analysis results indicated that compared with methimazole alone (control group), the experimental group administered methimazole + levothyroxine had no evident difference in the level of thyroid-stimulating hormone [standardized mean difference (SMD) =-0.34, 95% confidence interval (CI): -1.02, 0.35, P=0.33], but notably improved the efficacy of clinical treatment of hyperthyroidism in children [odds ratio (OR) =5.77, 95% CI: 2.62, 12.74, P<0.001]. Meanwhile, the experimental group had lower adverse reaction rates (OR =0.28, 95%CI: 0.19, 0.40, P<0.001), free triiodothyronine (FT3) level (SMD =-0.85, 95% CI: -1.57, 0.13, P=0.02), free tetraiodothyronine (FT4) level (SMD =-0.94, 95% CI: -1.59, -0.30, P=0.004) and reduced thyroid volume (SMD =-1.3, 95% CI: -1.67, 0.93, P<0.001).

DISCUSSION

Using methimazole + levothyroxine to treat hyperthyroidism in children can raise the levels of FT3 and FT4, reduce the thyroid volume, improve clinical efficacy, and lower the adverse reaction rate of patients.

Efficacy and adverse events related to the initial dose of methimazole in children and adolescents with Graves' disease

PURPOSE

The first-line antithyroid drug for children and adolescents with Graves' disease (GD) is methimazole (MMI). This study evaluated the relationship between the initial MMI dose and the clinical course of GD after treatment.

METHODS

We studied the efficacy of the initial MMI dose and the relationship between the initial MMI dose and adverse events (AEs). We retrospectively enrolled 22 males and 77 females and divided those subjects into 3 groups according to the initial dose of MMI: &lt;0.4 mg/kg/day (group A; n=32); 0.4-0.7 mg/kg/day (group B; n=39); and &gt;0.7 mg/kg/day (group C; n=28).

RESULTS

The mean time to the normalization of free thyroxine (fT4) levels upon initial treatment was 5.64, 8.61, and 7.98 weeks in groups A, B, and C, respectively (P=0.116). The incidence of liver dysfunction, neutropenia, and skin rash was 12.5%, 20.5%, and 42.9% in groups A, B, and C, respectively (P=0.018). Neutropenia, as a severe AE, was absent in group A, but its prevalence was 7.7% in group B and 21.4% in group C (P=0.015). When comparing only groups B and C, the incidences of liver dysfunction and neutropenia were higher in group C (P=0.04 and P=0.021, respectively).

CONCLUSION

The mean time to the normalization of fT4 levels did not differ among the 3 groups, but the incidence of AEs was higher in the groups that received high MMI doses. High doses of MMI (&gt;0.7 mg/kg/day) should be reconsidered as an initial treatment for children and adolescents with GD.

Thyroidectomy in Pediatric Patients with Graves' Disease: A Systematic Review of Postoperative Morbidity

BACKGROUND

Graves' disease (GD) is the most common cause of hyperthyroidism. In children, the overall relapse frequency after treatment with antithyroid drugs is high. Therefore, many pediatric GD patients eventually require thyroidectomy as definitive treatment. However, the postoperative complications of thyroidectomy in pediatric GD patients are poorly reported.

OBJECTIVE

To identify the frequency of short- and long-term postoperative morbidities after thyroidectomy in pediatric GD patients.

METHODS

A systematic review of the literature (PubMed and Embase) was performed to identify studies reporting short- and long-term postoperative morbidities after thyroidectomy in pediatric GD patients according to the PRISMA guidelines.

RESULTS

Twenty-two mainly retrospective cohort studies were included in this review evaluating short- and long-term morbidities in 1,424 children and adolescents. The frequency of transient hypocalcemia was 22.2% (269/1,210), with a range of 5.0-50.0%. The frequency of permanent hypocalcemia was 2.5% (36/1,424), with a range of 0-20.0%. Two studies reported high frequencies of permanent hypocalcemia, 20.0 (6/30) and 17.4% (9/52), respectively. The 20% frequency could be explained by low-volume surgeons in poorly controlled GD patients. Only 21 cases of permanent hypocalcemia were reported in the 1,342 patients included in the other 20 studies (1.6%). Transient and permanent recurrent laryngeal nerve injury were reported less frequently, with frequencies between 0-20.0 and 0-7.1%, respectively. Infection, hemorrhage/hematoma, and keloid development were only rarely reported as postoperative complications.

CONCLUSION

The results of this systematic review suggest that thyroidectomy is a safe treatment option for pediatric GD patients. The minority of patients will experience transient and benign morbidities, with hypocalcemia being the most common transient postoperative morbidity. Permanent postoperative morbidities are relatively rare.

Long-Term Outcomes of Radioiodine Therapy for Juvenile Graves Disease with Emphasis on Subsequently Detected Thyroid Nodules: A Single Institution Experience from Japan

OBJECTIVE

To investigate the long-term outcomes of radioiodine therapy (RIT) for juvenile Graves disease (GD) and the ultrasonographic changes of the thyroid gland.

METHODS

All of 117 juvenile patients (25 males and 92 females, aged 10 to 18 [median 16] years) who had undergone RIT for GD at our clinic between 1999 and 2018 were retrospectively reviewed. Each RIT session was delivered on an outpatient basis. The maximum 131I dose per treatment was 13.0 mCi, and the total 131I dose per patient was 3.6 to 29.8 mCi (median, 13.0 mCi). 131I administration was performed once in 89 patients, twice in 26, and three times in 2 patients. Ultrasonography of the thyroid gland was regularly performed after RIT. The duration of follow-up after the initial RIT ranged from 4 to 226 (median 95) months.

RESULTS

At the latest follow-up more than 12 months after RIT (n = 111), the patients' thyroid functions were overt hypothyroidism (91%), subclinical hypothyroidism (2%), normal (5%), or subclinical hyperthyroidism (2%). New thyroid nodules were detected in 9 patients, 4 to 17 years after initial RIT. Patients with newly detected thyroid nodules underwent RIT with lower doses of 131I and had larger residual thyroid volumes than those without nodules. None of the patients were diagnosed with thyroid cancer or other malignancies during the follow-up period.

CONCLUSION

Over a median follow-up period of 95 months (range, 4 to 226 months), RIT was found to be effective and safe in juvenile GD. However, cumulative evidence from further studies is required to confirm the long-term safety of RIT for juvenile GD.

ABBREVIATIONS

ATD = antithyroid drug; GD = Graves disease; KI = potassium iodide; LT4 = levothyroxine; MMI = methimazole; PTU = propylthiouracil; RAIU = radio-active iodine uptake; RIT = radioiodine therapy; 99mTc = technetium-99m; TSH = thyrotropin.

Long-term outcomes of graves disease in children treated with anti-thyroid drugs

BACKGROUND

Graves disease (GD) is the most common cause of thyrotoxicosis in children and adolescents, accounting for 15% of all thyroid diseases during childhood. Anti-thyroid drugs (ATD) are recommended as the first-line treatment in children and adolescents. However, the remission rate is lower in children than in adults, and the optimal treatment duration and favorable factors associated with remission remain unknown. We aimed to investigate long-term outcomes of pediatric GD patients receiving ATD.

METHODS

We retrospectively reviewed medical charts of 396 GD subjects from 1985 to 2017 at MacKay Children's Hospital. Ninety-six patients were excluded from the analyses, including 71 patients followed for less than one year, 6 patients who received radioactive therapy and 19 patients who received surgery. The remaining 300 patients initially treated with ATD and followed up for more than 1 year constituted our study population.

RESULTS

The 300 patients comprised 257 (85.7%) females and 43 (14.3%) males. Their median age at diagnosis was 11.6 (range 2.7-17.8) years with 11 patients (3.7%) younger than 5 years. Their median follow-up period was 4.7 (range 1.1-23.9) years. Overall, 122 patients achieved the criteria for discontinuing ATD treatment, and seventy-nine (39.9%) patients achieved remission, with a median follow-up period of 5.3 (range 1.5-20.1) years. Patients in the remission group were more likely to be aged <5 years (remission vs. relapse vs. ongoing ATD; 11.4 vs. 0 vs. 2.6%, P = 0.02), less likely to have a family history of thyroid disease (24.1 vs. 42.1 vs. 52.6%, P = 0.001), and had lower TSH receptor antibody (TRAb) levels (42.8 vs. 53.6 vs. 65.1%, P = 0.02) at the time of diagnosis.

CONCLUSION

Long-term ATD remains an effective treatment option for GD in children. Pediatric GD patients aged <5 years, having no family history of thyroid disease and having initial lower TRAb levels were more likely to achieve remission.

Thyroid Surgery in Children and Adolescents: A 10-year Retrospective Study at a Single Institution

Objective

The aim of the study was to analyze clinical characteristics, surgical treatment, complications, and prognosis related to thyroid surgery in children and adolescents in a 10-year study at a single institution. Study Design. Retrospective study.

Methods

We performed a retrospective analysis of clinical data of children and adolescents who underwent thyroid surgery due to benign thyroid disease and thyroid cancer from January 2011 to May 2020. We presented the clinical characteristics and type of surgical treatment for different thyroid diseases. Results. We present data on surgical procedures and complication rates following surgery, which was comparable to other published data. We emphasize the importance of radioiodine and hormone replacement postoperative therapy in cancer patients and our opinion on total thyroidectomy and neck dissection in thyroid cancer surgery.

Conclusion

This study demonstrated that thyroid surgery in children and adolescents is a safe and efficient procedure in the hands of experienced surgeon for adult thyroid surgery. For children and adolescents with thyroid carcinoma, our method of choice is total thyroidectomy with occasionally paratracheal neck dissection, whereas lateral cervical lymph node dissection is only necessary in fine needle aspiration positive lymph nodes. Our results according to postoperative outcomes and complications are comparable to other recently published data.

Thyroid-stimulating hormone receptor antibodies during follow-up as remission markers in childhood-onset Graves' disease treated with antithyroid drugs

Graves' disease is uncommon in children. The remission rate after antithyroid drugs (ATD) therapy is lower than in adults. We evaluated the clinical course of ATD therapy in children with Graves' disease in southern Taiwan to determine whether their biochemical markers could be used to predict remission in these patients. We retrospectively reviewed the clinical data of 53 children diagnosed with Graves' disease between 2009 and 2019. Clinical and biochemical parameters were analyzed for predictors of remission. About three-fourths of the patients were female. Their median age at diagnosis was 13 years. No sex differences were found in most clinical characteristics. There was no correlation between thyroid-stimulating hormone receptor antibody (TRAb) levels at diagnosis and thyroid function or adverse reactions to ATD. Relapse occurred in 62% of patients after discontinuation of first-course ATD therapy. Three variables-good initial response to ATD, a decrease in TRAb levels during the first year after diagnosis, and a decrease in TRAb levels during the second year after diagnosis-were significant predictors of remission for more than 18 months. In conclusion, children with Graves' disease who had early ATD-controlled Graves' disease and decreased TRAb levels during the first 2 years are likely to enter remission for more than 18 months.

How do paediatricians use and monitor antithyroid drugs in the UK? A clinician survey

OBJECTIVE

We aimed to document current practice in the medical management of paediatric hyperthyroidism in the UK and compare to international recommendations.

DESIGN

A 27-question online survey distributed via an electronic newsletter in August 2018.

PARTICIPANTS

Responses from 48 members (11%) of the British Society for Paediatric Endocrinology and Diabetes.

MEASUREMENTS

Information about antithyroid drug (ATD) preference, treatment duration, monitoring of full blood count (FBC), management of neutropaenia, agranulocytosis screening and patient education.

RESULTS

Carbimazole is favoured by 98% of respondents and a "dose titration" regimen preferred over "block and replace" (65% vs 29%). TRAbs (thyroid-stimulating hormone receptor antibodies) are used for diagnostic purposes by 85% and by 33% to look for evidence of disease remission. The majority (81%) treat for a minimum of 2 years before considering a trial off ATD. All respondents reported that they "always/usually" warn their patients about the risk of agranulocytosis before starting ATD, but written information is "rarely/never" provided by 63%. Sore throat (98%) and fever (92%) are the most commonly cited symptoms used to alert a patient to possible agranulocytosis. FBC is measured prior to treatment by 65% and measured periodically during treatment by 70%.

CONCLUSIONS

The management of paediatric hyperthyroidism with ATDs in the UK is not consistent with all international recommendations because a block and replace ATD regimen remains widely used. TRAbs are utilized at presentation, but underused for detecting disease remission. National consensus guidelines and written patient information may refine the management of paediatric patients on ATDs.

Management of Thyrotoxicosis in Children and Adolescents: A Turkish Multi-center Experience

OBJECTIVE

To determine the demographic and biochemical features of childhood and juvenile thyrotoxicosis and treatment outcome.

METHODS

We reviewed the records of children from 22 centers in Turkey who were diagnosed with thyrotoxicosis between 2007 to 2017.

RESULTS

A total of 503 children had been diagnosed with thyrotoxicosis at the centers during the study period. Of these, 375 (74.6%) had been diagnosed with Graves’ disease (GD), 75 (14.9%) with hashitoxicosis and 53 (10.5%) with other less common causes of thyrotoxicosis. The most common presenting features in children with GD or hashitoxicosis were tachycardia and/or palpitations, weight loss and excessive sweating. The cumulative remission rate was 17.6% in 370 patients with GD who had received anti-thyroid drugs (ATDs) for initial treatment. The median (range) treatment period was 22.8 (0.3-127) months. No variables predictive of achieving remission were identified. Twenty-seven received second-line treatment because of poor disease control and/or adverse events associated with ATDs. Total thyroidectomy was performed in 17 patients with no recurrence of thyrotoxicosis and all became hypothyroid. Ten patients received radioiodine and six became hypothyroid, one remained hyperthyroid and restarted ATDs and one patient achieved remission. Two patients were lost to follow up.

CONCLUSION

This study has demonstrated that using ATDs is the generally accepted first-line approach and there seems to be low remission rate with ATDs in pediatric GD patients in Turkey.

Long-term outcome of thyrotoxicosis in childhood and adolescence in the west of Scotland: the case for long-term antithyroid treatment and the importance of initial counselling

BACKGROUND

Thyrotoxicosis is both rarer and more severe in children than in adults, rendering management difficult and often unsatisfactory.

OBJECTIVE

To ascertain outcome in a geographically defined area of Scotland between 1989 and 2014.

METHOD

Retrospective case note review with follow-up questionnaire to family doctors for patients with Graves' disease and Hashimoto's thyroiditis.

RESULTS

Sixty-six patients (58 females:8 males) comprising 53 with Graves' disease and 13 with Hashimoto's thyroiditis were diagnosed at median 10.4 (2.9-15.8) years and followed up for 11.8 (2.6-30.2) years. Antithyroid drug (ATD) therapy was stopped electively in 35 patients after 4.5 (1.5-8.6) years, resulting in remission in 10/13 Hashimoto's thyroiditis and 10/22 Graves' disease. Side effects occurred in 12 patients receiving carbimazole, six of whom changed to propylthiouracil; no adverse events occurred in the latter patients.Second-line therapy was given to 37 patients (34 with Graves' disease), comprising radioiodine (22) at 15.6 (9.3-24.4) years for relapse (6), poor control/adherence (14) or electively (2); and surgery (16) at 12 (6.4-21.3) years for relapse (4), poor control/adherence (5) and electively (7). Adherence problems with thyroxine replacement were reported in 10/33 patients in adulthood.

CONCLUSIONS

Hashimoto's thyroiditis should be distinguished from Graves' disease at diagnosis since the prognosis for remission is better. Remission rates for Graves' disease are low (10/53 patients), time to remission variable and adherence with both ATD and thyroxine replacement often problematic. We recommend (a) the giving of long-term ATD rather than a fixed course of treatment in GD and (b) meticulous and realistic counselling of families from the time of diagnosis onwards.

Weight gain after treatment of Graves' disease in children

OBJECTIVE

The frequency of and risk factors for weight gain in children treated for Graves' disease have not been described. We evaluated change in BMI-Z score and predictors of weight gain in this population.

DESIGN

Retrospective review of data from January 2000 to July 2011.

PATIENTS

Two hundred and twenty two children and adolescents with Graves' disease (ages 2-18 years) evaluated following radioactive iodine administration (RAI); (n = 101), thyroidectomy (n = 9) and initiation of medical therapy (n = 112).

MEASUREMENTS

Changes in body mass index Z score over 12 months (ΔBMI-Z_0-12 ).

RESULTS

All treatment groups in each gender and race increased BMI-Z (median ΔBMI-Z_0-12 was positive). T3 levels following RAI (P = .04) and weight lost at the time of administration (P = .02) in the RAI group and free T4 levels in the medical therapy group (P = .03) were positively correlated with ΔBMI-Z_0-12 . Race was a significant predictor only in the medical therapy group (P = .01). Age negatively correlated with ΔBMI-Z_0-12 in both the RAI (P < .001) and medical therapy groups (P = .003). Gender, maximum TSH in the 12 months after RAI and initial dose of LT₄ replacement did not correlate with ΔBMI-Z_0-12 . The prevalence of overweight and obesity in our cohort was similar to US children.

CONCLUSIONS

Weight gain during treatment for Graves' disease is common in children, and many children become overweight or obese during treatment. Risk factors include greater degree of hyperthyroidism at presentation and time of RAI and younger age. Weight lost upon presentation may also predict greater weight gain. Control of subsequent hypothyroidism does not appear to affect weight gain.

Five cases of childhood-onset Graves' disease treated with either surgery or radio-iodine therapy

There are three major therapeutic options for the treatment of Graves’ disease (GD): antithyroid drugs (ATDs), thyroidectomy, and radio-iodine (RAI) therapy. ATDs are the initial treatment option for children. However, some pediatric GD patients who are initially treated with ATDs require other type of treatments later on. We reviewed the medical records of childhood-onset GD cases retrospectively to report the clinical course of patients who received either surgery or RAI therapy subsequent to treatment with ATDs. Childhood-onset GD was successfully managed in five girls with non-ATD treatments at the age of 7–14 yr following an unfavorable outcome of initial ATD treatment. Four cases had surgery and one case was managed with RAI therapy. The reasons for switching to non-ATD treatment included poor compliance, failure to maintain remission, serious adverse events resulting from ATDs, and religious background. In conclusion, surgery and RAI therapy could be good alternative treatment options for children with GD.