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Condition: Hyperthyroidism (also known as Grave’s disease)
Overview (“What is it?”)
- Hyperthyroidism is a condition when the thyroid gland in the neck becomes overactive and produces too much thyroid hormone. The thyroid is a gland in the neck that makes hormones that help the body grow. Any imbalance in hormone production affects the body in a negative way. Thyroid hormone stimulates the body’s metabolism, so too much thyroid hormone causes the body to work abnormally hard.
- Epidemiology: Conditions that affect the thyroid are not common in children and can occur in about 37 out of 1,000 children. The most common conditions include generalized enlargement of the thyroid (also called goiter or thyroiditis). Thyroiditis can come about due to several reasons. One reason can be that certain medications that one might be taking for a separate reason cause the thyroid to become larger. Other reasons for thyroiditis include an inflammatory or an autoimmune condition (one example is Graves’ Disease also called diffuse toxic goiter) that can occur which leads to thyroid enlargement. The thyroid can also be enlarged due to many cysts within the thyroid gland that are normally not supposed to be in the gland. A virus can even cause the thyroid gland to be enlarged and painful. Lastly, not having enough iodine from diet sources can cause the thyroid to be enlarged. In other parts of the world, this can be the most common reason for having an abnormally enlarged thyroid.
- Thyroid nodules (one or more separate masses in an otherwise normal sized thyroid gland) are even more uncommon in children than the condition above where the whole thyroid gland is enlarged. However, thyroid nodules in children can be cancerous 20% of the time. The most common reason why a person would have a cancerous thyroid nodule would be history of neck irradiation.
Signs and Symptoms (“What symptoms will my child have?”)
- Early signs: Childhood symptoms include nervousness, irritability, diarrhea, weight loss, insomnia, fatigue, hair thinning and poor performance in school. On examination they may have high blood pressure, fast heart rate and weight loss.
- Later signs/symptoms: Neck swelling (goiter) and exophthalmos (protruding eyes), weight loss, sweating, heart palpitations (irregular heart beat) may be seen over time.
Diagnosis (“What tests are done to find out what my child has?”)
- Labs and tests: Blood is checked for increased levels of thyroid hormones (T4 and T3). TSH, a hormone from a gland in the brain (pituitary gland) which stimulates the thyroid, should be low unless there is a pituitary tumor present.
- A thyroid scan may also demonstrate increased uptake (activity) throughout the gland. In this test, a very small amount of radioactive iodine tracer is injected in the vein and followed by a body detector to see how much is taken up by the thyroid gland.
- An ultrasound of the thyroid gland may be obtained if there is a question of a mass or a lump in the gland. An ultrasound uses sound waves to create an image or picture of parts of the body without using radiation.
- Obtaining thyroid tissue by using a needle inserted into a thyroid nodule—also called fine-needle aspiration (FNA)—may give information about thyroid nodule (not thryroiditis) and guide the next step in management. Ultrasound can guide the surgeon to where the needle can be placed to target the nodule.
- Conditions that mimic this condition: An enlarged thyroid gland can sometimes be caused by thyroid cysts, tumors or inflammatory conditions of the thyroid (thyroiditis).
Treatment (“What will be done to make my child better?”)
- Medicine: Depending on the kind of thyroiditis a child has, anti-inflammatory medicines, steroids or antibiotics and time is needed for the condition to get better. It can take two months to more than a year for some therapies for the child to get well fully. For Graves’ disease, anti-thyroid medication that block thyroid hormone production are usually tried first. These are quite effective. Sometimes, medication that blocks the side effects of racing heart rate and high blood pressure are added (beta blockers). Long-term remission may be achieved in 25-65% of patients after the medications are stopped.
- Radioactive isotopes: This method of treatment uses highly radioactive iodine (radioactive I131) to destroy the thyroid gland. The radioactive iodine is given through a vein, and it is taken up by the thyroid gland. The radioactivity destroys the thyroid. This is a good approach in some patients who are not good candidates for medical therapy or surgery. Although effective, there is concern that the long-term incidence of hypothyroidism (low thyroid levels) is increased especially when used in children. Typically, radioactive iodine is not recommended in kids younger than five years of age.
- Surgery: Surgery is reserved in thyroiditis for patients who do not respond to medicines, unable to get radioactive iodine. Total or near-total thyroidectomy (removal of all or part of the thyroid gland) is needed. Depending on the extent of the operation and the size of the gland removed, a drain may be left in place to gather fluid that may collect post-operatively
- Preoperative preparation: Patients are often started on a hormone blockade and a beta blocker preoperatively, to protect against the release of extra thyroid hormone during the operation. Extra release of hormones may increase the heart rate and blood pressure at dangerously high levels during the stress of surgery.
- Postoperative care: An overnight stay is usually recommended. Pain medications are given. Blood levels of calcium may be monitored as well as quality of voice (hoarseness or breathiness).
- Risks/Benefits: Surgery is very effective in treating hyperthyroidism. However, it does require an operation with complications occurring roughly 5% of the time. Complications include bleeding, wound infection, damage to the nerves that control the vocal cords, damage to the glands that control calcium levels in the blood. Of these complications, 1-2% may persist long term.
Home Care (“What do I need to do once my child goes home?”)
- Diet: Normal
- Activity: Normal
- Wound care: Keep the incision clean and dry for about three days after surgery. The child may shower after three days, but do not soak the wound for about a week.
- Medicines: Medication for pain such as acetaminophen (Tylenol®) or ibuprofen (Motrin® or Advil®) or something stronger like a narcotic may be needed to help with pain for a few days after surgery. Stool softeners and laxatives are needed to help regular stooling after surgery, especially if narcotics are still needed for pain.
- Take any thyroid hormone replacements as directed.
- If calcium levels are found to be low, calcium supplements may be necessary.
- What to call the doctor for: Wound redness, swelling or drainage, recurrence of symptoms (racing heart rate, palpitations), changes in voice patterns, tingling and numbness of the fingers and around the mouth.
- Follow-up care: You will follow up with your surgeon to check the wound and make sure things are healing well. Your pediatrician and/or endocrinologist will check thyroid hormone levels to make sure that these normalize after surgery.
Long-Term Outcomes (“Are there future conditions to worry about?”)
- The two major long-term risks of surgery are hoarseness caused by injury to the nerve that controls the voice box that runs adjacent to the thyroid gland and low calcium levels due to injury to the glands (parathyroid) that control calcium.
- If medications are used initially to treat the enlarged or overactive gland and the thyroid continues to cause symptoms, then surgery may be necessary.
- Your child will likely require long-term follow up with his/her pediatrician or endocrinologist (doctor specializing in disorders of endocrine glands such as the thyroid gland).
Author: Kathryn Q. Bernabe, MD; Michael B. Ishitani
Editors: Patricia Lange, MD; Marjorie J. Arca, MD