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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Spectrum of clinical presentation of thyroid disorders in children in a tertiary care teaching hospital: An observational study


 Department of Pediatrics, Faculty of Medicine, JN Medical College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

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Date of Submission29-Jun-2021
Date of Decision24-Jul-2021
Date of Acceptance27-Jul-2021
Date of Web Publication30-Aug-2021
 

  Abstract 


Introduction: Thyroid disorders during childhood are quite common and presentations are nonspecific. Congenital hypothyroidism (CH), among all causes of childhood hypothyroidism, is the most important, as early detection and appropriate therapy can prevent the onset of brain damage. The delay in diagnosis is attributable to the lack of awareness, lack of available facilities, or newborn screening programs. Aims: This study aims to study the spectrum of clinical presentation of thyroid disorders in children in a tertiary care teaching hospital. Materials and Methods: A descriptive observational study was conducted for a 2-year period, from January 2018 to January 2020. All children who were referred to the pediatric endocrine out-patients clinic for suspected thyroid dysfunction were included in this study. Data on patients history, clinical examination including the presence of goiter and laboratory tests were collected and analyzed. Results: Of 86 children with suspected thyroid dysfunction, 32 had abnormal thyroid function tests. Six had CH, 19 had overt acquired hypothyroidism and six had subclinical acquired hypothyroidism. Thyroid peroxidase antibodies were elevated in 13 children with no gender predilection. There was a female preponderance across all the age groups but no gender predilection was noted in the CH group. Short stature was noted in 70.9% of cases, diminution in school performance in 58% and pallor in 29%. Goiter was observed in 9.6% of children. Conclusions: In our study, 80.6% had acquired hypothyroidism. The most common presenting feature was short stature which was observed in 70.9% of our children. Diminution of scholastic performance was the second common clinical feature which was observed in 58% of children.

Keywords: Congenital hypothyroidism, goiter, short stature


How to cite this URL:
Ahmad A, Gupta S, Muhammed Saleeq P K. Spectrum of clinical presentation of thyroid disorders in children in a tertiary care teaching hospital: An observational study. Apollo Med [Epub ahead of print] [cited 2021 Nov 30]. Available from: https://www.apollomedicine.org/preprintarticle.asp?id=325194





  Introduction Top


Early neurocognitive development as well as growth throughout childhood is dependent on the adequacy of thyroid hormone status. Early recognition and treatment of thyroid dysfunction is, therefore, of utmost importance to optimize physical and neurodevelopmental outcomes.[1] The clinical features of hypothyroidism are nonspecific, often leading to a delay in diagnosis and irreversible neurological morbidities.[2],[3] The prevalence of thyroid disorders depends upon the geographical area, age, gender, and iodine intake; therefore, prevalence estimation from one geographical area cannot be extrapolated to another population.[3] Before the launching of the “universal salt iodization” program in 1983, iodine deficiency was the most common cause of hypothyroidism. Although iodine deficiency is the most common cause of hypothyroidism worldwide, its incidence in India has reduced over the last decade.[4] Hyperthyroidism, on the other hand, is rare during childhood.[1]

Delay in diagnosis is not uncommon, partly due to lack of awareness among primary healthcare givers and also the costs as well as availability of laboratory investigations. This coupled with lack of neonatal screening for hypothyroidism is responsible for the poor outcomes in affected children.[2],[3] This study was therefore planned to study the clinical presenting features in children with thyroid dysfunction.


  Materials and Methods Top


This was a descriptive observational study conducted in the Department of Pediatrics in a Tertiary care teaching hospital for a 2-year period, from January 2018 to January 2020. All children who were referred to the pediatric endocrine out patients clinic for suspected thyroid dysfunction were included in this study. Data on patients history, clinical examination including presence of goiter and laboratory tests were collected and analyzed. All children on any medications affecting the thyroid status and children where parental consent was refused were excluded. Approval for the study was given by the Institutional Ethical Clearance Committee.

Short stature was defined as height <2 standard deviation (SD) below the mean for age and gender as per the Indian Academy of Pediatrics standards. Pubertal staging was done as per Tanner Staging. Precocity was defined as appearance of secondary sexual characteristics before the age of 8 years in girls and 9 years in boys.[5] Clinical examination of neck was done for the assessment of thyroid gland enlargement. Goiter was graded as per recommendations of the WHO consultation on iodine deficiency disorders indicators (Grade 0: No goiter is palpable or visible. Grade 1: Palpable goiter, not visible when neck is held in normal position. Grade 2: A clearly swollen neck (also visible in normal position of the neck) that is consistent with a goiter on palpation).[6] The following serum assays were done: Free thyroxine (FT4) (Chemiluminescent Microparticle Immunoassay; Abbott diagnostics, reagent B7K660), free triiodothyronine (FT3) (Abbott diagnostics, reagent B7K640) and thyroid stimulating hormone (TSH) (Abbott diagnostics, reagent B7K620). Thyroid peroxidase (TPO) antibodies were tested by electrochemiluminescence assay (Cobas-Roche-Elecsys1010 analyzer), titers ≥34 IU/L were considered positive. Hypothyroidism and hyperthyroidism were defined as per standard cut offs of T3, T4, and TSH for various ages.[7],[8]

Statistical analysis

Data were expressed as mean ± SD for continuous variables and percentage for categorical data. SPSS version 19.0 statistical software package (IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp.) was used for analysis.


  Results Top


Eighty-six children with suspected thyroid dysfunction were referred to the endocrine clinic during the study. Thyroid dysfunction was detected in 32 of the children. Out of the 32, one child had hyperthyroidism and the rest had hypothyroidism [Table 1].
Table 1: Etiology of thyroid disorders in children (n=32)

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Six children were subsequently diagnosed as congenital hypothyroidism (CH) and 25 were due to acquired causes. Among acquired cases, 19 were overt hypothyroidism and six were subclinical cases with elevated TSH and free thyroxine (FT4) within normal limits. The mean age at presentation was 9 ± 2.6 years. TPO antibodies were elevated in 13 children with no gender predilection. There were no cases of secondary hypothyroidism.

There was a female preponderance across all the age groups with 12 females and 7 males in the primary acquired hypothyroid children. No such gender predilection was noted in the CH group. Short stature was the most common complaint for which the children were evaluated for thyroid dysfunction. Out of 86, 74 (86%) of children had short height as the main presenting feature. In children, subsequently diagnosed as hypothyroidism, it was noted in 70.9% of cases. The second most common clinical feature was diminution in school performance (58%) followed by pallor and constipation which was observed in nine (29%) and eight (25.8%) children, respectively. Goiter was observed in three (9.6%) of children [Table 2].
Table 2: Clinical features of children with hypothyroidism (n=31)

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Among cases with CH, the mean age of presentation was 49.6 months with the earliest detection at 6 weeks of age. The main presenting feature was developmental delay in three cases, followed by umbilical hernia and prolonged jaundice, observed in two cases each.

The most common associated conditions were precocious puberty, Down syndrome, and Type 1 diabetes mellitus, seen in two cases each [Table 3].
Table 3: Comorbidities associated with hypothyroidism

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  Discussion Top


Despite the implementation of the National Iodine Deficiency Control Programme, hypothyroidism is fairly common in most parts of India.[9] Female preponderance has been observed in many national as well as international studies with the male to female (M:F) ratio around 1:3.[10] Female preponderance was also noted in our study. The reasons cited for female preponderance is associated with estrogen and progesterone activity which appear to have antagonistic effects in thyroid disorders. Similarly, female preponderance has been observed in CH. In our study, an equal proportion of males and females was observed in CH but the number of cases is insufficient to comment about any significance. Our result is similar to a study by Rezaeian et al., in Iran who found that only season of birth is a risk factor for female preponderance in CH.[11]

The mean age of presentation among CH cases was 49.6 months, compared to study by Seth et al., where the mean age of presentation was found to be 86.6 months.[12] Nonspecific clinical features could account for a delayed diagnosis in children with CH. This emphasizes the need for a universal neonatal screening program for detecting CH.

Acquired hypothyroidism is the most common cause of thyroid dysfunction in childhood and is frequently due to chronic autoimmune thyroiditis.[1],[13],[14] In our study, autoimmune hypothyroidism accounted for 52% of cases. Subclinical hypothyroidism (SCH), where serum TSH values are high with thyroid hormones within the normal range was observed in 24% of cases. In a study by Marwaha et al., the prevalence of SCH was found to be 6.1% in a nationwide survey.[9] In another study by Rao et al., reported prevalence was 7.7% in children and 4.9% in adolescents.[15] SCH was once considered a benign disease but recent evidence shows an adverse cardiovascular morbidity and mortality in young adults with SCH.[16]

The most common presenting feature was short stature which was observed in 70.9% of our children. Similar observations were made in studies in Saudi[17] and Indian children,[3] where short stature was the most common clinical manifestation observed in 32.5% and 59% children, respectively. Diminution of scholastic performance was the second common clinical feature which was observed in 58% of children. The prevalence of goiter was 9.6% in our study which is lower than the prevalence range of 10%–38% observed in other studies.[1],[2],[3],[4] The low prevalence of goiter could be because iodine sufficiency as observed by Aslami et al. who found the mean urinary iodine in children to be 150 mcg/dl which denotes iodine sufficiency.[18]

Hypothyroidism can have atypical manifestations like precocious puberty which is postulated to be because of analogy of TSH with follicle stimulating hormone (FSH). Increased levels of TSH stimulate the FSH receptors leading to ovarian cysts and precocity in females and macroorchidism in males.[19] Two girls in our study presented with precocious puberty and ovarian cysts. There were 2 cases of Type 1 diabetes mellitus who had hypothyroidism as an associated condition. The prevalence of hypothyroidism in Type 1 diabetic children varies between 15% and 30% which is more than the general population.[20] One child presented with pericardial effusion; this could be due to increased pericardial vasculature permeability and altered lipid metabolism in hypothyroidism. Pericardial effusion, in contrast to pediatric age-group is relatively common in adults with hypothyroidism.[21] One child presented with pseudohypertrophy of calf muscles (Kocher–Debre–Semelaigne Syndrome), a rare association of long and untreated hypothyroidism in pediatric age group.[22] Another child presented with cutis marmorata, i.e., lacy reticular pattern of the skin as the presenting manifestation of hypothyroidism.

There are several limitations to the study. It is hospital based and the study population may not be representative of the entire population. The number of study subjects is low, thereby limiting the power of study. The referrals were not specific; any of our colleagues from other specialties in the hospital who suspected the children to be having thyroid dysfunction referred them to the pediatric endocrine clinic.


  Conclusions Top


In our observational study, carried out over a 2-year period, 80.6% of the patients with thyroid dysfunction had acquired hypothyroidism. The most common presenting feature was short stature which was observed in 70.9% of our children. Diminution of scholastic performance was the second common clinical feature which was observed in 58% of children.

Hypothyroidism is a fairly common condition during childhood. Manifestations can be varied and a delay in diagnosis can have deleterious effects on growth and development of children. Therefore, this condition should be suspected in children with both typical as well as atypical manifestations and a definitive diagnosis should always be sought lest a delay in diagnosis should lead to permanent neurological deficit.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Desai MP. Thyroid function in children. J Assoc Physicians India 2011;59:35-42.  Back to cited text no. 1
    
2.
Singh A, Purani C, Mandal A, Mehariya KM, Das RR. Prevalence of thyroid disorders in children at a tertiary care Hospital in western India. J Clin Diagn Res 2016;10:SC01-4.  Back to cited text no. 2
    
3.
Vir SC. Current status of iodine deficiency disorders (IDD) and strategy for its control in India. Indian J Pediatr 2002;69:589-96.  Back to cited text no. 3
    
4.
Yadav K, Pandav CS. National iodine deficiency disorders control programme: Current status and future strategy. Indian J Med Res 2018;148:503-10.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Bridges NA, Christopher JA, Hindmarsh PC, Brook CG. Sexual precocity: Sex incidence and aetiology. Arch Dis Child 1994;70:116-8.  Back to cited text no. 5
    
6.
World Health Organization, United Nation Children's Fund, International Council for Control of Iodine Deficiency Disorders. Assessment of the Iodine Deficiency Disorders and Monitoring their Elimination. Geneva: World Health Organization; 2001. WHO document WHO/NHD/01.1. Available from: https://apps.who.int/iris/handle/10665/61278. [Last accessed on 2021 Jun 04].  Back to cited text no. 6
    
7.
Sudhanshu S, Riaz I, Sharma R, Desai MP, Parikh R, Bhatia V. Newborn screening guidelines for congenital hypothyroidism in India: Recommendations of the Indian society for pediatric and adolescent endocrinology (ISPAE)-Part II: Imaging, treatment and follow-up. Indian J Pediatr 2018;85:448-53.  Back to cited text no. 7
    
8.
Marwaha RK, Tandon N, Desai AK, Kanwar R, Aggarwal R, Sastry A, et al. Reference range of thyroid hormones in healthy school-age children: Country-wide data from India. Clin Biochem 2010;43:51-6.  Back to cited text no. 8
    
9.
Marwaha RK, Tandon N, Garg MK, Desai A, Kanwar R, Sastry A, et al. Thyroid status two decades after salt iodization: Country-wide data in school children from India. Clin Endocrinol (Oxf) 2012;76:905-10.  Back to cited text no. 9
    
10.
Demirbilek H, Kandemir N, Gonc EN, Ozon A, Alikasifoglu A, Yordam N. Hashimoto's thyroiditis in children and adolescents: A retrospective study on clinical, epidemiological and laboratory properties of the disease. J Pediatr Endocrinol Metab 2007;20:1199-205.  Back to cited text no. 10
    
11.
Rezaeian S, Moghimbeigi A, Esmailnasab N. Gender differences in risk factors of congenital hypothyroidism: An interaction hypothesis examination. Int J Endocrinol Metab 2014;12:e13946.  Back to cited text no. 11
    
12.
Seth A, Aggarwal V, Maheshwari A. Hypothyroidism in children beyond 5 years of age: Delayed diagnosis of congenital hypothyroidism. Indian J Pediatrics 2012;79:891-5.  Back to cited text no. 12
    
13.
Mariotti S, Caturegli P, Piccolo P, Barbesino G, Pinchera A. Antithyroid peroxidase autoantibodies in thyroid diseases. J Clin Endocrinol Metab 1990;71:661-9.  Back to cited text no. 13
    
14.
Unnikrishnan AG, Menon UV. Thyroid disorders in India: An epidemiological perspective. Indian J Endocrinol Metab 2011;15:S78-81.  Back to cited text no. 14
    
15.
Rao PT, Subrahmanyam K, Prasad DK. Prevalence of subclinical hypothyroidism in children and adolescents of northern Andhra Pradesh population and its association with hyperlipidaemia. Int J Res Med Sci 2017;5:5168-74. [doi.org/10.18203/2320-6012.ijrms20175078].  Back to cited text no. 15
    
16.
Rodondi N, den Elzen WP, Bauer DC, Cappola AR, Razvi S, Walsh JP, et al. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. JAMA 2010;304:1365-74.  Back to cited text no. 16
    
17.
Al-Agha AE, Alshugair RM, Aljunedi WA, Badakhan BA. Clinical presentation of acquired hypothyroidism and associated disorders in children and adolescents at King Abdul-Aziz University Hospital in a Western Region of Saudi Arabia. J Pat Care 2016;2:123. [doi: 10.4172/2573- 4598.1000123].  Back to cited text no. 17
    
18.
Aslami AN, Ansari MA, Khalique N, Kapil U. Iodine deficiency in school children in Aligarh district, India. Indian Pediatr 2016;53:742-3.  Back to cited text no. 18
    
19.
Rastogi A, Bhadada SK, Bhansali A. An unusual presentation of a usual disorder: Van Wyk-Grumbach syndrome. Indian J Endocrinol Metab 2011;15:S141-3.  Back to cited text no. 19
    
20.
Umpierrez GE, Latif KA, Murphy MB, Lambeth HC, Stentz F, Bush A, et al. Thyroid dysfunction in patients with type 1 diabetes: A longitudinal study. Diabetes Care 2003;26:1181-5.  Back to cited text no. 20
    
21.
Martinez-Soto T, Deal C, Stephure D, Trussell R, Boutin C, Djemli A, et al. Pericardial effusion in severe hypothyroidism in children. J Pediatr Endocrinol Metab 2010;23:1165-8.  Back to cited text no. 21
    
22.
Shaw C, Shaw P. Kocher-debre-semelaigne syndrome: Hypothyroid muscular pseudohypertrophy – A rare report of two cases. Case Rep Endocrinol 2012;2012:153143.  Back to cited text no. 22
    

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Correspondence Address:
Ayesha Ahmad,
Department of Pediatrics, Faculty of Medicine, JN Medical College and Hospital, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_67_21




 
 
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