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Case Report

Hypothyroidism in
children
OLEH :
Riadhus Machfud Alfian

dr.Primo Parmato, Sp.A

PEMBIMBING :

KEPANITERAAN KLINIK
ILMU PENYAKIT ANAK
RS ISLAM SUKAPURA
FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH JAKARTA

patient identity
Name: DGY
Age
: 8 months
Sex
: Male
Address
: semper
Religion
:Islam
No.RM
: xxxxxx
Date of inspection:

Anamnesis
The main complaint : could not stomach his own
Disease History Now:
Patients can not stomach their own in comparison with other babies. Looks are
not agile, the patient's mother said often sticking out their tongue, hard BAB,
BAB usually up to 2x a day. Baby still want to drink. If crying hoarse, like a
limp.
Formerly Disease history:
had never experienced similar things
Family Disease History:
No family with similar complaints No family with complaints adenoids

Treatment history:
Never before treatment
Portfolio immunization:
In accordance with the schedule
Pregnancy history:
his mother says has never been sick during pregnancy, not taking medication
during pregnancy, radiation therapy tidah ever, control regularly scheduled
(+)
History of Birth:
babies born just months of age
Allergic history:
the patient had no history of allergy to food, beverage, or medication.

PHYSICAL EXAMINATION
General impression
GCS

: Komposmentis

: E4 V5 M6

Vital Signs
Pulse frequency: 110 x / min, content enough, regular
Respiratory rate: 36 x / minute
Temperature: 36.6 C per axila

Anthropometry
Weight

: 7.3 kg

Body length

: 60 cm

Head circumference : 39
Nutritional Status

weight / age

height / age

W/H

Head
Hair: Black evenly, not easily fall
Face: symmetric (+), edema (- ), Dull face (+)
Eyes: conjunctival pallor (- / -), sclera jaundice (- / -), light reflex (+ / +), pupil isokor
2mm / 2mm, sunken eyes (- / -)
Mouth: large tongue (+), dirty tongue (-), mouth sores (-), pharyngeal hyperemia (-),
mucosal wet lips, enlarged tonsils (- / -), bleeding gums (-)

Neck
Enlarged glands: submandibular lymphadenopathy (- / -),

Thorax
Inspection: the shape and motion of the chest wall symmetrical right and left,
retraction (- / -), iktus cordis does not seem
Palpation: chest wall movement dekstra = the left, iktus cordis palpable at ICS
V clavicula mid line of the left
Percussion: resonant in all lung fields
Auscultation: vesicular (+ / +), rhonki (- / -), wheezing (- / -), heart sounds 1 and 2
regular, murmur (-)

Abdomen
Inspection: protruding umbilicus (-)
Palpation:, tenderness (-), distention (-), skin
turgor quick return
Percussion: timpani
Auscultation: bowel sounds (+) normal
Extremities: akral warm (+), edema (-),
capillary refill test <2 seconds, cyanosis (-),
axillary lymphadenopathy (- / -), inguinal
lymphadenopathy (- / -), hypotonia (+)

Skin:dry skin (+), cutis marmorata (+),

Supportinginvestigation
There is no (-)

Plansinvestigations
Thyroid function tests T4 and TSH
routine hematological examination
WorkingDiagnosis: Congenital Hypothyroidism
Management
L-thyroxine 6-8 mg / kg / day

Monitoring
Growth and pekermbangan
Hearing screening at diagnosis
Monitoring the levels of T4 and TSH
2 weeks after initial therapy with L-tioksin
4 weeks after initial therapy with L-thyroxine
Every 1-2 months during the first 6 months of life
Every 3-4 months at the age of 6 months - 3 years
The next 6-12 months
bone0age monitoring every year
Psychometric monitoring (IQ test)

ITERATURE REVIEW

3. Hypothyroidism
Hypothyroidism is a condition in which
the body lacks sufficient thyroid
hormone.
Decreased free T4, increased TSH
Primary, secondary or tertiary

13

A. Congenital hypothyroidism
Causes

Maldescent thyroid, athyrosis


Dyshormonogenesis
Iodine deficiency
TSH deficiency

14

Clinical features
MOSTLY , ASYMPTOMATIC AT
BIRTH
FTT
Feeding problem
Prolonged jaundice
Constipation
Pale, cold, mottled skin
Quiet baby
Coarse face
Large tongue

15

16

Treatment
Timing

Should begin immediately after diagnosis is


established
If features of hypothyroidism are present,
treatment is started urgently.

Duration

Treatment is life long


Except in children suspected of having
transient hypothyroidism where re-evaluation
is done at 3 years of age.
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Preparation
L-thyroxine tablets
The L-thyroxine tablet should be
crushed, mixed with breast milk,
formula, or water and fed to the infant.
Tablets should not be mixed with soy
formulas or any preparation containing
iron (formulas or vitamins), both of
which reduce the absorption of T4.

18

Pediatric Protocol 3rd ed

19

Goal of therapy
To restore the euthyroid state
Serum FT4 level usually normalise within 1-2
weeks, and then TSH usually become normal
after 1 month of treatment.
Some infants continue to have high serum TSH
concentration (10 - 20 mU/L) despite normal
serum FT4 values due to resetting of the
pituitary-thyroid feedback threshold.
Compliance to medication has to be reassessed
and emphasised.
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Pediatric Protocol 3rd ed

21

Follow up
Monitor growth parameters and
developmental assessment.
Imaging studies
If the FT4 is low and the TSH value is
elevated, permanent hypothyroidism is
confirmed and life-long L-thyroxine
therapy is needed.

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Measurement schedule (FT4,


TSH)

The recommended by American


Academy of Pediatrics

At 2 and 4 weeks after initiation of T4


treatment.
Every 1 to 2 months during the first 6
months of life.
Every 3 to 4 months between 6 months and
3 years of age.
Every 6 to 12 months thereafter until
growth is completed.
After 4 weeks if medication is adjusted.
At more frequent interval when compliance

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Re-evaluation of patients likely


having transient hypothyroidism
Can be due to factors primarily affecting the
thyroid-like iodine deficiency or excess, maternal
TSHR antibodies, maternal use of anti thyroid
drugs
This is best done at age 3 years when thyroid
dependent brain growth is completed at this age.
Stop L-thyroxine for 4 weeks then repeat thyroid
function test: FT4, TSH.

24

Why hypothyroidism can cause an umbilical hernia?


How can a simple diagnosis of hypothyroidism?
Bagaimana jika ada

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