one response with one reference for each discussion below.
Hypothyroidism is a thyroid hormone deficiency that can impact people of all ages. I focused on congenital hypothyroidism as I started this week with little knowledge of it.
Congenital hypothyroidism (CH) is a deficiency of thyroid hormone at birth (Simonetti et al., 2022). Without early diagnosis, a lack of treatment can result in permanent neurological deficits and delayed psychomotor development (Simonetti et al., 2022). Thyroid hormone is essential to normal neurodevelopment, growth, and metabolism. It plays an important role in the differentiation of neurons, the development of synapsis, and the myelination of nerves (Bowden & Goldis, 2022). Primary CH is the most common. It is due to a thyroid gland defect or reduced production of thyroid hormone. Most of the time (80%), primary CH is due to thyroid dysgenesis which is either a lack of enough thyroid tissue or failure of the thyroid tissue to develop (Bowden & Goldis, 2022). With a smaller thyroid or reduced functional thyroid, low levels of T3 and T4 are available, causing negative feedback loops to elevate TSH and TRH levels (Bowden & Goldis, 2022).
Physical Exam Findings
There are few and subtle physical exam or clinical manifestations of CH at birth. Mothers can transfer thyroxine hormone which protects newborns lasting up to 6 weeks (Bowden & Goldis, 2022). However, within the first few weeks (usually two weeks) of life symptoms can become evident. Common physical exam findings include lethargy, jaundice, weak muscle tone, poor feeding, hypothermia, large anterior and posterior fontanels, hoarse cry, constipation, and swelling around the eyes (Bowden & Goldis, 2022). Late signs of CH include coarse facies which are rounded and broad features that lack a sharp definition of the eyebrows, nose, lips, and chin (NIH, 2022). Other late signs include a large tongue, thick, dry and mottled skin, coarse hair, decreased reflexes, distended abdomen, hypotension, bradycardia, and respiratory distress due to associated myxedema (Bowden & Goldis, 2022). Given the importance of early detection, screening for CH occurs ideally on days 2-4 of life (Bowden & Goldis, 2022). A heel prick blood sample is used to assess the baby’s T4 and TSH levels (Simonetti et al., 2022). A low T4 and elevated TSH are suggestive of CH. CH should be managed by a pediatric endocrinologist.
The differential diagnoses of CH include constipation, meconium plug syndrome, Hirschsprung disease, growth hormone deficiency (hyposomatotropism), pediatric malabsorption syndrome, and Hirschsprung disease (Sinha & Bowden, 2022). Given that fatigue and constipation are the most common early signs of CH (Bowden & Goldis, 2022), the differential diagnosis would involve a higher suspicion of GI disorders. However, the presentation can be vague. Thankfully, any child presenting with lethargy should be treated with high concern and CH should be in the back of the provider’s mind.
CH can be either permanent (life-long) or transient (after a few months or years the child produces normal thyroid levels) (Bowden & Goldis, 2022). The underlying cause of hypothyroidism will determine if it will be permanent versus transient. Regardless, treatment should persist for 36 months (Bowden & Goldis, 2022). Early detection and treatment of CH normally result in normal growth and development (Bowden & Goldis, 2022). Pharmacological treatment for CH, much like adults, is levothyroxine. Dosing depends on the severity of CH. For infants with severe CH, a dose of 10-15 MCG/Kg/day is recommended (Bowden & Goldis, 2022). Blood tests are routinely obtained every one to two months up until 6 months of age. Then every two to three months after 6 months of age.
Bowden, S., A., Goldis, M. (2022). Congenital hypothyroidism. Stat Pearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK558913/
NIH (2021). Coarse facial features. National Library of Medicine. https://www.ncbi.nlm.nih.gov/medgen/335284
Simonetti, S., D’Amato, G., Esposito, B. et al. (2022). Congenital hypothyroidism after newborn screening program reorganization in the Apulia region. Ital J Pediatr 48, 131 (2022). https://doi.org/10.1186/s13052-022-01328-0
Sinha, S. K., Bowden, S. A. (2022). Pediatric hypothyroidism guidelines. Medscape Pediatrics General Medicine. https://reference.medscape.com/article/922777-guidelines?icd=ssl_login_success_221119
Discussion 2-Growth hormone deficiency
Growth hormone deficiency (GHD) is also known as dwarfism or pituitary dwarfism and is caused by insufficient amounts of growth hormone in the body. GHD is the most common pituitary hormone deficiency in children and can be isolated or accompanied by a deficiency of other pituitary hormones. Growth hormone deficiency results in abnormally slow growth and short stature (Johns Hopkins Medicine, nd.).
Growth hormone deficiency typically manifests as growth failure, sometimes along with a delay in tooth development. Height below the 3rd percentile, and growth velocity < 6 cm per year before the age of 4 years old, < 5 cm per year from age 4 to 8 years, and < 4 cm per year before puberty. Even though of small stature, a child with hypopituitarism retains normal proportionality between upper and lower body segments. Skeletal maturation, assessed by bone age determination, is > 2 years behind chronologic age (Eledrisi,2022).
Symptoms of growth hormone deficiency in infants and children may include a younger-looking face than what’s expected for their age, delayed tooth development, impaired hair, and nail growth, delayed puberty, low blood sugar levels in infants and toddlers, and micropenis in newborns assigned male at birth (Cleveland Clinic, 2022).
Pathophysiology of growth hormone deficiency
The pathophysiology of somatopause is confounded by several variables that can contribute to the decline in growth hormone secretion. Decreased growth hormone is usually caused by damage to the pituitary gland or to the hypothalamus. This damage may be due to tumors, surgery, or problems with the blood supply to the pituitary gland (Cedars Sinai, 2022).
Physical exam findings of growth hormone deficiency
Most patients with growth hormone deficiency have a normal physical examination, while some may have reduced skeletal muscle and lean body mass but increased fat mass mainly in the abdominal region. Some patients have manifestations of deficiency of other pituitary hormones such as gonadal, adrenal, and thyroid hormones (Eledrisi,2022). Diagnosis is based on a combination of clinical findings, imaging studies, and laboratory testing, usually including provocative tests of GH production. Diagnosis involves the measurement of pituitary hormone levels and CT or MRI to detect structural pituitary anomalies or brain tumors. Other tests to diagnose growth Hormone Deficiency include auxologic assessment which involves recording the patient’s height and weight on a growth chart, checking the levels of the patient’s Insulin-like growth factor 1 (IGF-1) and IGF binding protein type 3 (IGFBP-3) levels, and evaluation of other pituitary hormones and for other causes of poor growth. Children with growth hormone deficiency have a slow or flat rate of growth. The slow growth may not show up until a child is 2 or 3 years old. The child will look much shorter than children of the same sex and age and may be chubby (Mount Sinai, 2022).
Differential diagnoses and rationale for growth hormone deficiency
Differential diagnoses for growth hormone deficiency are adrenal insufficiency and hypothyroidism, which are endocrine disorders resulting from a deficiency of thyroid hormone. (Eledrisi,2022). Conditions such as delayed puberty, celiac disease, and undernutrition can also affect and prevent growth (Cleveland Clinic, 2022).
Growth hormone deficiency management plan with a focus on pharmacotherapy agents based upon evidence-based practice guidelines
Growth hormone deficiency in children may be congenital, acquired, or idiopathic. Treatment for children with growth hormone deficiency is synthetic human growth hormone (somatropin). This requires daily injections which are painful and distressing for some children. The desire to reduce the frequency of injection has led to the development of long-acting analogs of growth hormone. The C-terminal modification extends the half-life of growth hormone to roughly 28 hrs. Somatrogon will remain in circulation for 6 days, so weekly subcutaneous dosing is possible While the injections of somatrogon are less frequent they are more painful and long-term follow-up is needed to address questions about immunogenicity and any effects from not having daily peaks and troughs in growth hormone concentrations (Australian Prescriber, 2022).
Australian Prescriber (2022). Somatrogon for growth hormone deficiency.
Cedars Sinai (2022). Adult Growth Hormone Deficiency. https://www.cedars-sinai.org/health-
Cleveland Clinic (2022). Growth Hormone Deficiency (GHD): Symptoms & Treatment.
Eledrisi, M. S. (2022). Growth Hormone in Adults Clinical Presentation. https://emedicine.
Johns Hopkins Medicine (nd.). Growth Hormone Deficiency.
Mount Sinai (2022). Growth hormone deficiency- children. https://www.mountsinai.org/health-