Paeds · endocrinology-diabetes-and-growth
Acquired hypothyroidism and Hashimoto thyroiditis
Also known as Hashimoto thyroiditis · Chronic lymphocytic thyroiditis · Autoimmune thyroiditis · Acquired hypothyroidism · Juvenile hypothyroidism
Acquired hypothyroidism is thyroid-hormone deficiency that develops after a period of normal thyroid function. In iodine-sufficient regions Hashimoto (chronic lymphocytic) thyroiditis is by far the commonest cause in children and adolescents: an autoimmune, antibody-mediated destruction of thyroid follicular cells that produces a goitre, a rising TSH and a falling free T4. Presentation is often subtle — growth slowdown, fatigue, constipation, weight gain and school decline — so the diagnosis rests on venous TSH with free T4 and anti-TPO antibodies. Treatment is levothyroxine, weight-based and titrated to a normal TSH; outcome is excellent once replacement begins, with catch-up growth and full cognitive preservation. The skill is recognising the insidious picture, confirming biochemically, screening the associated autoimmune syndromes (Down, Turner, type 1 diabetes, coeliac), and counselling the family on a long but reversible condition.
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Red flags
- Growth crossing centiles downward (height velocity slowing) with fatigue, constipation or weight gain in a school-age child or adolescent — check TSH and free T4; acquired hypothyroidism is the commonest endocrine cause of decelerating growth
- Goitre in a child or adolescent — weigh in, examine, and send TSH + free T4 + anti-TPO; do not dismiss a neck swelling as reactive
- Severe decompensation with hypothermia, bradycardia, hypoventilation, hyponatraemia and altered consciousness — myxoedema coma; give IV levothyroxine and hydrocortisone before T4 (rule out adrenal insufficiency)
- Earlier-than-expected puberty, menstruation change (menorrhagia or oligomenorrhoea) or galactorrhoea with growth arrest — check thyroid function; TRH-driven prolactin rise and premature thelarche can accompany hypothyroidism
- Child with Down syndrome, Turner syndrome, type 1 diabetes or coeliac disease — screen thyroid function at least annually; autoimmune thyroiditis is highly prevalent and frequently silent
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- Endocrinology — thyroid disorders in children and adolescents
- General and Community Paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 11: Managing chronic and complex conditions
- Endocrinology and diabetes
- Clinical Applications — growth and thyroid assessment
- Long Cases — chronic endocrine disease
- Short Cases — goitre and thyroid examination
- 9. Endocrinology and diabetes: Thyroid disorders
- 4. Professional skills and knowledge: Patient management
- Foundation of Practice (FOP) — endocrinology
- Applied Knowledge in Practice (AKP) — thyroid disease
- Clinical — endocrine short case and communication
- History and Management — thyroid and growth
- General Pediatrics Content Outline — Endocrinology domain
- Pediatric Endocrinology — disorders of the thyroid gland
- Patient Care 4: Clinical Reasoning — endocrine
- Medical Knowledge 1: Clinical Knowledge — thyroid axis
- Medical Expert — endocrinology
- Pediatrics: Core EPA — Managing endocrine and growth problems
Overview & Definition
A ten-year-old girl is brought in because her teacher says she is tired and "not herself," her trousers have tightened, and the family notices she feels the cold. On examination there is a firm, bosselated, symmetrically enlarged thyroid. This is the textbook face of acquired hypothyroidism from Hashimoto thyroiditis — and the reason every general paediatric trainee needs to recognise, confirm and treat it confidently. [3][4]
Acquired hypothyroidism means inadequate circulating thyroid hormone arising after the newborn period, once the gland has previously functioned normally. It is a clinical–biochemical state, not a single disease: the thyroid can fail because autoimmune lymphocytes destroy it, because iodine is too scarce or too plentiful, because the gland has been removed or irradiated, or because a drug suppresses hormone synthesis. [1][6]
Hashimoto thyroiditis (chronic lymphocytic thyroiditis) is the autoimmune form and the one you will meet most often. Lymphocytes and antibodies infiltrate and gradually destroy thyroid follicular cells, so hormone output falls and the pituitary raises TSH in compensation — producing the goitre, rising TSH and falling free T4 that define the condition. First described by Hakaru Hashimoto in 1912, it is now the commonest cause of acquired hypothyroidism in iodine-sufficient children and adolescents. [8][3]
The clinical skill is threefold: catch the insidious presentation before growth and school performance erode; confirm biochemically rather than treating symptoms alone; and place the child in context — screening for type 1 diabetes, coeliac disease, Down and Turner syndrome, where Hashimoto travels in company. [9][10][12]
References12ShowHide
- [1]Bhattacharyya SS Acquired Hypothyroidism in Children. Indian Journal of Pediatrics, 2023.PMID 37256446
- [2]Rodriguez L, Dinauer C, Francis G Treatment of hypothyroidism in infants, children and adolescents. Trends in Endocrinology and Metabolism, 2022.PMID 35537910
- [3]Hanley P, Lord K, Bauer AJ Thyroid Disorders in Children and Adolescents: A Review. JAMA Pediatrics, 2016.PMID 27571216
- [4]Diaz A, Lipman Diaz E Hypothyroidism. Pediatrics in Review, 2014.PMID 25086165
- [5]Salerno M, Improda N, Capalbo D Management of endocrine disease: Subclinical hypothyroidism in children. European Journal of Endocrinology, 2020.PMID 32580145
- [6]Chaker L, Razvi S, Bensenor IM, et al. Hypothyroidism. Nature Reviews Disease Primers, 2022.PMID 35589725
- [7]Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, Cooper DS, Kim BW, Peeters RP, Rosenthal MS, Sawka AM Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid, 2014.PMID 25266247
- [8]Caturegli P, De Remigis A, Rose NR Hashimoto thyroiditis: clinical and diagnostic criteria. Autoimmunity Reviews, 2014.PMID 24434360
- [9]Whooten R, Schmitt J, Schwartz A Endocrine manifestations of Down syndrome. Current Opinion in Endocrinology, Diabetes and Obesity, 2018.PMID 29135488
- [10]De Sanctis V, Khater D Autoimmune diseases in Turner syndrome: an overview. Acta Bio-Medica, 2019.PMID 31580326
- [11]Gallizzi R, Crisafulli C, Aversa T, et al. Subclinical hypothyroidism in children: is it always subclinical? Italian Journal of Pediatrics, 2018.PMID 29454373
- [12]Ridha MF, Al Zubaidi MA Thyroid auto immune antibodies in children with Type-I Diabetes mellitus in relation to diabetes control. Pakistan Journal of Medical Sciences, 2019.PMID 31372126