Graves Disease in Childhood

Abstract

While diagnosing Graves disease in childhood and adolescence does not usually present specific problems, the treatment of hyperthyroidism is still controversial. In particular, with regard to the use of radioiodine therapy, strategies vary between many European and North American pediatric endocrinology centers. After the diagnosis is made, antithyroid drug treatment with methimazole (thiamazole), carbimazole, or propylthiouracil should be performed with caution, in particular, because of severe adverse effects, such as agranulocytosis or hepatitis, that are found in up to 1% of patients. Antithyroid drug treatment should not be continued long-term, particularly since definitive remission cannot be expected in more than 30-40% of patients. In contrast, the risk of severe adverse effects is still present, and the risk of thyroid carcinoma increases with time and appears to be considerably higher than after radioiodine treatment. To a great extent, the success of surgery depends on the skills of a trained surgeon. The question of whether to perform total or subtotal thyroidectomy is yet to be resolved. Surgery should be considered in patients with a large thyroid gland (>80g), severe ophthalmopathy, and a lack of remission on antithyroid drug treatment. Success rates have increased to up to 97%, while severe adverse effects (laryngeal nerve palsy, hypoparathyroidism) occur in approximately 4% of patients. Mortality is below 0.1%. Radioiodine treatment in children >5 years of age does not appear to be associated with an increased risk of thyroid carcinoma; however, long-term data are lacking. Compared with the surgical approach, success rates are lower, particularly if low doses of radioiodine are used. In general, adverse effects are less prevalent than in patients who have undergone surgery.

Incidence of vitiligo in children with Graves' disease and Hashimoto's thyroiditis

“…In children, the peak age of Graves' disease is 11-15 years, and it is three to five times more common in females than in males. In young children, no gender differences have been found [14,15]. …”

“…Graves' disease most commonly occurs in teenagers, and less than 5% of pediatric patients present at less than 5 years of age [14,15]. Hashimoto's thyroiditis is also an autoimmune disease associated with the presence of anti-thyroid antibodies that can result in either hypothyroidism or a euthyroid state [16,17].…”

“…Hashimoto's thyroiditis is also an autoimmune disease associated with the presence of anti-thyroid antibodies that can result in either hypothyroidism or a euthyroid state [16,17]. Like Graves' disease, the peak prevalence is in the teenage years [14,15,18,19]. The incidence of antithyroid antibodies in the pediatric population is as high as 1% in some studies [16-20].…”

Guidelines for the treatment of childhood-onset Graves’ disease in Japan, 2016

“…According to the ATA guidelines (19), the suggested starting dose of MMI is 0.2–0.5 mg/kg/d, and MMI should be used within a range of 0.1–1.0 mg/kg/d (27, 44, 50, 69,70,71,72). Specifically, the suggested doses are 1.25 mg/d for infants, 2.5–5.0 mg/d for children aged 1–5 yr, 5–10 mg/d for children aged 5–10 yr, and 10–20 mg/d (i.e., the adult dose) for children and adolescents aged 10–18 yr. For severe cases, the dose can be increased to as high as twice the above-listed amounts.…”

Pediatric Graves’ disease: management in the post-propylthiouracil Era

“…In the pediatric age group, remission rates range from 20 to 30% following ATDs use for two years or more [18,35,36,42,43]. More than 25 years ago, Lippe and coworkers estimated that 25% of children go into remission for every two years of treatment [44].…”