Endocrinology

1. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 1 Endocrinology DR V K Rajpal MD

2. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 2 Introduction Thyroid in Pediatric Practice Prof Dr V K Rajpal MD Pediatric Endocrinologist and Growth Hormone Expert

3. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 3 Topics of Discussion Neonatal Thyroid screening Cretinism Hypothyroidism in children and Adolescence Treatment and followup

4. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 4 Neonatal Thyroid screening Hypothyroidism is Common disorder of child hood Incidence among neonates is 1:4500 in west As per Bombay study 1:2500 In endemic area it is even higher

5. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 5 Causes of hypothyroidism Primary 1 congenital 2 acquired CONGENITAL 1 Dysgensis either aplasia,hypoplasia or ectopic thyroid 85% Inborn errors of thyroid hormone synthesis 5% Maternal medications Radio iodine/ PTO/ carbimizole

6. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 6 Causes Continued Acquired Iodine deficiency Autoimmune chronic lymphocytic thyroiditis,Hashimotos thyroiditis Irradiation-therapeutic radio iodine, After treatment of Lymphomas Surgical ablation Ingestion of Goitrogens Drug induced Iodides PTU carbimazole lithium

7. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 7 Causes Continued Secondary Hypothyroidism Due to deficiency of TSH or TRH Hypopituitrism

8. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 8 CONGENITAL May be familial or sporadic In 85% -Dysgensis and manifest at birth,In ectopic present later In 15% inborn errors of thyroid synthesis Often present late in infancy

9. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 9 May be missed on clinical examination only 3% may be picked .so screening is the powerful tool for detection Earlier signs Patent posterior fontanel/wide-open cranial sutures Skin may be dry,thick and coarse ,cool and mottled. The abdomen may be large ,weight may be higher than normal

10. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 10 Lethargy,sleepy,cry little,have noisy breathing Nasal obstruction and apnea. Prolonged physiological jaundice Constipation and hypotonia are not uncommon

11. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 11

12. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 12 On long standing cases Muscles may be hypertrophic with an athlete pock Social smile is delayed,short attention span,marked physical and mental retardation Does not regard slow moving objects in front of him Short stature,normal head size and extremities are short,Dentition delayed,sutures are widely open Sexual precocity,delayed skeletal maturation,slow pusw,heart murmurs with refractory anemia

13. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 13 By the age 8 to 10 weeks The characteristic coarse features Puffy face,swollen eyes lids,widely separated eyes narrow palpebral fissures,broad nose with depressed bridge,open mouth broad thick protuberant tongue.the neck is short,hairs are sparse,coarse and brittle,grow down on the forehead The muscles are hypo tonic and ther is marked hypotonia

14. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 14 Acquired hypothyroidism Sign and symptoms depend on the age of onset ,severity and duration of hypothyroidism Onset insidious,low growth velocity Shot stocky,large head and trunk than limbs Some times only evidence is isolated short stature US?LS ratio increased

15. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 15 Acquired hypothyroidism Face appear puffy,skin and SC tissue thick and coarse and pigmented giving myxodemous appearance. School performance detoriates Lethargy intolerance to cold Slow pulse low BP May have sexual pecocity

16. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 16 Diagnosis Check T3, and TSH Or FT3,FT4,TSH RAIU AMA,Thyroglobulin levels for CLT Fine needle aspiration in case size of Gland increasing in spite of Eltroxin TRH test in case of suspected Secondary Hypothyroidism

17. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 17 Diagnosis X-ray of the Bones At birth �absence of distal femoral epiphysis punctate epiphyseal Dysgensis Beaking of 12 thoracic,L1 and L2 vertebra, Delayed sutures Sella turcia enlarged and rounded Serum cholesterol is high

18. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 18 Prognosis Preventable cause of mental retardation so neonatal screening absolutely essential Depends on the age of onste ,duration and severity and adequacy of management

19. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 19 Eltroxin 10-15 microgram /kg for neonates For older children 4to 8 microgram/kg In secondary cases replace cortisonrne before starting the Eltroxin to avoid precipitation of adrenal failure

20. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 20 Follow up Assess the clinical improvement Gain in height Normal activity Improved mental performance TSH normalization followed by T4 and T3 radiological improvement anually Untoward effects are dose related

21. 6/12/2012 Prof V K Rajpal Sr Ped. Endocrinologist .Agra India .mobile no 9319107454 21 Neonatal Thyroid screening Chord blood samples Low T4 and Low T3 High TSH Means Primary hypothyroid T4 low T3 and low TS H means secondary hypothyroidism Treatment to be monitored by T 4 and TSH