Niger J Paed 2014; 41 (4): 302 - 306

REVIEW

Jaja T

Clinical characteristics of

Yarhere IE

children and adolescents with

thyroid disorders seen at the

University of Port Harcourt

Teaching Hospital: A five year

review

DOI:http://dx.doi.org/10.4314/njp.v41i4,2

Accepted: 17th June 2014

Abstract Background Thyroid dis-

13 years with male to female ratio

orders constitute a large proportion

1.7:1. Of the 18 children,

Jaja T

(

)

of endocrine diseases in children

5(27.8%)

had

hyperthyroidism

Yarhere IE

and adolescents. Diseases of the

Department of Paediatrics,

with a case of neonatal thyrotoxi-

University of Port Harcourt Teaching

thyroid have profound effect on

cosis, 10(55.6%) hypothyroidism

Hospital

metabolism, cognition, growth and

and 3(16.7%) euthyroidism. eight

Port Harcourt, Nigeria.

development in children. The pat-

(44.4%) had goiter. Nine (90.0%)

Email: tamunopriyej@yahoo.com.

tern of thyroid disorders in children

of the children with hypothyroid-

in our region is still under reported.

ism had congenital hypothyroid-

Objectives: To describe the clini-

ism with two cases of transient

cal characteristics of children and

hypothyroidism. Mean age at diag-

adolescents with thyroid diseases

nosis of children with congenital

seen over a 5 year period in a terti-

hypothyroidism was 9.81months.

ary centre in Port Harcourt

Only 2(22.2%) with congenital

Methods: A retrospective review

hypothyroidism presented before

of all cases of thyroid disorders

the age of 3weeks, the mean dura-

seen in the Paediatric endocrinol-

tion of neck swelling before pres-

ogy clinic

of the University of

entation of children with goitre

Port Harcourt Teaching Hospital

was 19.6months. One (5.6%) child

from January 2009 to December

had thyroid cancer. Initial wrong

2013.The

information

obtained

referrals and lost to follow up in

from endocrine registers and case

22.2% of cases each were common

files were patients’ biodata, clinical

challenges encountered in manage-

features, diagnosis, management,

ment.

challenges and outcome. Diagnosis

Conclusion: Congenital hypothy-

of each disorder was based on

roidism was the commonest thy-

clinical features, relevant labora-

roid disorder in this report, delayed

tory investigations and imaging

diagnosis and its consequences

studies.

were noted, emphasizing the need

Result: Eighteen (29.3%) out of

for routine new-born screening in

62 children with various endocrine

Nigeria.

disorders had thyroid diseases,

accounting for 0.1% of all children

Keywords:

Thyroid

disorders,

seen in the specialist outpatient

children, endocrine diseases, anti-

clinics. Age range at presentation

thyroid treatment

of children reported was 5days to

Introduction

Disorders of thyroid function in children as in adults

manifest as hypothyroidism, hyperthyroidism and vary-

Thyroid disorders constitute a large proportion of endo-

ing degree of thyroid gland swelling (goitre) or a combi-

nation of these . The frequency of thyroid disorders

3

crine disorders in childhood. It is the second commonest

endocrine disorder after diabetes mellitus in children

varies from region to region with higher frequency in

worldwide . The importance of thyroid disorders in chil-

1

Iran, India and Bangladesh and lower frequency in La-

tiva however, this condition is recorded worldwide . In

4

dren is due to the profound effect of thyroxine on

metabolism, cognition, growth and development .

2

Nigeria, most studies on thyroid disorders were done in

303

Definitions of Terminologies

11

adults. There are only few but old reports mentioning

thyroid diseases in children . The prevalence of thyroid

5,6

disorders in children range from 0.07 -1.7% and fre-

Hyperthyroidism is the production and secretion of

quency appears to be increasing . In the report by Ladi-

3

excessive amount of thyroid hormone (Triiodothyronine

tan et al in 1979, in the University College Hospital

T3 and/ or Thyroxine T4) from the thyroid gland with

Ibadan, the prevalence of thyroid diseases in children

high serum hormone levels.

was 0.07% and three decades later, a higher prevalence

Thyrotoxicosis: is the hyper metabolic clinical syn-

of 0.12% was recorded in Benin City by Onyeruika and

drome that occurs when there is elevated serum level of

colleagues . In an earlier report on pattern of endo-

3,5

T3 and/or T4 irrespective of source of thyroid hormone.

crine diseases in Port Harcourt by Anochie etal col-

Hypothyroidism is the reduced production and secretion

leagues , thyroid diseases accounted for 13.3 % of all

of T3 and/ or T4 from the thyroid gland with low serum

endocrine diseases . In Africa, iodine deficiency is the

7

hormone levels

commonest cause of thyroid disorders in both adults and

Hypothyroidism : Is the reduced production and secre-

children . The UNICEF, estimates that 8% of newborn

8

tion of T3 and / or T4 from the thyroid gland with low

from Sub Saharan Africa are unprotected from learning

serum hormone levels.

disabilities resulting from iodine deficiency related dis-

Euthyroidism: is a state of normal production and se-

orders .

8

cretion of T3 and T4 from a thyroid gland with normal

serum hormone levels.

Presentation of thyroid diseases in children depends on

Goitre: This is the presence of swelling in front of the

the age and geographic region. In infancy, congenital

neck due to thyroid gland enlargement with or without

hypothyroidism caused mainly by thyroid dysgenesis is

abnormality in T3 and/or T4 hormone production

a common presentation diagnosed from new-born

Data was entered into an excel sheet and analysed using

screening or due to presentation with mental retardation

descriptive statistics and presented in text and tables

and short stature during childhood. In later childhood

and adolescence, asymptomatic goitre with autoimmune

disorders is commonest with a female preponderance .

9

In most developing countries, iodine deficiency account

Result

for the commonest cause of thyroid disorders ranging

General Description

from congenital hypothyroidism to goitre in older chil-

dren . The purpose of this study is therefore to describe

10

Eighteen (29.3%) out of 62 children with various endo-

the clinical characteristics of children and adolescents

crine disorders had thyroid diseases and were reviewed

with thyroid disorders seen in the Paediatric endocrinol-

accounting for 0.1% of total cases seen in the paediatric

ogy clinic of the University of Port Harcourt Teaching

specialist clinics. Age range at

presentation of chil-

Hospital over a five year period.

dren reported was 5days to 13 years with mean age of

72.9months. Nine (50%) of the patients were below five

years. There were 11 (61.1%) males and M: F of 1.7:1.

Of the 18 children with various thyroid disorders, 5

Subjects and Methods

(27.8%) had hyperthyroidism with a case of neonatal

thyrotoxicosis, 10(55.6%) hypothyroidism and 3(16.7%)

The study was carried out in the endocrinology unit of

euthyroidism as in. Table 1. Overall, eight (44.4%) pa-

the department of Paediatrics, University of Port Har-

tients had goitre. Table 2 shows the general characteris-

court Teaching Hospital. The endocrine unit was started

tics of children with various categories of thyroid disor-

in 2001 as joint Nephrology/ Endocrine unit and became

ders.

an independent unit in March 2013 with paediatric endo-

crinologist. The unit treats children and adolescents with

Table 1: Pattern of Thyroid Disorders in Children Studied

various endocrine diseases. Children are referred from

Disorders

Male

Female

Total (%)

various private and government hospitals in Rivers State

and neighbouring states like Bayelsa, Imo, Abia and

Euthyroidism

1

2

3 ( 16.7)

Akwa-ibom.

Hypothyroidism

8

2

10 (55.6)

Hyperthyroidism

2

3

5 (27.8)

Total

11(61.1%)

7 (38.9%)

18 (100%)

A retrospective review of all thyroid cases seen over five

year period 2009 to 2013 was done. Information about

Hypothyroidism: Ten (55.6%) patients had hypothy-

the cases was retrieved from endocrine register, clinic

roidism out of which 9(90%) had congenital hypothy-

and ward records and case notes. Information on age,

roidism. Mean age at diagnosis of children with con-

sex, clinical features and duration of symptoms, diagno-

genital hypothyroidism was 9.81months. Of the nine

sis, treatment and outcome were retrieved. Diagnosis of

patients with congenital hypothyroidism 2(22.2%) cases

thyroid disorders was from clinical features, confirma-

had transient hypothyroidism. Two (22.2%) children

tory thyroid function test, antibody and histopathology

with congenital hypothyroidism were diagnosed by the

test.

age of 3weeks. Only one child (10%) an 11 year old

who was being investigated for short stature with cold

intolerance and constipation had acquired hypothyroid-

ism. In children with permanent congenital hypothyroid-

304

ism, coarse fascie, protruding tongue and mental apathy/

19.6months. Challenges and outcome in children with

delayed milestone were the commonest features as

various thyroid disorders is as shown in Table 4. Infor-

shown in Fig 1.

mation was retrieved from documentations on patient’s

Table 2: Characteristics of patients with various thyroid dis-

case note and endocrine register during counseling sec-

orders

tions on treatment at clinic visits. Four (22.2%) contin-

Characteristics

Euthy-

Hypothy-

Hyperthyroid-

ued to express worry over the prolonged use of the

roidism

roidism

ism

drugs. Four patients which included two children with

Number of Patients

3

10

5

Euthyroid goitre, the child with acquired hypothyroid-

Mean age at presenta-

10.67year

22.07months

11 years

ism and one male with congenital hypothyroidism were

tion

s

(excluding

neonate with

lost to follow up. Only one, the child with the thyroid

Graves Dis-

cancer died giving a disorder -specific case fatality rate

ease)

of 5.6 %.

Age range at presenta-

9-12 years

19 days -11

6weeks- 13

tion

years

years

Table 4: Challenges and outcome in management of children

M:F

1:2

4: 1

2:3

reported

Mean duration of symp-

19.6

11.27months

12.8months

Challenges/Outcome

Freq (%)

toms at presentation

No with Goitre

3

1

5

Initial wrong referral

4(22.2)

Difficulty doing baseline investigations

2(11.1)

Fig 1: Clinical features in children with congenital hypothy-

Poor drug compliance

3(16.7)

roidism

Concern for prolonged drug therapy during counseling

4(22.2)

Lost to follow up in last 1 year

4(22.2)

Death

1(5.6)

Discussion

The prevalence of thyroid disorder in this study is 0.1%.

It contributes to a significant proportion of paediatric

endocrine disorders seen in our centre. This prevalence

is similar to a report of 0.12% by Onyeruika and col-

leagues in Benin City Edo State but it is 1.4 times

3

higher than a report by Laditan in University College

Hyperthyroidism: Table 2 shows the general character-

Hospital (UCH) Ibadan that was done three decades

ago . The higher prevalence reported in this study, com-

5

istics of children with hyperthyroidism. All children

with hyperthyroidism except one child with neonatal

pared to the report by Laditan in UCH may be due to

Graves’ disease presented between the age of 9 years

better awareness of the disease condition compared to

and 13 years. Soft goitre grade II to III, weight loss and

three decades ago when the study was done in UCH and

proptosis were the commonest reasons for presentation

also due to better access to specialist health care now.

however, the commonest clinical features of thyrotoxi-

cosis recorded at admission were weight loss, excessive

In contrast to most reports on thyroid disorders in chil-

sweating and goitre seen in 100% of the cases as shown

dren and adults, this report found thyroid disorders was

in Table 3. All children with hyperthyroidism were

1.7 times commoner in males. In the study by Onyeruika

and colleagues , it is four times commoner in females;

3

treated for Graves’ disease.

similarly, Ogbera and Kuku reported it was five times

commoner in adult females . The reason for a higher

8

Table 3: Frequency of symptoms at presentation in children

with hyperthyroidism

number of males with thyroid diseases in this report is

Features

Frequency (% )

not very clear and calls for a need to carry out a larger

population study to confirm this finding.

Weight Loss

5(100)

Excessive sweating

5(100)

Goitre

5(100)

Thyroid disorders in children can present at any age,

Proptosis

4(80)

previous studies have shown that majority present dur-

ing adolescence

3,8,9

Frequent Stools

3(60)

. Onyeruika in his study in Benin

Poor Sleep

3(60)

reported a mean age of 11.2 years. This is however in

Palpitations

1(20)

contrast to the finding in this study where the mean age

Family History

1(20)

at presentation of the children studied was 6.1 years

(72.3months). This was similar to the report by Laditan

in 1979 in UCH who noted a mean age of 5.4 years .

5

Euthyroidism: Three (16.7%) children were euthyroid

at

presentation,

mean

age

at

presentation

was

This reported younger age at presentation in this study

10.67years. The three children with euthyroidism pre-

and that by Laditan may be due to the fact that 50 to

sented with goitre (grade III) firm to hard lobulated goi-

60% of children reported in this study and that by Ladi-

tre out of which one had papillary thyroid cancer. Mean

tan had congenital hypothyroidism and most presented

duration of neck swelling before presentation was

before the age of 5 years.

305

The expanding spectrum of thyroid diseases in children

Graves’ disease mother who presented with weight loss

and adolescents includes three important clinical catego-

despite voracious appetite. He received carbimazole

ries i.e. hypothyroidism, hyperthyroidism and euthyroid-

tablets transiently for three months and is presently on

ism. The commonest disorder in this report was hypo-

follow up. The commonest reason for presentation of the

thyroidism accounting for half of all cases seen; which

patients with Graves’ disease was goitre and proptosis.

is in contrast to the report by Onyeruika and colleagues

3

Features of thyrotoxicosis were reported in all children

in Benin Southern Nigeria where hypothyroidism ac-

with hyperthyroidism similar to reports from other studi-

es

3,18

counted for 22.2% of all cases of thyroid disorders seen

, however; in children unlike in adults cardiovas-

cular complications such as heart failure is rare

3,18

over a seven year period but similar to a report from

.

Singapore, and earlier report by Laditan in UCH where

hypothyroidism accounted for 40% and 60% of cases

Two subjects presented with euthyroid goitre, account-

of thyroid disorders in children respectively

5,12

. In an-

ing for 28.6% of all cases of goitre in this report. One of

other report from Mumbai, Northern India, hypothyroid-

the cases with euthyroid goitre was suspected to have

ism accounted for 75% of cases reported in children in a

chronic lymphocytic thyroiditis (CLT) which is the

referral centre . The differences in these rates may be

13

commonest cause of acquired thyroid disorder in chil-

accounted for by genetic and environmental factors of

dren with an initial preservation of thyroid function as

was recorded in this subject.

2, 9

which iodine deficiency may contribute. Iodine defi-

About 75% of cases of

ciency disorder is a common risk factor for thyroid dis-

CLT are Thyroid peroxidase antibody positive, though

eases including congenital hypothyroidism. The high

this could not be done before patient was lost to follow

number of children with CH in this report although can-

up. The second case of goitre with normal thyroid func-

not directly be attributed to iodine deficiency related

tion was the patient with thyroid cancer which was diag-

disorders but it is important to note that in spite of the

nosed by a fine needle aspiration biopsy. Thyroid cancer

success in salt iodization and the availability of iodine

is rare in children but is the second commonest malig-

rich foods such as periwinkle, oysters and water in this

nancy in children exposed to radiation, Hodgkin’s lym-

phoma and leukemia survivors . It also occurs in pa-

9

region, there is a rising incidence of endemic goitre

tients with existing chronic lymphocytic thyroiditis .

9

amongst the populace . This rising incidence of en-

14

demic goitre have been attributed to disorders of iodine

The patient with thyroid cancer did not have any family

metabolism caused by food ,water and soil pollution

history of cancer and died in theatre during surgery.

from oil exploration as obtains in Port Harcourt .

14

Several management challenges were noted in this re-

The second commonest thyroid disorder in this report

port. These challenges include high cost and non-

was hyperthyroidism, which accounted for 27.8% of all

availability of investigations. In most cases, individual

cases. This finding is much lower than the report by

hormone profiles are expensive and are done by only

Onyeruika and colleagues who reported 67% of cases .

3

few laboratories. There is non– availabity in our centre

The difference in the rate between these studies is not

of facilities such as thyroid scintigraphy needed to deter-

immediately obvious but may be due to environmental

mine actual cause of thyroid disease such as in congeni-

influences such as iodine consumption, diet and preva-

tal hypothyroidism or to exclude a toxic thyroid nodule

lence of endocrine disruptors. The possible reason for

in children with hyperthyroidism. In this report, as in

the high rate of hyperthyroidism in the Benin study as

other reports low awareness both in the general populace

speculated by Onyeruika and colleagues may be due to

and even amongst health workers has been demon-

exposure to increased levels of iodine following the salt

strated; wrong referrals by health workers was noted in

iodization policy by the Government. The increased risk

children with proptosis who were wrongly treated for

of hyperthyroidism following exposure to iodine has

eye disorders and referred to the ophthalmologist. Also

been reported in some studies

15,16

, although no evalua-

the parent of a child with congenital hypothyroidism

who presented as early as 3 month of life with worry

rd

tion was done to determine the part of iodine levels in

children with hyperthyroidism in this study, however

over the dull disposition of the baby when compared to

Madukosiri in a pilot study on aetiology of goitre in

other babies was only reassured until the child was di-

Bayelsa State cautioned that the presence of iodine defi-

agnosed at age of 11 months. The delay in diagnosis of

ciency should be established in iodine replete areas be-

most of the children with congenital hypothyroidism and

fore salt iodization to prevent the excessive exposure of

presentation with mental retardation as was noted in this

the thyroid gland to iodine and its consequences such as

study was also reported in other studies, due to non-

increased thyroxine production .

14

availability of routine newborn screening. About a quar-

ter of the patients were lost to follow up in this report

In this report all children with hyperthyroidism were

and this is not surprising as this is the pattern in our en-

treated for Graves’ disease an autoimmune disorder of

vironment in most chronic illnesses as parents tend to

the thyroid gland that results from complex genetic traits

seek alternative treatment. These challenges were also

noted in other studies

3,5,19

that occur in genetically predisposed individuals, it ac-

done in other centres stressing

counts for 60 -70% of cases of hyperthyroidism in pae-

the need for creation of awareness even amongst health

diatric age . Graves’ disease as in most other reports

17

workers.

was the commonest cause of hyperthyroidism in this

report with a female preponderance. One of the children

with hyperthyroidism was a neonate, an infant of

306

Conclusion

increase in children with mental retardation arising from

this. There is therefore the need for commencement of

Thyroid disorders are prevalent amongst children in Port

routine neonatal screening for congenital hypothyroid-

Harcourt adequate management is still hindered by lack

ism in our country and creation of awareness on thyroid

and high cost of diagnostic facilities. The commonest

disorders and other endocrine disorders.

disorder in this report was congenital hypothyroidism.

Delay in diagnosis of children with congenital hypothy-

Conflict of interest: None

roidism is still a major concern with a cumulative

Funding: None

References

5.

Laditan AAO, Johnson AOK. Thy-

1.

Becker KL, Nylen ES, Snider RH.

roid gland disorders in African

12. Siok HT, Hock BW. Review of

Endocrinology and the endocrine

Children. J Natl Med Assoc. 1979;

thyroid Disorders in Singapore

patient. In: Becker L, Ronald CK,

71(2): 139-141

Children. J Trop Pediatr1985;31

Rebar RW. eds, Principles and

6.

Edino ST, Mohammed AZ,

(1):54-58

practice of endocrinology and

Ochicha O, Thyroid diseases in

13. Desai MP. Disorders of Thyroid

metabolism. 3 ed Lippincott,

rd

Kano. Niger Postgrad Med J.

gland in India. Indian J Pediatr,

Williams and Wilkins, 2002: 82-

2004;11:103-106

1997;64(1):11-20

85.

7.

Anochie IC, Opara I, Inimgba N.

14. Madukosiri CH. Delange F, de

2.

Desai MP.2009. Disorders of thy-

Pattern of endocrine diseases in

Benoist B, Alnwick D. Risks of

roid gland. In: Pathasarathy A, ed.

children in the University of Port

iodine- induced hyperthyroidism

I A P Textbook of Pediatrics, 4

th

Harcourt Teaching Hospital. Port

after correction of iodine defi-

ed. New Delhi, Japee Brothers

Har count Med J 2009;3:145-152

ciency by iodized salt. Thyroid

Medical Publishers Ltd, 931-935

8.

Ogbera AO, Kuku SF. Epidemiol-

1999;9:545-556.

3.

Onyiruika AN, Abiodun PO, Ony-

ogy of thyroid diseases in Africa.

15. Nte A, Idiki Ogan M, George I.

iruika LC. Thyroid Disorders in

India J Endocrinology 2011;5(6):

Paediatric thyroid gland disorders

Childhood and Adolescence:

82-88

in Port Harcourt: Has the universal

Analysis of clinical data and man-

9.

Brown RS. Disorders of thyroid

salt iodization programme any

agement challenges in patients

gland in infancy, childhood and

role? TNHJ 2005;5:283-286

seen in a Nigerian Teaching Hos-

adolescence. Available at:

16. Menon PS, Singh GR. Hyperthy-

pital. Greener J Med Sci 2012; 2

www.thyroidmanager.org.

roidism in children: an Indian ex-

(2): 045-050

10. Fisher D. Next generation newborn

perience. J Pediatr Endocrinol

4.

Rendon-Macias ME, Morales-

screening for congenital hypothy-

Metab 1996; 9: 441-446.

Gracia I, Huerta- Hermandez E,

roidism? J Clin Endocrinol Metab

17. Zimmerman D, Lteif AN. Thyro-

Silva-Batalla A, Villasis-Keever

2005; 90(6):3797-9.

toxicosis in children. Endocrinol

MA. Birth Prevalence of Congeni-

11. La Frenchi S. Disorders of the

Metab Clin North Am 1998: 27;

tal Hypothyroidism in Mexico.

thyroid gland In: Kliegman RM,

109-126.

Paediatr and Perinatal Epidemiol

Berhman RE, Jenson HB, Stanton

18. Hanna CE, La Frenchi SH. Adoles-

2008;22(5): 478-485

BF eds. Nelson Textbook of Paedi-

cent thyroid disorders. Adolesc

atrics 18 ed. Philadelphia, Saun-

th

Med. 2002; 13(1):13-15

ders Elsevier, pp2316-2340