Management of infants with hyperthyroidism | Right Decisions

Right Decisions
SPEG (Scottish Paediatric Endocrine Group)
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Management of infants born to mothers with Graves’ Disease and at risk of thyrotoxicosis
Management of infants with hyperthyroidism

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We are pleased to advise that deep linking capability, enabling users to directly download individual mobile toolkits, has now been released on the RDS mobile app. When you install the update, you will see that each toolkit has a small QR code icon the header area beside the search icon – see screenshot below. Clicking on this icon will open up a window with a full-size QR code and the alternative of a short URL for sharing with users. Instructions are provided.

You may need to actively install the update to install RDS app version 4.7.1 to see this improvement. Installing this update is also strongly recommended to get the full benefits of the new contingency arrangements – specifically, that if the RDS website should fail, you will still be able to download new mobile app toolkits.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. To install latest updates:

On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

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Please get in touch with ann.wales3@nhs.scot with any questions.

Positive or unknown TRAb with normal thyroid function in an asymptomatic infant requires follow up age 4 weeks and 2-3 months.
Positive or unknown TRAb with abnormal thyroid function requires assessment of clinical features and likely treatment with antithyroid drugs (ATD).

The aim of treatment in symptomatic infants is to facilitate return to biochemical euthyroid state.

Treatment should be initiated at the onset of symptoms to avoid short and long term complications.

There is no clear evidence that biochemical hyperthyroidism in the absence of symptoms should be treated.

This should be a decision made by the relevant consultant and endocrine team.

Early discussion with the local endocrine team is essential. All infants who are hyperthyroid should be discussed with the local endocrine team.

Recommendations

Biochemical hyperthyroidism in a symptomatic infant:

Start carbimazole 0.750mg/kg/day in single or divided doses.
Use propylthiouracil 2.5 to 5mg/kg twice daily instead of carbimazole if there are significant side effects with carbimazole.

Biochemical hyperthyroidism in asymptomatic infant:

Consider carbimazole: 0.2-0.750mg/kg/day in single or divided doses (but this may not be necessary if the infant remains asymptomatic).

Signs of sympathetic hyperactivity:

Consider adding Propranolol 2mg/kg/day in 3 to 4 divided doses
(+/- admission to hospital).

Haemodynamically unstable:

Infants should be admitted and management discussed with local endocrine team.
Iodine solution (Lugol’s solution) 1 drop (0.05ml) TDS.

Table 2: Adverse effects of medication

Carbimazole
Mild	Serious
Transient liver transaminitis Transient leucopenia Skin rashes GI upset Arthralgia, myalgia	Agranulocytosis – fever, mouth ulcers, neutropenia Liver injury Vasculitis Stevens-Johnson syndrome