Pediatric Endocrinology Expert Forum
Does this baby need medical treatment?
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Questions in the Pediatric Endocrinology forum are answered by Dr. Deanna L Aftab Guy. Topics covered include adrenal problems, diabetes insipidus, menstrual irregularities, obesity, parathyroid abnormalities, pituitary abnormalities, puberty concerns, rapid growth, rickets and bone disease, short stature, and thyroid.

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Does this baby need medical treatment?

My friend in China has a baby having slightly high TSH, she is getting different opinions from different doctors there.  So she was asking me to post the question in this forum to see what doctors in U.S. will do for her baby.  Here are the test results, and the baby is about 3-and-half-month old now.

(1) Test results when the baby is 7 weeks old.
Anti-TPO: 8.0 IU/mL (ref range: 0-12.0)
Anti-TG: 11.6 IU/mL (ref range: 0-34.0)
Total T3: 1.13 ug/L (ref range: 0.79-1.49)
Total T4: 78.3 ug/L (ref range: 45.0-120.0)
TSH: 6.96 mIU/L (ref range: 0.47-4.64 adult)
Free T3: 4.05 pmol/L (ref range: 2.22-5.34)
Free T4: 14.96 pmol/L (ref range: 9.13-23.8)

(2) Test results when the baby is 11 weeks old.
Total T3: 2.3 nmol/L (ref range: 1.2-3.4)
Total T4: 114.0 nmol/L (ref range: 54-174)
TSH: 6.46 mIU/L (ref range: 0.34-5.60)
Free T3: 7.0 pmol/L (ref range: 3.54-10.16)
Free T4: 19.4 pmol/L (ref range: 10.0-31.0)
Anti-TPO: 20.0 IU/mL (ref range: <35)
Anti-TG: <20.0 IU/mL (ref range: <40)

(3) Test results when the baby is 13 weeks old.
Total T3: 2.9 nmol/L (ref range: 1.2-3.4)
Total T4: 157.0 nmol/L (ref range: 54-174)
TSH: 6.694 mIU/L (ref range: 0.34-5.60)

We can see the baby's TSH is close to 7.0 and higher than the ref, but the T3 and T4 are normal.  Is this normal for babies? and does the baby need any medical treatment?  Please advise. Thank for the help.
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I see that several folks have offered advice and ultimately this child's care needs to be directed by a physician who is actually seeing the child. I am not alarmed by the labs, per se, there is no reason to get thyroid antibodies, these do not need repeated, the tsh was indeed as you mentioned mildly elevated, this can be due to a few things, congenital hypothyroidism-safer to treat initially if the dose is appropriate for weight as you follow labs, next can be a hypothalamic pituitary problem in which the baby's hypothalamus (above the pituitary) is not signalling therefore the thermostat rather than the thyroid itself is the problem. In this case the other hormones that the pituitary makes need to be assessed, including growth hormone but most importantly acth which is the hormone that directs to the adrenal gland to kick in during times of stress. In premature babies, the thermostat does not mature as quickly and often the tsh will be mildly off.
So starting treatment did not completely correct the tsh but a full 8 weeks did not even pass for this to be interpreted correctly and as you so correctly mentioned the free T4 was normal. Now I see that a whole lot of literature was quoted but ultimately you need to work with the child and how they are doing clinically, if they are thriving, growing, gaining weight I see no harm in continuing the medication until the labs are reassessed, especially if the dose is weight appropriate, the ultimate concern is not overtreatment rather delay in treatment given the concern for brain development. So be sure that the child is not only followed by the pediatrician but that they may have the possibility to see a pediatric endocrinologist. I see many many babies adopted from China who have abnormal thyroid functions. Hope this is helpful.
5 Comments
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Avatar_n_tn
Sorry, forgot mention the baby boy was taking medicine during test 2 and 3, but TSH level is still slightly high.  The old doctor thinks it is normal, but the young doctor told my friend it is better to take medicine if TSH is higher than 5.0.
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Avatar_n_tn
Deep appreciation from me and my friend to both of you...We know we all want the best for the baby though sometime we human beings may struggle with what we should do.  Fortunately, I just heard the results of the most recent test done on the baby last Thursday, the TSH level dropped to 4.X which is within the normal range.  The baby had medicine for 12 days from the beginning to the middle of November, and the mom stopped the medicine since then.  (Sorry, I mistakenly typed 6 weeks before).

Thanks again for the help and best wishes for ttyy's nephew.
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Avatar_m_tn
That was so grrrrrrrrrrrrrrreeeeeeeaaaaaaaaaat news to hear. I am almost flying from happiness for the little baby and her mom. What  a wonderful peace of mind finally by the Lord of heaven and earth you were granted. And what a wonderful to start a whole new year even though I know it is not the chinease new year yet :) I hope your days, mom's and her little one are filled with health, prosperity and happiness.

With the best wishes ever
Very very happy and  healthy new year
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Avatar_m_tn
Your remark  "I see many many babies adopted from China who have abnormal thyroid functions" got stuck in my mind. While doing some more search I came across this Japanese paper in 2004 I wanted to share with my Chinese friend thinking of the similarity of both cultures' diets:

Ref: Nishiyama S, et al. (Transient hypothyroidism or persistent hyperthyrotropinemia in neonates born to mothers with excessive iodine intake). Thyorid. 2004;14:1077-1083

In  Japan there is ingestion of large quantities of iodine-rich seaweed such as kombu (tangle weed, Laminaria japonica), which contains a high level of iodine (1.3 mg per gram of kombu), hijiki (Hizikia fusiformis) and  wakame (Undaria pinnatifida). Rolled sushi is also an iodine-rich Japanese traditional food.

So healthy mothers with excessive iodine intake through food during or after pregnancy can have babies with elevated TSH and normal T4 (hyperthyrotropinemia).

The authors stated that hyperthyrotropinemia related to excessive iodine ingestion by mothers during pregnancy is transient in most cases.

However, consumption of iodine from breast milk of such mothers, baby foods flavored with kombu, and kombu products ingested in the postnatal period contributed to persistent hyperthyrotropinemia.

The Editor comment was: The ordinary intake of iodine by Japanese women is 500-1500 μg per day. This iodine intake is excessive as compared with the recommenced daily allowance of 150 μg of iodine for adults given by the United States National Research Council.

However, the consumption of iodine in the US has also increased with the widespread use of iodized salt, reaching 240 - 740 μg of iodine per day in some areas.

Thus, the assessment of iodine intake and urinary excretion should be made in infants with hyperthyrotropinemia (elevated TSH, normal T4).



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