My 8 year Old Daughter...

[JRMK]

My 8 year old Daughter has TSH Sensitive levels of 29.6 and T4 levels of .9. Do you have any idea what this could possibly be or lead to? She had blood work done due to excessive stomach aches and they placed her on Zantac and she is fine now but that is how they found her TSH levels. She is 4'4" and now 73 lbs. Her Family Dr. said she is Myphed as to why she has levels that she does and re-tested her again and came back with the same levels again. She is ALWAYS cold and now has an appetite that won't quit. The Dr. is going to contact an endocrinologist but that is moving really slow. We are stationed on a SMALL remote island overseas with the military so medical care is not at our finger tips. No thyroid illness runs in our family. Thank you in advance for all your help

[Deanna L Aftab Guy, MD]

ok, an elevated tsh and a normal free T4 can be a few things, the most common is subclinical hypothyroidism, meaning that the thermostat (TSH) in the pituitary is working overtime to get the gland to make free T4 to keep up with the normal body's needs since for some reason the gland pooped out. The likely cause is autoimmune disease from Hashimoto's-antibodies will be positive. So here is the thing about the adrenal gland.
Being that the tsh is elevated another reason is that the thermostat is not working and really should not be as high and is not responding to normal free T4 levels to shut off, this is a rare but important concern for hypothalamus pituitary problems, those are the upper areas in the brain that control alot of our hormones.
So elevated, normal or low tsh can happen from time to time in the hypothalamic problems, so here is the part about the adrenals, the adrenals are also managed by the pituitary and hypothalamus and if the tsh is not behaving maybe the hormone that tells the adrenals is also not behaving-this is called acth, this is more dangerous since if there is missignalling to the adrenals we cannot make good cortisol to mount a stress response and can have low blood pressure and collapse and shock(this is an extreme description)
Also thyroid hormone breaks down cortisol naturally and if you are already low in your cortisol signalling and production once you go back on thyroid you will reveal a cortisol deficiency by breaking down what you have, causing adrenal crisis.
So it is rare and many many of us endocrinologist are smart enough to know about it and decide who needs testing first versus who can be treated and tested
She more than likely has subclinical hypothyroid, antibodies will help, an am cortisol will help decide if she makes enough at the time in the day when we make our peak level(again not the perfect test but definitely helpful and reassuring when it is a good level)
In regards to treatment if her antibodies are positive there is a likelihood that she will remain on treatment, but she needs treatment and followed through her pubertal growth spurt, and around that time you may see that she is either outgrowing her dose or not needing it any longer.
A pediatric endocrinololgist can take care of these things for her, it is alot of what we see, almost 50% of our patients have this. She should be seen every 3-4 months perhaps with labs done a month after any medication change. She sounds like she will be fine!
Take care

[JRMK]

RE: the above post about my 8 year old Daughter, The Family Practice called me back just now and said that they are going to put her on Synthroid at 75 MCG once a day and she has to go in for an AM Cortsol Level and an Anti-body count. They mentioned something about questioning Adreanal Insuffiency. They want to do a retest on the TSH count on Dec. 10th to see if the Synthroid is at a food level or needs to be adjusted. Otherwise we are not being sent to an endocrinoligist because of the cost for the military to send her off island to see the specialist. So my questions are.... Do you feel that everything has been covered and should I feel comfortable with the treatment she is getting from Family Practice, is this a lifelong issue, will she always be stable with her Thyroid after she is on the Synthroid or will she need to be followed up, does it get worse as she gets older, what could have caused this with no family history, is there anything else I should be looking for that could stem off of this issue, will this cause her any difficulty with child bearing when and if she chooses when she is older? I do appologize for all the questions but I am nervous and we will not be leaving this shoebox sized - foreign island for another 3 years. Thank you in advance for your help!

[JRMK]

My daughters Thyroglobul AB level came back at 175.2 and her Thyroid Pero AB level came back at 307.8 her Cort AM level came back at 9.1.

With her TSH Sensitive levels of 29.6 and T4 levels of .9 what is your opinion of what is wrong and what is causing this?

Thank you so much.

[Deanna L Aftab Guy, MD]

I would call this Hashimoto's thyroiditis, she is low thyroid due to antibodies, very very common, not to worry about the cortisol, it is very tricky, she makes cortisol, the acth level would have been nice to check too but this is straight forward, so stay on the thyroid, your doc has made a good call and is very thorough! the tsh is the hormone that the pituitary makes, alot like your thermostat, the free T4 and total t4 are the hormone that the thyroid gland itself make, if the gland is not keeping the house warm the thermostat goes on and tsh rises to get the gland in gear, and this gland has been pooped out and doesn't listen, so with treatment the pituitary will finally see a level in the blood that it likes and calm down and the level of the free T4 and total T4 will rise a little, then it is the job of your doc to check every few months or sooner if a dose change is done to be sure she is on enough  or not too much. A pill a day and she will do fine, not to worry. Sometimes they outgrow this and by puberty her doc may want to see if he can wean her, other times and most cases they tend to need the hormone. The dose may increase with her growth.
She is going to be fine. Tell your doc great job-what island are you on?

[JRMK]

Thank you so very much. You have placed my mind at ease!

We are on the shoe-box sized island of Okinawa, Japan for the next 3 years. This island is only 60 miles long by 20 miles wide. We have been here for 6 months and if feels like we stepped back atleast 20 years in time. This island is not current in technology like mainland Japan.

Again thank you sooo much!

[Deanna L Aftab Guy, MD]

wow, I have put out a message to my peds endo colleagues to see if there is someone near you, but otherwise work with her doc and stay on the med and recheck levels about a month after any changes and then if no change is needed then about every 4-6 months and eventually once a year if she is doing well. She should be fine