Graves' disease in children

Jody Ginsberg's clinical review¹ is appropriate for physicians treating adults with Graves' disease, but children with this condition may not present in the same way as adults, and the diagnosis and management of the disorder differ in several respects between adults and children.

The clinical findings in children can be similar to those in adults, often involving multiple systems in a subtle manner. Most affected children do have diffuse goitre and ocular signs, but neither is a common, isolated presenting complaint.² Rather, children often present with behavioural disturbances such as decreased attention span, difficulty concentrating (which leads to poorer academic performance), hyperactivity, difficulty sleeping, tachycardia, tremor and weight loss despite increased appetite.³

As in adults, hyperthyroidism in youth can be confirmed by measurements of serum thyroid-stimulating hormone, free thyroxine and triiodothyronine. However, a 24-hour radioiodine uptake scan is not needed to elucidate the cause of hyperthyroidism in young patients because, although other diagnostic possibilities exist, hyperthyroidism in this age group is almost always (more than 95% of cases) related to Graves' disease.⁴

The recommendation to consult a specialist to assist in managing Graves' disease is mandatory for both adults and children. However, although the treatment modalities are similar, there are variations in choice of first-line therapy. Most pediatric endocrinologists currently recommend thionamide as a first-line treatment.⁵ Radioactive iodine has traditionally been used if major side effects are experienced or if the hyperthyroidism does not remit after several years of drug treatment. However, reliable clinical predictors of future relapse after medical therapy are not well established, and radioactive iodine is being increasingly used in some Canadian centres as first-line therapy for adolescents and for patients who have trouble adhering to the medication schedule.⁶ Although near-total thyroidectomy is an effective treatment for Graves' disease, it is not recommended for children. However, lifelong monitoring of thyroid function is indicated for children with this disease because of the risks of relapse or hypothyroidism.⁷ Young women must be educated about the potential for neonatal Graves' disease in their own children, even if they have been definitively treated with radioactive iodine.

Jennifer Webster Second-Year Medical Student Shayne P. Taback Assistant Professor Elizabeth A.C. Sellers Assistant Professor Heather J. Dean Professor Section of Endocrinology and Metabolism Department of Pediatrics and Child Health University of Manitoba Winnipeg, Man.