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How to Give Levothyroxine to Your Baby

If iodine deficiency occurs very early during pregnancy, newborns may have severe growth failure, abnormal facial features, intellectual disability, and stiff muscles that are difficult to move and control (called spasticity). If the underlying cause of hypothyroidism is not identified and hypothyroidism remains undiagnosed or untreated, brain development slows moderately to severely. If the newborn has an enlarged thyroid gland (congenital goiter), the gland may press against the windpipe and interfere with breathing.

Iodine deficiency remains the most common worldwide cause of hypothyroidism in children but is rare in the United States. Iodine deficiency may occur in children whose diet is restricted because of multiple food allergies or in those who require long-term parenteral nutrition. Treatment of hypothyroidism is directed by a doctor who specializes in treating children with problems of the endocrine system (called a pediatric endocrinologist). Doctors continue to monitor children by doing blood tests at regular intervals depending on their age.

Conditions & Treatments

• Less often, the gland has developed normally but does not produce normal amounts of thyroid hormone.
• Doctors do magnetic resonance imaging (MRI) of the brain and pituitary gland in children who have central hypothyroidism to rule out problems in the brain.
• Once-daily administration and close follow-up with your endocrinologist is needed to ensure the best possible results.
• Liquid formulations are available commercially for children of any age, but there is limited experience with the use of these formulations in the treatment of congenital hypothyroidism.
• If not treated, thyroid function should be monitored every 6 to 12 months for a period of time to make sure function does not worsen.
• The spoon, dropper, or syringe should be “washed through” with more liquid 2 more times until all the thyroid hormone has been given.

To date, there is limited experience with these liquid formulations in congenital hypothyroidism, and it is unclear whether dosing is the same as for crushed tablets. If levothyroxinemust be given intravenously, 75% of the oral dose should be used. Although T3 is the biologically active thyroid hormone, levothyroxine (T4) is usually given as monotherapy and it is not necessary to use T3 because the majority of brain T3 arises through enzyme conversion of T4 to T3. In children and adolescents with suspected hypothyroidism (elevated TSH and low T4/free T4), thyroid antibody titers (to thyroid peroxidase and thyroglobulin) should be measured to evaluate for autoimmune thyroiditis.

Treatment of Hypothyroidism in Infants and Children

The rare side effects of thyroid hormone medication are related to overdose, or too much medication, and can include rapid heart rate, sweating, anxiety, and tremors. If your child experiences these signs and symptoms, you should contact the physician who prescribed the medication for your child. A child will not have these problems if the thyroid hormone dose prescribed is only slightly more than is needed. Worldwide, the most common cause of hypothyroidism is iodine deficiency, but this cause is rare in the United States.

At first, newborns who have hypothyroidism that is caused by a problem with their thyroid gland usually have few if any symptoms because some thyroid hormone from the mother crosses the placenta. Once newborns no longer receive thyroid hormone from their mother, symptoms develop slowly and the disorder is detected only when they undergo newborn screening tests. Most children who have congenital hypothyroidism usually need to take thyroid hormone replacement for life. However, some children who have congenital hypothyroidism, usually those who have not required a dose increase after infancy, may be able to stop treatment after they are about 3 years of age. In congenital hypothyroidism,treatment with levothyroxine orally once a day must be started immediately and be closely monitored.

Symptoms of Hypothyroidism in Infants and Children

The spoon, dropper, or syringe should be “washed through” with more liquid 2 more times until all the thyroid hormone has been given. Making a mixture of crushed tablets and water or formula for storage is not recommended because this preparation is not stable. Some pharmacies will prepare a compounded suspension of levothyroxine, but it is only guaranteed to be stable for a month and it is more expensive. Other less common causes of acquired hypothyroidism include radiation therapy to the head and neck for certain cancers and the use of certain medications (for example, lithium or amiodarone).

However, pregnant women in the United States can develop mild iodine deficiency because theirbodies need more iodine when they are pregnant. Children whose diet is restricted because they have multiple food allergies or who are fed through a tube inserted into a vein (parenteral nutrition) may not eat enough of the proper foods and thus develop iodine deficiency. For both forms of hypothyroidism, the dose is titrated to maintain serum T4 and TSH levels within the normal range for age.

• Treatment of hypothyroidism is directed by a doctor who specializes in treating children with problems of the endocrine system (called a pediatric endocrinologist).
• Most children who have congenital hypothyroidism usually need to take thyroid hormone replacement for life.
• About 50% of affected children have a family history of autoimmune thyroid disease.
• Most children with hypothyroidism who properly take their medications achieve normal growth and development.

Older children and adolescents

For those who have an illness, thyroid function becomes normal once the illness goes away. Routine newborn screening detects hypothyroidism before clinical signs are evident (1). If screening is positive, confirmation is necessary with thyroid function tests, including measurement of free serum thyroxine (free T4) and thyroid-stimulating hormone (TSH) (2). Free T4 is a better measure of thyroid function than total T4 in these patients because the levels of thyroid-binding proteins (thyroid-binding globulin, transthyretin, and albumin) affect total T4 levels. It is particularly important to measure free T4 rather than total T4 in preterm or low birthweight infants in whom alterations in binding proteins lead to low total T4 levels despite normal free T4 levels.

Symptoms that do occur may be subtle or develop slowly because some maternal thyroid hormone crosses the placenta. Rarely, delayed diagnosis and treatment of severe hypothyroidism lead to intellectual disability and short stature. Permanent hypothyroidism is also the goal of therapy for patients undergoing definitive therapy for Graves disease (see treatment of hyperthyroidism in infants and children) or thyroid cancer. Rarely in the United States but commonly in countries where iodine is not routinely added to table salt, hypothyroidism results from maternal iodine deficiency. Rarely, transplacental transfer of antibodies, goitrogens (eg, amiodarone), or antithyroid medications (eg, propylthiouracil, methimazole) causes transient hypothyroidism.

Is it OK To Switch Between Brands of Thyroid Hormone Medication?

If the screening is positive, tests to determine levels of thyroid hormones in the blood (thyroid function tests) are done to confirm the diagnosis of hypothyroidism. If confirmed, newborns must be treated quickly to prevent developmental delays. In another rare cause, the pituitary synthroid nails gland is abnormally formed and fails to stimulate the thyroid gland to produce thyroid hormones. This pattern of thyroid abnormality also can develop in children who take certain medications (such as antiseizure medications and medications that help the body recognize and attack cancer cells) or who have certain illnesses.

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