Failure to thrive and Hyperthyroidism Flashcards
What is failure to thrive?
Failure to thrive – current weight or rate of weight gain is below expected. Crossing 2 major growth centiles.
What is the functional aetiology of failure to thrive?
· Nutritional neglect: no understing of feeding techniques.
· Emotional negelct: stimulus deprivation
· Abuse: physical or psychological
· Psychiatric: AN, depression
What is the organic aetiology of failure to thrive?
· Feeding difficulties: mechanical (cleft) neurological (palsy)
· Poor retention (GORD, eosinophilic oesophagitis
· Poor absorption of food: coelaic, IBD, CF
· Poor metabolism: metabolic issues (hypothyroid, Ghdef), inborn errors of metabolism (AA/Gluc)
· Metabolism: CHD, CF
· Chronic disease: anaemia, UTIs, CRF, HIV
· Chromosomal: Downs, Turners
What is the epidemiology of failure to thrive?
6w/1y prevalence 5%.
What would you find in the history of a child with failure to thrive?
General: antenatal history, birth hx, post natal, family hx of disease. BW, complications.
Feeding hx: how, how long, how much, regurgitation, choking, stools, mucu, blood in stools.
Social hx: maternal illness, depression, who looks afte child, neglact or abuse.
What would you find in the examination of a child with failure to thrive?
General: observe movement and interactions. Measure ht, wt, hcirc, plot on growth chart.
Assess % BW loss, look a tmuscle wasting and loss (coeliac). Developmental assessment, milestones, school.
What investigations would you do for a child with failure to thrive?
Bloods: Hb, TFT, UE, ESR, CRP, coeliac screen.
Specific tests may be indicated if organic cause suspected (i.e. sewat test in CF, USS renal tract)
What is the management of a child with failure to thrive?
Nutritional cause: improve nutrition, dietician input. Funcitonal cause: MDt approach required depending on cause, educate, psychology. Organic cause: treat. Hospitalisation may be required if high degree of weight loss.
What are the complications and prognosis of failure to thrive?
Developmental delay, growth retardation, low milestones, psychological implications, family stress.
Depends on duraiton before treatment.
What is hyperthyroidism?
Depends on duraiton before treatment.
What is subclinical hyperthyroidism?
Subclinical hyperthyroidism -> normal T3/4 and low TSH
Which condition makes up 80% of hyperthyroidism?
Graves disease is 80% of hyperthyroidism. More common in females than males (1% vs 0.1%)
What is the aetiology of hyperthyroidism?
· Graves disease: IgG to thyroid TSH receptors which stimulates smooth hyperplasia, hypersecretion of T3/4 and increased sensitivity.
· Toxic multinodular goiter
· Toxic adenoma
What is the aetiology of thyroiditis?
· De Quervains
· Post partum
What are the rare causes of high T3/4?
Rare causes: TSH secreting pituitary tumors, drugs (amoidarone or doping), choriocarcinoma (tumor secretin hCG which is structurally similar to TSH).
What would you find in the history of a child with hyperthyroidism?
Heat intolerance, palpitations, sweating, flushing, weight loss, anxiety, insomnia, menstrual abnormalities, decreased libido, exertional dyspnea.
Graves exopthalmus: blurred vision, double vision, eye protrusion
De quervains thyroiditis will have a history of infection
What are the systemic signs of hyperthyroidism?
General: underweight, restless, may have signs of associated AIDs.
Hands: tremor, sweaty, palmary erythema, oncholysis
Thyriod: bruit, goiter
Eyes: lid retraction and lid lag, Graves’ opthalmopathy (periorbital odema, proptosis, conjunctival odema, increased tears, opthalmoplegia and optic nerve atrophy
Neurological: proximal muscle weakness, hyperreflexia
What signs are specific to graves disease?
clubbing, opthalmopathy (see above) and pretibial myxedema.
What signs are specific to thyroid crisis?
hyperpyrexia, signs of dehydration, tachycardia, restlessness, coma.
AF
What are the levels of hyperthyroidism?
· I hyperparathyroidism has high T3/4 and low TSH
· II hyperparathyroidism has high T3/4 and high / normal TSH
How would a T99 scan differ with different thyroid diseases?
· Graves disease: diffuse increased uptake
· Toxic multinodular goiter: multiple areas of increased uptake
· Toxic adenoma: single area of uptake with suppression of uptake in the rest of the gland
· Thyroiditis: no uptake
When would you use TSHr Ab testing?
Expensive test. Only positive in Grave’ disease. Often not required as diagnosis can be made from the above tests.
When would you do CT/ MRI of orbits?
often used in follow up of patients with Graves’ opthalmopathy.
What is the management of acute thyroiditis?
· Propylthiouracis PTU
· IV hydrocortisone (blocks T3 -? 4 peripherally)
· Propranolol (B blocker)
· KI (too much iodine blocks its use in thyroid)
· Rehydrate and stabilize, treat the underlying cause
What is the medical treatment of hyperthyroidism?
· Antithyroid drugs: PTU or carbimazole (both inhibit TPO)
· Propranolol
· ATD can sometimes cause agranulocytosis, Therefore patients on this must be wary of fevers. In case of fever STOP ATD and contact doctor
How would you use radiotherapy in hyperthyroidism?
· Radioactive iodide used. I135
· Must avoid pregnancy for 4 months and contact with pregnant women for 2 weeks
When is surgery indicated in hyperthyroidism?
· Reserved for patients who have distruption to airway or oesophagus due to severe enlargement of goiter, those who are pregnant, those who have bad Graves opthalmopathy, or those who develop agranulocytosis post ATD
· Preoperative preparation includes control of hyperthyroidism with ATD, KI and propranolol.
· Vocal cords must be examined by ENT specialists.
Treatment for opthalmopathy includes corneal protection with drops, and surgery for realignment
What are the complications of hyperthyroidism?
Thyrotoxic crisis. Heart failure. Osteoporosis. Infertility.
Complicaitons of surgery (ie. Vocal cord damage, RLN damage).
Side effects of radiation (ie. Malignancy)
Subclinical thyrotoxicosis patients have increased risk of AF and osteoporosis
What is the prognosis of hyperthyroidism?
Most patients eventually become hypothyroid.
