Failure to thrive and Hyperthyroidism

Question 1

What is failure to thrive?

Answer 1

Failure to thrive – current weight or rate of weight gain is below expected. Crossing 2 major growth centiles.

Question 2

What is the functional aetiology of failure to thrive?

Answer 2

· Nutritional neglect: no understing of feeding techniques.

· Emotional negelct: stimulus deprivation

· Abuse: physical or psychological

· Psychiatric: AN, depression

Question 3

What is the organic aetiology of failure to thrive?

Answer 3

· 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

Question 4

What is the epidemiology of failure to thrive?

Answer 4

6w/1y prevalence 5%.

Question 5

What would you find in the history of a child with failure to thrive?

Answer 5

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.

Question 6

What would you find in the examination of a child with failure to thrive?

Answer 6

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.

Question 7

What investigations would you do for a child with failure to thrive?

Answer 7

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)

Question 8

What is the management of a child with failure to thrive?

Answer 8

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.

Question 9

What are the complications and prognosis of failure to thrive?

Answer 9

Developmental delay, growth retardation, low milestones, psychological implications, family stress.

Depends on duraiton before treatment.

Question 10

What is hyperthyroidism?

Answer 10

Depends on duraiton before treatment.

Question 11

What is subclinical hyperthyroidism?

Answer 11

Subclinical hyperthyroidism -> normal T3/4 and low TSH

Question 12

Which condition makes up 80% of hyperthyroidism?

Answer 12

Graves disease is 80% of hyperthyroidism. More common in females than males (1% vs 0.1%)

Question 13

What is the aetiology of hyperthyroidism?

Answer 13

· Graves disease: IgG to thyroid TSH receptors which stimulates smooth hyperplasia, hypersecretion of T3/4 and increased sensitivity.

· Toxic multinodular goiter

· Toxic adenoma

Question 14

What is the aetiology of thyroiditis?

Answer 14

· De Quervains

· Post partum

Question 15

What are the rare causes of high T3/4?

Answer 15

Rare causes: TSH secreting pituitary tumors, drugs (amoidarone or doping), choriocarcinoma (tumor secretin hCG which is structurally similar to TSH).

Question 16

What would you find in the history of a child with hyperthyroidism?

Answer 16

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

Question 17

What are the systemic signs of hyperthyroidism?

Answer 17

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

Question 18

What signs are specific to graves disease?

Answer 18

clubbing, opthalmopathy (see above) and pretibial myxedema.

Question 19

What signs are specific to thyroid crisis?

Answer 19

hyperpyrexia, signs of dehydration, tachycardia, restlessness, coma.
AF

Question 20

What are the levels of hyperthyroidism?

Answer 20

· I hyperparathyroidism has high T3/4 and low TSH

· II hyperparathyroidism has high T3/4 and high / normal TSH

Question 21

How would a T99 scan differ with different thyroid diseases?

Answer 21

· 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

Question 22

When would you use TSHr Ab testing?

Answer 22

Expensive test. Only positive in Grave’ disease. Often not required as diagnosis can be made from the above tests.

Question 23

When would you do CT/ MRI of orbits?

Answer 23

often used in follow up of patients with Graves’ opthalmopathy.

Question 24

What is the management of acute thyroiditis?

Answer 24

· 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

Question 25

What is the medical treatment of hyperthyroidism?

Answer 25

· 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

Question 26

How would you use radiotherapy in hyperthyroidism?

Answer 26

· Radioactive iodide used. I135

· Must avoid pregnancy for 4 months and contact with pregnant women for 2 weeks

Question 27

When is surgery indicated in hyperthyroidism?

Answer 27

· 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

Question 28

What are the complications of hyperthyroidism?

Answer 28

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

Question 29

What is the prognosis of hyperthyroidism?

Answer 29

Most patients eventually become hypothyroid.