Approach to the diagnosis and treatment of neonatal hypothyroidism

Congenital hypothyroidism, occurring in 1:3000 newborns, is one of the most common preventable causes of mental retardation. Neurodevelopmental outcome is inversely related to the age of diagnosis and treatment. Infants detected through newborn screening programs and started on L-T ₄ in the first few weeks of life have a normal or near-normal neurodevelopmental outcome.Therecommendedstarting dose of L-T ₄ (10-15 μg/kg · d) is higher on a weight basis than the dose for children and adults. Tailoring the starting L-T ₄ dose to the severity of the hypothyroidism will normalize serum T ₄ and TSH as rapidly as possible. It is important to obtain confirmatory serum thyroid function tests before treatment is started. Further diagnostic studies, such as radionuclide uptake and scan and ultrasonography, may be performed to determine the underlying cause of hypothyroidism. Because results from these tests generally do not alter the initial treatment decision, however, these diagnostic studies are rarely indicated. The developing brain has a critical dependence on thyroid hormone for the first 2-3 yr of life; thus, monitoring occurs at more frequent intervals than in older children and adults. Serum free T ₄ and TSH should be checked at intervals frequent enough to ensure timely adjustment of L-T ₄ dosing and to keep serum free T4 and TSH levels in target ranges. Given the success of early detection and treatment of neonates with congenital hypothyroidism, a public health mandate should be to develop similar programs for the 75% of babies worldwide who are born in areas without newborn screening programs.