Indian Academy of Pediatrics (IAP)

STANDARD
TREATMENT
GUIDELINES 2022

Hypothyroidism
Under the Auspices of the
IAP Action Plan 2022
Remesh Kumar R
IAP President 2022
Upendra Kinjawadekar Lead Author
IAP President-Elect 2022 Ahila Ayyavoo
Piyush Gupta Co-Authors
IAP President 2021
Ravindra Kumar, Tushar Godbole
Vineet Saxena
IAP HSG 2022–2023
© Indian Academy of Pediatrics

IAP Standard Treatment Guidelines Committee

Chairperson
Remesh Kumar R
IAP Coordinator
Vineet Saxena
National Coordinators
SS Kamath, Vinod H Ratageri
Member Secretaries
Krishna Mohan R, Vishnu Mohan PT
Members
Santanu Deb, Surender Singh Bisht, Prashant Kariya,
Narmada Ashok, Pawan Kalyan
 112
Hypothyroidism

;; Congenital hypothyroidism (CH) is the most common cause of preventable mental

Introduction

retardation.
;; Incidence of CH is more common in India than in west = 1:1,000 to 1:1,500 live births.
Early detection and treatment of CH through neonatal screening prevent irreversible
neurodevelopmental delay and optimize developmental outcome.
Congenital Hypothyroidism

Screening for Congenital Hypothyroidism

;; Either cord blood or postnatal sample at 48–72 hours should be collected for
screening.
;; Strategy of second screening may be required in the following conditions: Preterm
neonates (<37 weeks); low birth weight (LBW) and very low birth weight (VLBW)
neonates; ill and preterm neonates admitted to neonatal intensive care unit
(NICU); specimen collection within the first ½–24 hours of life; and multiple births,
particularly in cases of same-sex twins. The repeat specimen should be collected
after 2 weeks of age, or 2 weeks after the first screening test was carried out.
;; Primary thyroid-stimulating hormone (TSH) screen is more sensitive and specific
for the diagnosis of primary CH compared to T4 screen. Primary TSH screening
may fail to detect central CH (incidence is 1: 16,000 to 1: 30,000 live births).
;; The TSH measured from a dried blood spot (DBS) is expressed in whole blood
units while the venous TSH is expressed in serum units. (2.2 × whole blood units
= Serum units).

;; Imaging (ultrasound and scintigraphy) should be done after CH is biochemically confirmed.

Imaging

Scintigraphy can be done up to 7 days after start of levothyroxine (if TSH is high).
;; A thorough physical examination should be carried out in all neonates with high
TSH concentrations for the detection of congenital malformations, particularly those
affecting the heart.
 Hypothyroidism

Treatment with thyroxine should be started as soon as possible, and no later than the

Treatment
first 2 weeks of life. Initial thyroxine dose is 10–15 μg/kg/day. In dyshormonogenetic
CH, treatment can be stopped for 4 weeks at 3 years of age to reassess whether it
is transient or permanent CH. Structural thyroid abnormalities causing CH require
lifelong thyroxine replacement.

;; Follow-up T4/FT4 after 2 weeks and T4/FT4 and TSH after 4 weeks. Target T4/FT4
should reach the upper half of reference range by 2 weeks and TSH should reach
Follow-up

lower half of reference range by 4 weeks.

;; Thyroid function test (TFT) for follow-up: 1–2 monthly until 6 month and 2–4 monthly
from 6 to 36 months; further thyroxine doses are adjusted based on TFT.
;; Repeat hearing test should be carried out before school age and as required.
Congenital Hypothyroidism

Flowchart 1: Congenital hypothyroidism.

(DBS: dried blood spot; FT4: free T4; TSH: thyroid-stimulating hormone; TT4: total T4)
4
 Hypothyroidism

Clinical features that would raise possibility of acquired hypothyroidism (AH) are as follows
Short stature Pseudo-precocious puberty
Poor growth velocity Macroorchidism
Goiter Weight gain (edema)
Dry skin Calf muscle hypertrophy
Constipation Galactorrhea
Sluggishness Cardiomyopathy/effusions

Acquired Hypothyroidism
Common causes of AH are as follows

;; Autoimmune (Hashimoto’s) thyroiditis

;; Drugs: Anticonvulsants, amiodarone, lithium, chemotherapy, and radiotherapy
;; Iodine deficiency
;; Central hypothyroidism: Trauma, tumor, and tuberculosis
;; Miscellaneous: Post-ablative, post-thyroidectomy, etc.

Flowchart 2: Approach to acquired hypothyroidism.

(FT4: free T4; TBG: thyroxine-binding globulin; TFT: thyroid function test;
TPO: thyroid peroxidase; TSH: thyroid-stimulating hormone)

5
 Hypothyroidism

;; Clinical features
;; Biochemistry
Diagnosis
Acquired Hypothyroidism

;; Essential = TSH + total T4/free T4; optional = antithyroid peroxidase/antithyroglobulin

antibody titers
;; Imaging: Ultrasound (if necessary) for primary hypothyroidism and MRI brain for
central hypothyroidism

Oral levothyroxine dose can be started based on weight of the child or body surface
area (BSA) and should be continued lifelong.
100 µg/m2 BSA (OR)
;; Age 1–3 years: 4–6 µg/kg body weight

Treatment
;; Age 3–10 years: 3–5 µg/kg
;; Age 10–16 years: 2–4 µg/kg
Further dose adjustments are adjusted to maintain TSH and total T4/FT4 in range.
Caveat: For long-standing full-blown untreated hypothyroidism, thyroxine should be
started at a lower dose and gradually stepped up over several weeks to reach full
dosing.

;; Desai MP, Sharma R, Riaz I, Sudhanshu S, Parikh R, Bhatia V. Newborn Screening Guidelines for
Congenital Hypothyroidism in India: Recommendations of the Indian Society for Pediatric and
Adolescent Endocrinology (ISPAE)—Part I: Screening and Confirmation of Diagnosis. Indian J Pediatr.

Further Reading
2018;85(6):440-7.
;; Rivkees S, Bauer AJ. Thyroid disorders in children and adolescents. In: Sperling MA, Majzoub JA, Menon
RK, Stratakis Ca (Eds). Sperling Pediatric Endocrinology, 5th edition. Philadelphia: Saunders; 2021. pp.
395-416.
;; Sudhanshu S, Riaz I, Sharma R, Desai MP, Parikh R, Bhatia V. Newborn Screening Guidelines for Congenital
Hypothyroidism in India: Recommendations of the Indian Society for Pediatric and Adolescent
Endocrinology (ISPAE)—Part II: Imaging, Treatment and Follow-up. Indian J Pediatr. 2018;85(6):448-53.
;; van Trotsenburg P, Stoupa A, Léger J, Rohrer T, Peters C, Fugazzola L, et al. Congenital Hypothyroidism: A
2020–2021 Consensus Guidelines Update—An ENDO-European Reference Network Initiative Endorsed
by the European Society for Pediatric Endocrinology and the European Society for Endocrinology.
Thyroid. 2021;31:387-419.

6 Please mail your valuable feedback’s at feedbacks.stg@gmail.com