Graves disease in childhood: a review of the options for diagnosis and treatment

Abstract

While diagnosing Graves disease in childhood and adolescence does not usually present specific problems, the treatment of hyperthyroidism is still controversial. In particular, with regard to the use of radioiodine therapy, strategies vary between many European and North American pediatric endocrinology centers. After the diagnosis is made, antithyroid drug treatment with methimazole (thiamazole), carbimazole, or propylthiouracil should be performed with caution, in particular, because of severe adverse effects, such as agranulocytosis or hepatitis, that are found in up to 1% of patients. Antithyroid drug treatment should not be continued long-term, particularly since definitive remission cannot be expected in more than 30-40% of patients. In contrast, the risk of severe adverse effects is still present, and the risk of thyroid carcinoma increases with time and appears to be considerably higher than after radioiodine treatment. To a great extent, the success of surgery depends on the skills of a trained surgeon. The question of whether to perform total or subtotal thyroidectomy is yet to be resolved. Surgery should be considered in patients with a large thyroid gland (>80g), severe ophthalmopathy, and a lack of remission on antithyroid drug treatment. Success rates have increased to up to 97%, while severe adverse effects (laryngeal nerve palsy, hypoparathyroidism) occur in approximately 4% of patients. Mortality is below 0.1%. Radioiodine treatment in children >5 years of age does not appear to be associated with an increased risk of thyroid carcinoma; however, long-term data are lacking. Compared with the surgical approach, success rates are lower, particularly if low doses of radioiodine are used. In general, adverse effects are less prevalent than in patients who have undergone surgery.