When we think of thyroid problems, we often picture adults.

But did you know that children and teenagers can also have thyroid disorders?

One such condition is hyperthyroidism, with the most common cause in children being a condition called Graves’ disease.

More common in girls

The thyroid is a small, butterfly-shaped gland located in the neck.

It produces hormones that regulate the body’s metabolism, i.e. how we use energy.

When the thyroid becomes overactive and makes too much of these hormones, it’s called hyperthyroidsism.

Although not so common in children, hyperthyroidism does occur.

It affects about one in every 5,000 children, with the teenage years – especially among girls – being the most commonly affected age group. 

Graves’ disease accounts for over 95% of hyperthyroidism cases in children.

It is an autoimmune disorder, meaning that the body’s own immune system mistakenly attacks the thyroid gland.

This causes the gland to enlarge and produce too much thyroid hormone, leading to the symptoms of hyperthyroidism.

We don’t always know why this happens, but Graves’ disease tends to run in families and is more common in girls than boys.

Meet Aisha

Aisha is a 13-year-old girl with a typical presentation of severe hyperthyroidism.

For several months, she had been experiencing a gradual weight loss despite eating well – in fact, she was always hungry.

Her parents noticed that she had become unusually restless, struggled to sleep, and that her hands were shaky.

She was sweating more than usual and had started having trouble focusing in school.

Her teachers thought she was anxious, and some wondered if she was going through “teen mood swings”.

Then one evening, Aisha developed severe palpitations – her heart was racing, she was short of breath, and she looked flushed and distressed.

Her parents rushed her to the hospital emergency room.

There, she was found to have a dangerously fast heart rate, high fever and confusion.

The doctors quickly recognised this as a thyroid storm.

This is a rare, but life-threatening complication of severe hyperthyroidism.

She was admitted to the intensive care unit (ICU) and started on medications to slow down her heart and block the excess thyroid hormone.

She was referred to a paediatric endocrinologist, where she was diagnosed with Graves’ disease.

Symptoms and diagnosis

Hyperthyroidism in children can look different from adults.

Here are some common symptoms parents and healthcare professionals should watch out for:

• Unexplained weight loss despite normal or increased appetite
• Feeling hot or sweating more than usual
• Tremors or shakiness of the hands
• Trouble sleeping or feeling constantly restless
• Palpitations (fast or irregular heartbeat)
• Irritability, mood swings or difficulty concentrating
• Bulging eyes (in some cases of Graves’ disease)
• Enlarged thyroid gland (a goiter) in the neck.

Not every child will have all these signs, and sometimes, the changes are subtle.

That’s why awareness is so important.

Diagnosis is done through blood tests that measure levels of thyroid hormones (free T3 and T4) and TSH (thyroid-stimulating hormone).

The diagnosis of hyperthyroidism is confirmed by high levels of thyroid hormones with a suppressed (low) TSH.

In Graves’ disease, thyroid receptor stimulating antibodies (TSH-receptor antibodies) – the antibodies that cause the overactivity – will be present.

Sometimes, other thyroid antibodies, or a thyroid scan or ultrasound, may be needed to rule out other causes.

Treatment and management

Treating Graves’ disease in children involves reducing the production or effect of thyroid hormones.

These include:

The most common first-line treatment involves daily anti-thyroid drugs (carbimazole or methimazole) that block hormone production.

Treatment is often needed for at least a few years, as stopping too early often results in a relapse of the condition.

Carbimazole or methimazole is usually safe and effective, although they require regular blood monitoring.

After initial stabilisation, the lowest effective dose should be used to avoid over- and undertreatment.

Serious side effects are rare, but include agranulocytosis (a dangerous drop in white blood cells) and liver dysfunction.

Patients should report symptoms like sore throat, fever or jaundice immediately.

Other thyroid drugs such as propylthiouracil (PTU), are generally not recommended for children due to potential liver toxicity.

This is more commonly used in older teens and adults than younger children.

It destroys overactive thyroid tissue and renders the patient hypothyroid, requiring them to go on thyroid hormone replacement after RAI.

Hypothyroidism is more stable and relatively easier to treat compared to hyperthyroidism, which is why this is a treatment option for the latter.

In some cases, especially if medications fail or there are complications, surgery of the thyroid gland may be necessary.

Similar to RAI, the patient would then be rendered hypothyroid and need thyroid hormone replacement.

For Aisha, she was started on daily carbimazole pills with regular visits to her paediatric endocrinologist.

Over the next several months, her symptoms gradually improved.

Her appetite stabilised, her weight returned to normal and she started sleeping better.

Her school performance improved and her energy levels were back to normal.

Most importantly, the racing heart and dangerous symptoms of thyroid storm did not return.

What parents should know

Hyperthyroidism is a serious, but treatable condition.

Early recognition and treatment are key to preventing complications like thyroid storm, or growth, bone and development issues.

If your child has any of the symptoms mentioned earlier, especially unexplained weight loss, restlessness or palpitations, don’t hesitate to speak to your paediatrician.

Because hyperthyroidism in children requires specialised care, it’s important to see a paediatric endocrinologist – a doctor trained to manage hormone disorders in children.

Regular monitoring, medication adjustments and support are essential parts of long-term care.

Graves’ disease and hyperthyroidism in children and teenagers are often overlooked, but can significantly affect a child’s health and potentially life-threatening when severe.

Thankfully, with the right diagnosis and treatment, symptoms can be controlled and most children can return to living full, healthy lives – just like Aisha.

Dr Jeanne Wong Sze Lyn is a consultant paediatrician and paediatric endocrinologist. For more information, email starhealth@thestar.com.my. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.