Scientific Letter
Proposed guidelines in the neonatal screening for congenital hypothyroidism in large premature newborns
Propuesta de pauta en el cribado neonatal de hipotiroidismo congénito en grandes prematuros
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array:1 [ 0 => array:4 [ "autoresLista" => "Raquel Yahyaoui, Rocío Jiménez-Machado, Juan Pedro López Siguero" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Raquel" "apellidos" => "Yahyaoui" "email" => array:1 [ 0 => "raquelyahyaoui@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Rocío" "apellidos" => "Jiménez-Machado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Juan Pedro" "apellidos" => "López Siguero" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Laboratorio de Metabolopatías, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sección de Endocrinología Pediátrica, Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Propuesta de pauta en el cribado neonatal de hipotiroidismo congénito en grandes prematuros" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Congenital hypothyroidism (CH) is the most frequent preventable cause of intellectual disability in children. Early diagnosis and treatment of this disease prevent neurodevelopmental impairment. In recent years, there has been an increase the prevalence of CH, probably due to the increased survival of preterm infants.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The diagnosis of CH starts with the detection of elevation of thyroid stimulating hormone (TSH) during neonatal screening, conducted 24–72<span class="elsevierStyleHsp" style=""></span>h post birth, followed by imaging tests to determine the aetiology of this abnormality—thyroid scintigraphy (Tc<span class="elsevierStyleSup">99</span> and I<span class="elsevierStyleSup">123</span>) and, in some cases, a cervical ultrasound scan.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In very small or very preterm newborns (weight<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>1500<span class="elsevierStyleHsp" style=""></span>g or gestational age<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>32 weeks), delayed elevation of TSH is common, and thus CH cannot be detected in the first 48<span class="elsevierStyleHsp" style=""></span>h post birth. Therefore, it is recommended that the screening be repeated in subsequent weeks in these patients, for which there is currently no standardised protocol in Spain. The European consensus guidelines recommend a second screening at 2 weeks post birth in preterm and very low birthweight newborns.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> This protocol has been applied in Andalusia since 2011, with the addition of a third screening in very preterm newborns at the time of hospital discharge.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We present 3 clinical cases that were very similar (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). All of them concerned very preterm newborns that had normal levels of TSH in the neonatal screenings performed at 48<span class="elsevierStyleHsp" style=""></span>h and 2 weeks post birth. Detection of elevated TSH and, consequently, initiation of replacement therapy occurred between 60 and 90 days post birth (at the time of discharge). In every case, the level of free thyroxine (T<span class="elsevierStyleInf">4</span>) was far below normal. The antithyroid antibodies test was negative, and in 2 cases a thyroid scan with Tc<span class="elsevierStyleSup">99</span> revealed a thyroid gland in situ.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The neonatal records did not document the administration of iodine or any other drugs that may have interfered with the level of TSH or its measurement.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Although given the time elapsed since birth we were unable to analyse the persistence of hypothyroidism, the diagnosis was delayed in all 3 cases and there is a possibility of future neurodevelopmental impairment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The approximate prevalence of CH is of 1 per 2240 births, with delayed elevation of TSH in 1 out of 295 cases in preterm newborns (1000–1500<span class="elsevierStyleHsp" style=""></span>g) and in 1 out of 58 cases in newborns with birth weights of less than 1000<span class="elsevierStyleHsp" style=""></span>g.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In preterm infants, CH has a multifactorial aetiology that involves the immaturity of the hypothalamic-pituitary-thyroid axis, a reduced synthesis of thyroxine-binding globulin by the liver, non-thyroid diseases associated with complications commonly found in preterm infants (respiratory distress, intraventricular haemorrhage and necrotising enterocolitis), drugs that suppress the production of TSH (dopamine and corticosteroids) and low iodine intake.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">There is evidence that the delayed elevation of TSH occurs between weeks 2 and 6 post birth<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> and that the delay is associated with low birth weight, small size for gestational age and/or multiple gestation, a 5-min Apgar score of less than 5 and duration of positive-pressure ventilation.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Given the evidence on the delayed elevation of TSH in preterm infants, the authors of some studies have already recommended repetition of neonatal screening. Thus, Woo et al. reported performing the initial screening between days 2 and 5 post birth and repeating it in weeks 2, 6 and 10 or once the infant reaches a weight of 1500<span class="elsevierStyleHsp" style=""></span>g.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> They also recommend repeating the screening in infants weighing more than 1500<span class="elsevierStyleHsp" style=""></span>g if they remain critically ill. At present, there is no agreement on whether low thyroid hormone levels may have an impact on morbidity and mortality in preterm infants with transient hypothyroxinaemia.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The recommendations of the Working Group on the Thyroid of the Sociedad Española de Endocrinología Pediátrica (Spanish Society of Paediatric Endocrinology, <a href="http://www.seep.es/">www.seep.es</a>), published in 2015, stipulate that in newborns weighing less than 1500<span class="elsevierStyleHsp" style=""></span>g, in addition to neonatal screening, the serum level of TSH should be measured at 15 days post birth and at discharge. However, as demonstrated by the cases presented here, this may not be sufficient, especially if the hospitalisation is prolonged.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In light of all of the above, we propose performance of at least 4 measurements of serum TSH levels in preterm newborns with birth weights of less than 1500<span class="elsevierStyleHsp" style=""></span>g for detection of CH: at 24–72<span class="elsevierStyleHsp" style=""></span>h, at 15 days and at 6 weeks post birth, and once the infant reaches a weight of 1500<span class="elsevierStyleHsp" style=""></span>g. In our opinion, it would be optimal to implement this schedule of tests in the framework of neonatal screening programmes.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Yahyaoui R, Jiménez-Machado R, López Siguero JP. Propuesta de pauta en el cribado neonatal de hipotiroidismo congénito en grandes prematuros. Arch Bronconeumol. 2020;92:46–47.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BW, birth weight; F, female; GA, gestational age; M, male; NA, not available; TGIS, thyroid gland in situ; TSH, thyroid stimulating hormone; T<span class="elsevierStyleInf">4</span>, thyroxine.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Case/sex \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1/F \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2/M \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3/M \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GA (weeks) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BW (g) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">580 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">840 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1150 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TSH-48<span class="elsevierStyleHsp" style=""></span>h (mIU/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TSH-15 days (mIU/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TSH-discharge (mIU/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">487 (90 days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">234 (60 days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91.1 (67 days) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Free T<span class="elsevierStyleInf">4</span> (ng/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.31 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thyroid scintigraphy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TGIS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TGIS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2240078.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical and laboratory data of very preterm newborns with a discharge diagnosis of congenital hypothyroidism detected by neonatal screening.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Increased congenital hypothyroidism detection in preterm infants with serial newborn screening" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D.C. 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| Year/Month | Html | Total | |
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| 2020 July | 94 | 31 | 125 |
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