Treatment Approaches for Children

Based on what is now known about the risks and benefits of different treatments and the pathogenesis of Graves' disease, we can now be more selective in our approach to therapy. To reduce treatment risks and expedite cures, the treatment of the child or adolescent with Graves' disease can be guided by the patient's age and the nature of the intrinsic autoimmune disease.

For children less than 5 years of age, we consider antithyroid medications as a first line therapy. Although radioactive iodine has also been successfully used in this age group without an apparent increase in cancer rates, it may be best to defer radioactive iodine therapy because of the possible increased risks of thyroid cancer after radiation exposure in very young children in the event that any thyroid tissue remains after radioactive iodine therapy.

Because young children are less likely to have remission than older children on drug treatment [15, 16], prolonged drug therapy may be needed. If there are no toxic effects, continuing antithyroid drugs is reasonable until the child is considered old enough for radioactive iodine therapy. Alternatively, thyroidec-tomy or ablative radioactive iodine therapy can be considered if reactions to medications develop or there is the desire to avoid prolonged drug use.

Fortunately, less than 5% of children with Graves' disease present at 5 years of age or younger [8].

Fifteen percent of children with Graves' disease will present between 6 and 10 years of age [8]. Considering drug therapy as a first-line measure for this age group is reasonable. Yet, as 10 years of age are approached, either radioactive iodine or drug therapy can be considered as initial therapy, as the risks of thyroid cancer in remaining irradiated thyroid tissue is expected to be less at 10 than at 5 years and there will be lower whole-body radionuclide exposure at 10 than at 5 years.

Children 10 years of age and older account for 80% of the pediatric cases of Graves' disease. For this age group, radioactive iodine or antithyroid drugs can be considered as first-line treatment options. In determining if drug therapy is likely to be successful, TRAb levels and thyroid size may be predictive of remission rates. The presence of low TRAb levels and a small thyroid suggests the possibility of remission on medical therapy. Yet, if TRAb levels are high and the thyroid is large, the odds of spontaneous remission are low [119, 121, 123]. However, TRAb levels and thyroid size may not always be indicative of remission likelihood.

The critical issue about drug therapy is whether a lasting cure can be achieved after using medications to palliate the hyperthyroid state. Thus, for patients with normal TRAb levels and a small thyroid size, it seems reasonable for to treat for 6-12 months and stop the drug when a clinical remission has been achieved. If a relapse occurs, medical treatment can be resumed or an alternative form of therapy chosen. For patients with elevated TRAb levels and a large thyroid, it is much less likely that remission will occurs after short-term or long-term medical therapy, and consideration should be given to definitive treatment after euthyroidism is achieved.

When radioactive iodine is used, it is important that higher doses of 131I be used in children. The goal of radioactive iodine therapy in children should be to ablate thyroid gland and achieve hypothyroidism. If no thyroid tissue remains, the risk of thyroid cancer will be very small if present at all. To achieve this goal we now use doses of 131I of 250-300 |xCi/g thyroid tissue.

Finally, irrespective of the treatment option selected, careful follow-up is needed for all patients treated for Graves' disease. Long-term follow-up should include regular examination of the thyroid gland and measurement of circulating levels of thyroid hormones once or twice a year. All newly appearing thyroid nodules should be biopsied or excised.

Choosing a treatment approach for childhood Graves' disease is often a difficult and highly personal decision. Discussion of the advantages and risks of each therapeutic option by the physician is essential to help the patient and family select a treatment option (table 2).

Table 2. Graves' disease treatments
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