Hipotiroidismo subclínico en pediatría: ¿Qué necesita saber el médico?
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Introducción: El hipotiroidismo subclínico en niños se caracteriza por niveles elevados de tirotropina con tiroxina libre normal. Aunque a menudo es transitorio, puede progresar a hipotiroidismo manifiesto y repercutir en el crecimiento, el metabolismo y el riesgo cardiovascular. Objetivo: Revisar los aspectos clínicos y terapéuticos del hipotiroidismo subclínico pediátrico, con especial atención a la indicación de levotiroxina. Método: Revisiones, metaanálisis, guías y estudios originales de las bases de datos PubMed, SciELO y Embase de los últimos 20 años, centrados en pediatría. Resultados: El nivel basal de tirotropina es el principal predictor de progresión. Los casos leves e idiopáticos tienden a la remisión espontánea, sin impacto significativo en el crecimiento ni la cognición. El hipotiroidismo subclínico asociado a tiroiditis de Hashimoto presenta un mayor riesgo de progresión. Los hallazgos cardiovasculares y óseos aún son inciertos. El uso de levotiroxina está indicado cuando la tirotropina es superior a 10 mUI/L. En casos leves (4,5-10 mUI/L), solo se recomienda seguimiento clínico y de laboratorio. Conclusiones: En la mayoría de los casos, el hipotiroidismo subclínico pediátrico tiene una evolución benigna. El tratamiento debe ser individualizado, reservado para situaciones de alto riesgo, priorizando la vigilancia en casos leves.
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1. Crisafulli G, Aversa T, Zirilli G, Pajno GB, Corica D, De Luca F, Wasniewska M. Subclinical hypothyroidism in children: when a replacement hormonal treatment might be advisable. Front Endocrinol [Internet]. 25 fev 2019 [citado 28 ago 2025];10. https://doi.org/10.3389/fendo.2019.00109
2. Bissell MG. Inverse log-linear relationship between thyroid-stimulating hormone and free thyroxine measured by direct analog immunoassay and tandem mass spectrometry. Yearb Pathol Lab Med [Internet]. Jan 2012 [citado 28 ago 2025];2012:288-9. https://doi.org/10.1016/j.ypat.2011.08.009
3. Metwalley KA, Farghaly HS. Subclinical hypothyroidism in children: updates for pediatricians. Ann Pediatr Endocrinol Amp Metab [Internet]. 30 jun 2021 [citado 27 ago 2025];26(2):80-5. https://doi.org/10.6065/apem.2040242.121
4. Salerno M, Capalbo D, Cerbone M, De Luca F. Subclinical hypothyroidism in childhood — current knowledge and open issues. Nat Rev Endocrinol [Internet]. 1 jul 2016 [citado 27 ago 2025];12(12):734-46. https://doi.org/10.1038/nrendo.2016.100
5. Monzani A, Prodam F, Rapa A, Moia S, Agarla V, Bellone S, Bona G. Natural history of subclinical hypothyroidism in children and adolescents and potential effects of replacement therapy: a review. Eur J Endocrinol [Internet]. Jan 2013 [citado 28 ago 2025];168(1):R1—R11. https://doi.org/10.1530/eje-12-0656
6. Gallizzi R, Crisafulli C, Aversa T, Salzano G, De Luca F, Valenzise M, Zirilli G. Subclinical hypothyroidism in children: is it always subclinical? Ital J Pediatr [Internet]. 17 fev 2018 [citado 27 ago 2025];44(1). https://doi.org/10.1186/s13052-018-0462-4
7. Karmisholt J, Andersen S, Laurberg P. Variation in thyroid function in subclinical hypothyroidism: importance of clinical follow-up and therapy. Eur J Endocrinol [Internet]. Mar 2011 [citado 28 ago 2025];164(3):317-23. https://doi.org/10.1530/eje-10-1021
8. Wasniewska M, Corrias A, Aversa T, Valenzise M, Mussa A, De Martino L, Lombardo F, De Luca F, Salerno M. Comparative evaluation of therapy with l-thyroxine versus no treatment in children with idiopathic and mild subclinical hypothyroidism. Horm Res Paediatr [Internet]. 2012 [citado 28 ago 2025];77(6):376-81. https://doi.org/10.1159/000339156
9. Cerbone M, Bravaccio C, Capalbo D, Polizzi M, Wasniewska M, Cioffi D, Improda N, Valenzise M, Bruzzese D, De Luca F, Salerno M. Linear growth and intellectual outcome in children with long-term idiopathic subclinical hypothyroidism. Eur J Endocrinol [Internet]. Abr 2011 [citado 28 ago 2025];164(4):591-7. https://doi.org/10.1530/eje-10-0979
10. Rodondi N, den Elzen WP, Bauer DC, Cappola AR, Razvi S, Walsh JP, Åsvold BO, Iervasi G, Imaizumi M, Collet TH, Bremner A, Maisonneuve P, Sgarbi JA, Khaw KT, Vanderpump MP, Newman AB, Cornuz J, Franklyn JA, Westendorp RG, Vittinghoff E, Gussekloo J, Thyroid Studies Collaboration FT. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. Jama [Internet]. 22 set 2010 [citado 28 ago 2025];304(12):1365. https://doi.org/10.1001/jama.2010.1361
11. Wasniewska M, Aversa T, Salerno M, Corrias A, Messina MF, Mussa A, Capalbo D, De Luca F, Valenzise M. Five-year prospective evaluation of thyroid function in girls with subclinical mild hypothyroidism of different etiology. Eur J Endocrinol [Internet]. Dez 2015 [citado 29 ago 2025];173(6):801-8. https://doi.org/10.1530/eje-15-0484
12. Aversa T, Valenzise M, Corrias A, Salerno M, De Luca F, Mussa A, Rezzuto M, Lombardo F, Wasniewska M. Underlying hashimoto's thyroiditis negatively affects the evolution of subclinical hypothyroidism in children irrespective of other concomitant risk factors. Thyroid [Internet]. Fev 2015 [citado 29 ago 2025];25(2):183-7. https://doi.org/10.1089/thy.2014.0235
13. Lee YJ, Jung SY, Jung HW, Kim SY, Lee YA, Lee SY, Shin CH, Yang SW. Unfavorable course of subclinical hypothyroidism in children with Hashimoto’s thyroiditis compared to those with isolated non-autoimmune hyperthyrotropinemia. J Korean Med Sci [Internet]. 2017 [citado 29 ago 2025];32(1):124. https://doi.org/10.3346/jkms.2017.32.1.124
14. Biondi B, Cappola AR, Cooper DS. Subclinical hypothyroidism. Jama [Internet]. 9 jul 2019 [citado 29 ago 2025];322(2):153. https://doi.org/10.1001/jama.2019.9052
15. Chaudhary V, Bano S. Thyroid ultrasound. Indian J Endocrinol Metab [Internet]. 2013 [citado 29 ago 2025];17(2):219. https://doi.org/10.4103/2230-8210.109667
16. Pittock S. Thyroid nodules [Internet]. Cham: Springer International Publishing; 2017. Thyroid nodules in children; [citado 29 ago 2025]; p. 207-31. https://doi.org/10.1007/978-3-319-59474-3_14
17. Ittermann T, Thamm M, Wallaschofski H, Rettig R, Völzke H. Serum thyroid-stimulating hormone levels are associated with blood pressure in children and adolescents. J Clin Endocrinol Amp Metab [Internet]. 1 mar 2012 [citado 29 ago 2025];97(3):828-34. https://doi.org/10.1210/jc.2011-2768
18. Çatlı G, Kır M, Anık A, Yılmaz N, Böber E, Abacı A. The effect of L-thyroxine treatment on left ventricular functions in children with subclinical hypothyroidism. Arch Dis Child [Internet]. 10 set 2014 [citado 29 ago 2025];100(2):130-7. https://doi.org/10.1136/archdischild-2014-306381
19. Sue LY, Leung AM. Levothyroxine for the treatment of subclinical hypothyroidism and cardiovascular disease. Front Endocrinol [Internet]. 21 out 2020 [citado 29 ago 2025];11. https://doi.org/10.3389/fendo.2020.591588
20. Yao K, Zhao T, Zeng L, Yang J, Liu Y, He Q, Zou X. Non-invasive markers of cardiovascular risk in patients with subclinical hypothyroidism: A systematic review and meta-analysis of 27 case control studies. Sci Rep [Internet]. 15 mar 2018 [citado 29 ago 2025];8(1). https://doi.org/10.1038/s41598-018-22897-3
21. Urgatz B, Razvi S. Subclinical hypothyroidism, outcomes and management guidelines: a narrative review and update of recent literature. Curr Med Res Opin [Internet]. 12 jan 2023 [citado 29 ago 2025]:1-47. https://doi.org/10.1080/03007995.2023.2165811
22. Tacito LH, Pires AC, Yugar-Toledo JC. Impaired flow-mediated dilation response and carotid intima-media thickness in patients with type 1 diabetes mellitus with a mean disease duration of 4.1 years. Arch Endocrinol Metab [Internet]. 13 jul 2017 [citado 29 ago 2025];61(6):542-9. https://doi.org/10.1590/2359-3997000000281
23. Iacobellis G. Epicardial adipose tissue [Internet]. Cham: Springer International Publishing; 2020. Coronary artery disease and epicardial adipose tissue; [citado 29 ago 2025]; p. 77-90. https://doi.org/10.1007/978-3-030-40570-0_8
24. Farghaly HS, Metwalley KA, Raafat DM, Algowhary M, Said GM. Epicardial fat thickness in children with subclinical hypothyroidism and its relationship to subclinical atherosclerosis: a pilot study. Horm Res Paediatr [Internet]. 2019 [citado 29 ago 2025];92(2):99-105. https://doi.org/10.1159/000503287
25. Ahn MB, Suh BK. Bone morbidity in pediatric acute lymphoblastic leukemia. Ann Pediatr Endocrinol Amp Metab [Internet]. 31 mar 2020 [citado 29 ago 2025];25(1):1-9. https://doi.org/10.6065/apem.2020.25.1.1
26. Ko A, Kong J, Samadov F, Mukhamedov A, Kim YM, Lee YJ, Nam SO. Bone health in pediatric patients with neurological disorders. Ann Pediatr Endocrinol Amp Metab [Internet]. 31 mar 2020 [citado 29 ago 2025];25(1):15-23. https://doi.org/10.6065/apem.2020.25.1.15
27. Yang HR. Updates on bone health in children with gastrointestinal diseases. Ann Pediatr Endocrinol Amp Metab [Internet]. 31 mar 2020 [citado 29 ago 2025];25(1):10-4. https://doi.org/10.6065/apem.2020.25.1.10
28. Simm PJ, Biggin A, Zacharin MR, Rodda CP, Tham E, Siafarikas A, Jefferies C, Hofman PL, Jensen DE, Woodhead H, Brown J, Wheeler BJ, Brookes D, Lafferty A, Munns CF. Consensus guidelines on the use of bisphosphonate therapy in children and adolescents. J Paediatr Child Health [Internet]. Mar 2018 [citado 29 ago 2025];54(3):223-33. https://doi.org/10.1111/jpc.13768
29. Lee YA, Kwon A, Kim JH, Nam HK, Yoo JH, Lim JS, Cho SY, Cho WK, Shim KS. Clinical practice guidelines for optimizing bone health in Korean children and adolescents. Ann Pediatr Endocrinol Amp Metab [Internet]. 31 mar 2022 [citado 29 ago 2025];27(1):5-14. https://doi.org/10.6065/apem.2244060.030
30. Tuchendler D, Bolanowski M. The influence of thyroid dysfunction on bone metabolism. Thyroid Res [Internet]. Dez 2014 [citado 29 ago 2025];7(1). https://doi.org/10.1186/s13044-014-0012-0
31. Dhanwal D. Thyroid disorders and bone mineral metabolism. Indian J Endocrinol Metab [Internet]. 2011 [citado 29 ago 2025];15(6):107. https://doi.org/10.4103/2230-8210.83339
32. Bassett JH, Williams GR. Role of Thyroid Hormones in Skeletal Development and Bone Maintenance. Endocr Rev [Internet]. 1 abr 2016 [citado 29 ago 2025];37(2):135-87. https://doi.org/10.1210/er.2015-1106
33. Veldscholte K, Barjaktarovic M, Trajanoska K, Jaddoe VW, Visser TJ, de Rijke YB, Peeters RP, Rivadeneira F, Korevaar TI. The association of thyroid function with bone density during childhood. J Clin Endocrinol Amp Metab [Internet]. 17 jul 2018 [citado 29 ago 2025];103(11):4125-34. https://doi.org/10.1210/jc.2018-00294
34. Deladoëy J, Ruel J, Giguère Y, Van Vliet G. Is the incidence of congenital hypothyroidism really increasing? A 20-year retrospective population-based study in québec. J Clin Endocrinol Amp Metab [Internet]. Ago 2011 [citado 29 ago 2025];96(8):2422-9. https://doi.org/10.1210/jc.2011-1073
35. Buluş AD, Tiftik E. Evaluation of neurodevelopment of children with congenital hypothyroidism by the Denver Developmental Screening Test. J Pediatr Endocrinol Metab [Internet]. 1 jan 2017 [citado 29 ago 2025];30(10). https://doi.org/10.1515/jpem-2016-0188
36. Sociedade Brasileira de Pediatria. Departamento Científico de Endocrinologia. Hipotireoidismo congênito: triagem neonatal. Porto Alegre: SBP; 2018.
37. Demir C, Gökdeniz E, Dilek İ. The effects of iron deficiency anemia on the thyroid functions. J Clin Exp Investig [Internet]. 17 dez 2010 [citado 29 ago 2025];1(3). https://doi.org/10.5799/ahinjs.01.2010.03.0033
38. Benvenga S, Vita R, Di Bari F, Fallahi P, Antonelli A. Do not forget nephrotic syndrome as a cause of increased requirement of levothyroxine replacement therapy. Eur Thyroid J [Internet]. 2015 [citado 29 ago 2025];4(2):138-42. https://doi.org/10.1159/000381310
39. Karlsson FA, Burman P, Öberg K, Karlsson-Parra A. Autoimmune thyroiditis [Internet]. Berlin, Heidelberg: Springer Berlin Heidelberg; 1991. Thyroid autoimmunity induced by interferon therapy; [citado 29 ago 2025]; p. 293-8. https://doi.org/10.1007/978-3-642-76301-4_33
40. Benedetti MS, Whomsley R, Baltes E, Tonner F. Alteration of thyroid hormone homeostasis by antiepileptic drugs in humans: involvement of glucuronosyltransferase induction. Eur J Clin Pharmacol [Internet]. 24 nov 2005 [citado 29 ago 2025];61(12):863-72. https://doi.org/10.1007/s00228-005-0056-0
41. Fiore E, Rago T, Provenzale MA, Scutari M, Ugolini C, Basolo F, Di Coscio G, Miccoli P, Grasso L, Pinchera A, Vitti P. L-thyroxine-treated patients with nodular goiter have lower serum TSH and lower frequency of papillary thyroid cancer: results of a cross-sectional study on 27 914 patients. Endocr Relat Cancer [Internet]. Mar 2010 [citado 29 ago 2025];17(1):231-9. https://doi.org/10.1677/erc-09-0251