Slightly Elevated TSH Levels Not a Cause for Referral to Pediatric Endocrinologists

Children with thyroid stimulating hormone (TSH) levels slightly above reference range shouldn’t be referred to pediatric endocrinologists unless there is another cause for clinical concern, according to a paper recently published in the Journal of the Endocrine Society.

Researchers led by Perrin C. White, MD, of the Division of Pediatric Endocrinology at the University of Texas Southwestern Medical Center in Dallas, point out that limited data are available to help primary care physicians distinguish abnormal lab results that show actual thyroid disease from things like laboratory error or acute illness. “Such information could help primary care practitioners limit referrals to pediatric endocrinologists for evaluation of abnormal thyroid function to those patients likely to require treatment,” the authors write.

The researchers looked at determining the reproducibility of TSH testing in pediatric patients referred to pediatric endocrinologists. They write that they also wanted to identify the threshold TSH levels that would predict presence of antithyroid autoantibodies and inform decisions by pediatric endocrinologists at our institution to initiate or continue treatment with levothyroxine.

The team analyzed data from a retrospective case series of 325 children aged one to 18, referred to the endocrinology clinic at a tertiary children’s hospital for hypothyroidism. Of these 325 children, 191 were treated, and the treated children were more likely to have higher referral TSH, positive autoantibodies, and abnormal thyroid gland examination findings, according to the authors. “Mild elevations of TSH (5 to 6 mIU/L) were unlikely to be reproduced with repeat testing, to be associated with positive autoantibodies, or to result in decisions by pediatric endocrinologists to treat the patients,” they write.

The authors note that this study did have a few potential limitations, like the fact that the decision by the endocrinologist to treat was subjective and that TSH reference ranges in children have varied in the reported data. “Finally, the decision to continue or start therapy was determined by each individual endocrinologist, and no written standard of care was used,” the authors write. “The present study was undertaken to provide data for such a guideline.”

Still, based on their findings, the authors conclude: “TSH levels slightly above the reference range should not prompt referral to pediatric endocrinologists unless another basis for clinical concern is present.”

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