Quick Refresher

• What is the thyroid gland and what does it do
• Hypothyroidism (underactive, low thyroid)
• Hyperthyroidism (over-active, high thyroid)
• Autoimmune thyroid disease
• Congenital hypothyroidism
• Acquired hypothyroidism

Question 1: I’d never heard of thyroid problems in children until my child was diagnosed with hypothyroidism. Are thyroid problems increasing in children?

Answer: It depends on the specific thyroid problem to which you are referring.

Acquired hypothyroidism is a maybe. Autoimmune thyroid disease also known as Hashimoto disease is the leading cause of acquired hypothyroidism in adults. Research studies have definitely shown a worldwide increase of Hashimoto disease in adults, and there is likely also an increase in children.

The most scientifically validated reason for the worldwide increase in Hashimoto disease is improved iodine intake. Iodine is a very important mineral that is necessary for thyroid hormone production. Lack of the mineral remains a common cause in certain third-world areas of the world for a specific form of hypothyroidism termed endemic goiter. For some reason, however, the improved supplementing of iodine may be a culprit in triggering autoimmune thyroid disease in adults.

Congenital hypothyroidism is a yes. Researchers are trying to understand the observed increase in incidence of congenital hypothyroidism. The historic quoted incidence is roughly 1 in every 4000 new births. Current trends are showing higher incidence at roughly 1 in every 2500 births. There are a number of different theories about why this is seen. One factor is the increased number of surviving premature babies. Many of these babies have a thyroid problem termed transient hypothyroidism during their early life requiring treatment with thyroid hormone and are counted in the same category as congenital hypothyroidism .

An increase in the Hispanic population is another factor theorized to account for the change. There is a higher incidence overall in Hispanics of congenital hypothyroidism which may be influencing the incidence numbers.

Radioactive iodine exposure during pregnancy has definite negative impact on fetal thyroid activity, and exposure must be avoided. Concern was sparked in 2012 with a controversial study published suggesting a link between the Fukushima nuclear disaster and a spike in the number of cases of congenital hypothyroidism seen in U.S. Pacific Coast states.

Question 2: Why did my child develop Hashimoto disease?

Answer: Medical science doesn’t know the precise reason(s) for autoimmune thyroid disease which includes Hashimoto thyroiditis. We believe that there are factors both genetic and environmental involved.

Research suggests that genetics underlies about 70 percent of the susceptibility in Hashimoto disease which is why a family history of thyroid problems is often seen in children with Hashimoto disease. Of the various genes identified with risk for Hashimoto disease, the HLA-DR gene association is best known. The gene location is known most widely for its importance in organ transplant

Environmental triggers are the great unknown not only in Hashimoto disease but also in many other autoimmune conditions. Infection triggers seem to be the most likely candidates in this process. Hepatitis C infection and Rubella (German measles) are two infections with known links to autoimmune thyroid disease. In addition to known harmful infections, possible impact of disturbance in beneficial intestinal bacteria as a trigger in autoimmune thyroid disease as well as other autoimmune conditions is being investigated.

Smoking in adults has been linked to increased risk for autoimmune thyroid disease and is another of the many reasons to avoid smoking. More controversial theories include environmental pollutants role in autoimmune thyroid disease. PCBs and PBDEs have been linked to increased risk in some research studies mainly in animals.

Radiation exposure is a known risk in many thyroid problems in both adults and children. Childhood thyroid cancer rates increased drastically after the Chernobyl disaster. Both autoimmune thyroid disease and thyroid cancer risk are increased in cancer survivors who received radiation treatment. Fortunately, routine medical radiation exposure doesn’t appear to be linked to higher risk of thyroid damage.

Question 3: Can diet help prevent or improve thyroid problems?

Answer: Yes, to some extent

The mineral iodine is essential for proper thyroid hormone production. Fortunately, in the U.S., lack of iodine is extremely uncommon. Seafood and dairy are both good sources of iodine, and iodine is added to salt as well. Risk of iodine deficiency is very low in in children who eat a healthy, balanced diet and have no digestive problems.

Goitrogens are naturally occurring chemicals in certain vegetables such as cauliflower that can interfere with function of the thyroid. Overall, the health benefits of goitrogen-containing vegetables probably outweigh the risks to the thyroid when eaten in a balanced manner.

Question 4: What can I do to help others in my family or family friends be more aware of thyroid problems?

Answer: Awareness is the key.

Awareness of symptoms of thyroid disease is important when there is a family history of thyroid problems. An exam of the thyroid and a blood testing can uncover thyroid problems. Sharing the story of your child’s medical history with concerned friends can also help.

I hope these answers help those of you who have a child diagnosed with a thyroid issue. If you still have questions or need more help, please contact your primary care doctor or the Cook Children’s Endocrinology division.

There’s been a lot of progress in type 1 diabetes care in the last five years, and I can only expect more in 2016 and upcoming years. I offer my thoughts on three areas for anticipated progress in type 1 diabetes care.

DRUGS

Insulin has been the mainstay in type 1 diabetes care since its purification and use in 1929. We’ve come a long way from purified animal insulin. We’ve had synthetically produced human insulin now for about 20 years.

Further modifications were made to human insulin creating long and short acting insulin analogs which are used today in basal/bolus insulin plans - considered standard of care in those with type 1 diabetes.

Several new analog insulin, either released or awaiting FDA approval, could be game changers for 2016.

Long-acting insulin activity is currently around 24 hours, but having a longer range of activity may benefit some patients with diabetes. Two new long-acting insulins, Tuojeo and Tresiba, continue working beyond 24 hours and have been approved for use only in adults with type 1 diabetes.

Fast acting insulin is essential at meals to control the rise in blood sugar from carbohydrates eaten. An “ultra-fast” acting insulin faster than the current batch of rapid-acting insulins recently started the review process for approval.

None of the current long or short acting analog insulins are generic. The cost of insulin and other diabetes supplies is a significant ongoing expense. A new “semi-generic” form of the long-acting insulin analog, Lantus, received recent approval.

The release of new analog insulin offers more choices, and research will be essential to see how these insulin can be used in children. Also, the number of insulin and increased choices will hopefully mean lower prices for vital medicine in the future.

DEVICES

Technology continues to move forward in its role helping children and families co-pilot type 1 diabetes.

Continuous glucose monitoring (GGM) continues to move into mainstream as a vital tool giving children and families real-time blood sugar information and better managing the highs and lows in blood sugar.

CGM in the clouds refers to the technology allowing remote monitoring of blood sugars. CGM sensor information is broadcasted via a smart phone to a server where it can be retrieved by using another smart phone or internet connected device. Parents can be hundreds of miles away and still have the comfort of monitoring their child’s blood sugar.

All the major insulin pumps have or will shortly have CGM integration allowing the most efficient use in these two tools together. The ultimate pairing of these tools, the artificial pancreas, continues in development.

The artificial pancreas holds the promise to lessen the work in diabetes care and help children have more stable blood sugars by allowing the insulin pump to use CGM information to make adjustments in insulin delivery.

Recent major funding received from the National Institute of Health and other sources will help fuel continued development and improvement.

Ditching the needles

Needles and sharp things are tough reality in diabetes care. Shots and finger pokes are a daily necessity in diabetes care. There’s been talk about non-invasive, needle-free monitoring in diabetes care for decades, but little progress has been made. Although CGM represents major progress, a needle is still needed to insert the device.

Wouldn’t it be great if monitoring of blood sugars or insulin treatment could be done without needles?

2016 has the potential to move forward in this area.

Inhaled insulin was recently approved for use only in adults with type 1 and type 2 diabetes. Further study is needed to see if inhaled insulin has a safe, effective place in treating children with type 1 diabetes.

Google’s glucose-sensing contact lens is probably the most recognized in the effort of various companies developing blood glucose checking without the stick. An ear sensor is being tested by two different companies.

The hormone glucagon is essential in the body to work against insulin and keep blood sugars up. Glucagon treatment, given as an injection, is an emergency measure used in type 1 diabetes when severe low blood sugars happen.

Nasal glucagon development is progressing and will probably reach the market soon with the promise of one less shot needed in an emergency situation of low blood sugar.

Defeat Diabetes

Removed first part For all of us in the field of endocrinology, defeating diabetes is the ultimate goal. For now though, I think 2016 offers the promise of new technology making those the life of someone with type 1 diabetes easier.

Research is also ongoing in re-creating insulin producing cells for re-implantation in the body which is the ultimate in defeating diabetes for good and what a great story that would be as we look ahead to 2017.

I’m always on the lookout for the latest news about developments in my field. In fact, I sometimes learn about the most up-to-date information by searching the news before I read about them in a medical journal.

A new diabetes technology under development caught my attention. The innovative technology developed at Stanford University uses a microchip for detection of type 1 diabetes.  A small sample of blood is placed on the microchip. The testing procedure detects auto-antibodies commonly found in those with Type 1 diabetes. The hope is that this new device can rapidly identify children who are at a high risk for developing Type 1 diabetes.

Illness symptoms of Type 1 diabetes, sometimes severe, are almost uniformly present at the time of diagnosis. It is frustrating both to me and parents that no easy screening is available to detect Type 1 diabetes earlier in its course when there are more possibilities of intervention. This new technology excites me as a way to overcome this barrier and expands intervention research opportunities in those in the early phase of type 1 diabetes. 

Screening for Type 1 diabetes is only currently done in large research studies such as the Trialnet Pathway to Prevention Study  and only in children who have a parent or sibling with Type 1 diabetes. It is possible that this new microchip will allow for wider, faster screening. The promise of an inexpensive, rapid test may help the growing number of children in countries with limited resources receive a prompt diagnosis and proper care for their Type 1 diabetes. 

The incidence of Type 1 diabetes continues to rise worldwide, and those of us in pediatric endocrine and other medical fields continue in efforts to better understand this mysterious condition. I believe a cure will come one day, but in the meantime, technology tools such as this microchip will form the new wave of innovation in Type 1 diabetes.