Thyroid conditions

Disclaimer

These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

 

Introduction

This guideline is suggested for use by doctors when concerns for thyroid disease exist and tertiary endocrine assessment is sought.

Please provide all information requested in this guideline to avoid the referral being declined and risking a delay in the provision of care for the child and family.

When to refer

Referrals for thyroid disease where specialist care is indicated are typically categorised as urgent. It is critical that all relevant information is therefore provided.

Please refer once all assessments have been requested (minimum) and /or completed (preferred).

Refer to the Endocrinology Department as outlined below:

1. Congenital hypothyroidism

Urgent referral - please call to begin therapy until patient can be seen

Clinical findings 

Pre-referral work-up

  • TSH
  • free T4

2. Central hypothyroidism

Urgent referral

Clinical findings

  • Low to low normal TSH with low free T4
  • History of traumatic brain injury, midline facial defects, brain irradiation, hypoxic brain injury

Pre-referral work-up

  • Confirmatory TSH
  • free T4
  • Consider repeating labs prior to referral to assure validity 

3.Aquired/autoimmune thyroiditis/hypothyroidism

Urgent referral - please call to begin therapy until patient can be seen

Clinical findings

  • Elevated TSH
  • Low free T4

Pre-referral work-up

  • TSH
  • free T4
  • Anti-thyroglobulin antibody
  • Anti-TPO antibody
  • If TSH is abnormal but <10mU/ml and the free T4 is normal: obtain thyroid antibodies and repeat TSH, free T4 in 2 to 3 months
  • If TSH rising and antibodies are positive: refer to be seen

4. Acquired/autoimmune (Grave's Disease) hyperthyroidism 

Urgent referral

  • Hypertension
  • Tachycardia
  • Goitre
  • Exophthalmos
  • TSH <0.1mU/ml
  • Elevated free T4, T3

Pre-referral work-up

  • Current TSH, free T4, free T3
  • Thyroid receptor antibody (TRAb)
  • Anti-Thyroglobulin Antibody
  • Anti-TPO Antibody

Referrals are/may not be required for

  • Children with Trisomy 21 with mildly elevated TSH levels (hyperthyrotropinaemia) and normal free T4
  • Children with positive thyroid antibodies but normal thyroid function tests. These children may never develop hypothyroidism.
  • Obese children with slight elevations in TSH (5-10 mU/ml) secondary to metabolic syndrome. No endocrine referral is indicated unless the thyroid antibodies are positive. You may wish however, to refer to the Departments Health Weight Service (HWS) for lifestyle intervention
  • Alopecia or hair loss with normal TSH and free T4

In these cases, monitoring and assessment in primary settings by a GP is recommended and referral ONLY initiated if an abnormal result occurs on regular screening (3 to 6 monthly)

How to refer

Essential information

  • Serial measurements of the patient in a growth chart
  • Relevant clinical notes
  • Physical examination findings
  • Blood tests and results (and/or means of how they can be accessed- vital if not performed at Pathwest)
  • Imaging results (if imaging is undertaken)

If you are unsure if a referral is required, please call 6456 2222 and ask to speak to the on-call Endocrinologist.

Useful resources


Reviewer/Team: Dept of Endocrinology Last reviewed: Nov 2021


Review date: Nov 2022
Endorsed by:

Dr Aris Siafarikas, Head of Dept, Endocrinology Date:  Nov 2021


This document can be made available in alternative formats on request for a person with a disability.


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