Juvenile Autoimmune Thyroid Disease

What Is Juvenile Autoimmune Thyroid Disease?

Juvenile autoimmune thyroid disease is an autoimmune disorder occurring in childhood that targets and damages the thyroid gland, often causing goiter. It is characterized by abnormal circulating thyroid hormone levels in the bloodstream.

Recent evidence suggests that thyroid autoimmunity originates from an interaction of genetic, endogenous and environmental factors which end up activating thyroid-specific autoreactive T-lymphocyte cells in susceptible children.¹

Q: What is the thyroid gland?

A: The thyroid is an endocrine (hormone secreting) gland that produces thyroid hormones in response to the action of thyroid stimulating hormone (TSH) produced by the pituitary gland, and releases them into the bloodstream to be quickly carried to their site of action.

The three thyroid hormones are thyroxine, called T4, triiodothyronine, called T3, and calcitonin. T4 and T3 hormones control the rate of metabolism, meaning 1) the rate of food usage for energy production, 2) the rate of protein production and breakdown in most tissues, 3) the heart rate and force of heart muscle contraction, 4) body temperature, and 5) the rate of growth and development in children.

Dietary iodine and selenium are required for T3 production. Specifically, selenium is part of the enzyme that converts T4 to the active form, T3. Calcitonin hormone is needed to build and maintain dense bones and regulate calcium blood level. The thyroid gland is located in the front of the neck at the top of the trachea (windpipe).

Who Is Affected in the General Population? Autoimmune thyroid disease is the most common etiology of acquired thyroid dysfunction in pediatrics. It is more common in females and usually occurs in early to mid-puberty. Presentation is rare under the age of 3 years, but cases have been described even in infancy.² 

What Is Juvenile Autoimmune Thyroid Disease In Celiac Disease and/or Gluten Sensitivity?

• Relationship between juvenile autoimmune thyroid disease and celiac disease. Juvenile autoimmune thyroid disease occurs as an associated disorder in both treated and untreated celiac disease. The association may be due to the sharing of a common genetic background, such as HLA antigens (genetic markers). However, in a very large study, involving 909 patients with celiac disease, Ventura and his associates found that the development of immune disorders in celiac disease was clearly related to the duration of exposure to gluten.³
• Relationship between juvenile autoimmune thyroid disease and predictive factors. A retrospective cross-sectional study investigating the natural course of pediatric patients with Hashimoto’s thyroiditis and hyperthyrotropinaemia and looking for possible prognostic factors found that celiac disease, elevated thyroid stimulating hormone and antithyroid antibodies at presentation and a progressive increase in  thyroid stimulating hormone are predictive factors for thyroid failure in Hashimoto’s thyroiditis patients.⁴
• Relationship between juvenile autoimmune thyroid disease and hormone therapy failure in celiac disease. The early identification of celiac disease in polyglandular disease is clinically important not only for the high risk of complications inherent to untreated celiac disease, but also because celiac disease is one of the causes for the failure of substitute hormonal therapy in patients with autoimmune thyroid disease.⁵
• Relationship between juvenile autoimmune thyroid disease and puberty. Hypothyroidism typically causes pubertal delay but may also induce pseudoprecocious puberty, manifested as testicular enlargement in boys, breast development, and/or vaginal bleeding in girls. This syndrome clinically differs from true precocity by the absence of accelerated bone maturation and linear growth.⁶

How Prevalent Is Juvenile Autoimmune Thyroid Disease In Celiac Disease and/or Gluten Sensitivity?

• The prevalence of juvenile autoimmune thyroid disease is 26.2% in patients with celiac disease vs.10% of controls. Hypothyroidism was observed in 8.1% of children with celiac disease vs. 3.5% of controls and hyperthyroidism in 1.1% of children with celiac disease vs. none of control subjects. 15.7% of children with celiac disease had euthyroidism (normal thyroid) vs. 6% of controls.⁷
• A retrospective study of children diagnosed with non-diarrheal celiac disease observed a prevalence of 5.7% with autoimmune thyroiditis.⁸

What Are The Symptoms Of Juvenile Autoimmune Thyroid Disease In Celiac Disease and/or Gluten Sensitivity?

Juvenile autoimmune thyroid disease is marked by thyroid enlargement or symptoms arising due to dysfunction of the thyroid gland. Asymptomatic enlargement of the thyroid gland is a common presenting complaint, especially in older children and adolescents. Asymptomatic means there are no symptoms showing thyroid dysfunction.

Thyroid function can vary from euthyroidism to subclinical or overt forms of hypothyroidism and, less commonly, hyperthyroidism. Accordingly, patients can be symptomatic.⁹ 

Euthyroidism estimates of eye manifestations are 25–60% frequency in children, but usually the ocular signs are mild such as lid retraction, a slight proptosis that can be attributed to the inflammation and muscle swelling rather than to infiltrative disease of the orbital structures.¹⁰

Hypothyroidism slows metabolism, heart rate, body temperature and growth and causes these symptoms:

• Fatigue.
• Sleepiness.
• Depression.
• Inattentiveness.
• Impaired memory.
• Sensitivity to cold.
• Muscle cramps.
• Constipation.
• Dry, itchy skin.
• Thin hair.
• Weight gain and water retention.

Hyperthroidism (Grave’s Disease), speeds metabolism, heart rate, body temperature and growth and causes excitability, mania, anxiety, unintended weight loss, sensitivity to heat, and loose bowels.

• Most often children present with behavioral disturbances: decreased attention span, difficulty concentrating (which may lead to deteriorating performance in school), emotional lability, hyperactivity, difficulty sleeping, and nervousness.
• Typical cardiovascular findings include tachycardia, palpitations, widened pulse pressure, and an overactive precordium. Any child who has persistent tachycardia should be evaluated for hyperthyroidism.
• Tremors, a shortened deep tendon reflex relaxation phase, fatigue, and proximal muscle weakness are possible neuromuscular manifestations of thyrotoxicosis (excessive quantities of circulating thyroid hormones).
• Despite an increase in appetite, affected children often lose weight and sometimes have diarrhea, but usually have frequent bowel movements associated with intestinal motility.
• Increased perspiration, warmth, and heat intolerance tend to be late findings.
• Postpubertal girls often have menstrual irregularities.
• A goiter is palpable in the majority of cases, characterized by diffuse enlargement which is smooth, firm, and nontender.
• The pretibial myxedema that is a common feature of Grave’s disease in adults is rare in children.¹⁰

How Does Juvenile Autoimmune Thyroid Disease Develop In Celiac Disease and/or Gluten Sensitivity?

• Juvenile autoimmune thyroid disease results from linked autoimmune mechanism with celiac disease.
• In view of the role played by selenoproteins in apoptosis (cell death) inhibition, the presence of selenium deficiency can be considered an important direct factor of thyroidal damage in development of autoimmune thyroid diseases where interleukin-15 (IL-15) expression also increases in active celiac disease.  Interleukin-15 is a cytokine (protein) that stimulates the production of T-lymphocytes, causing tissue damage.¹¹

Does Juvenile Autoimmune Thyroid Disease Respond To Gluten-Free Diet?

Juvenile autoimmune thyroid disease has a poor response to gluten free diet.

6 Steps To Improve Juvenile Autoimmune Thyroid Disease In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both juvenile autoimmune thyroid disease and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.¹²
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.¹³
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.¹³
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.¹³.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.¹³
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.¹³
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.¹³
• Cocoa and Black Tea increase blood sugar.
• Rosemary. Increases blood sugar levels and should not be used by persons with insulin resistance or diabetes. [/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Certain medications used to treat thyroid disease deplete nutrients. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

THYROID MEDICATION to treat hypothyroidism.

• Synthroid® depletes calcium.

[/box]

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination that provides 100% once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Calcium citrate is the best absorbed of calcium supplements. Calcium carbonate is a poor choice.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion. However, because it increases blood sugar levels, it should not be used by persons with insulin resistance or diabetes.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Juvenile Autoimmune Thyroid Disease In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Celiac disease presentation in a tertiary referral centre in India: current scenario.” This facility-based retrospective observational study compared the clinical spectrum of nondiarrheal celiac disease  (NDCD) with that of diarrheal/classical celiac disease (CCD) included consecutive patients diagnosed with celiac disease (CD) (as per modified ESPGHAN criteria) from October 2009 to August 2011. A total of 381 patients were diagnosed with CD during the study period. NDCD was present in 192 (51.8 %). NDCD had higher mean age at presentation (5.8 ± 2.8 years vs. 6.9 ± 2.9 years respectively) and longer duration of symptoms prior to diagnosis (2.9 ± 1.7 years vs. 3.6 ± 2.2 years) as compared to CCD.

In the NDCD group, the most frequent gastrointestinal (GI) symptoms were recurrent abdominal pain [122 (63.5 %)] and abdominal distension [102 (53.1 %)] followed by constipation [48 (25 %)], vomiting [76 (39.6 %)] and recurrent oral ulcers [89 (46.4 %)]. Vomiting and constipation were more frequently seen in NDCD as compared to CCD. Common extraintestinal manifestations in NDCD included failure to thrive [109 (56.8 %)], isolated short stature [36 (18.8 %)], persistent anemia [83 (43.2 %)] and hepatomegaly/splenomegaly or both [56 (29.2 %)].

Associated comorbidities included autoimmune thyroiditis [11 (5.7 %)], type 1 diabetes mellitus [8 (4.2 %)], bronchial asthma [23 (11.9 %)], idiopathic pulmonary hemosiderosis [4 (2.1 %)], Down’s syndrome [3 (1.6 %)], alopecia areata [6 (3.1 %)], polyarthritis [2 (1.0 %)], dermatitis herpetiformis [6 (3.1 %)] and chronic liver disease [6 (3.1 %)].¹⁴

“The natural history of the normal/mild elevated TSH serum levels in children and adolescents with Hashimoto’s thyroiditis and isolated hyperthyrotropinaemia: a 3-year follow-up.” This retrospective cross-sectional study investigating the natural course of pediatric patients with Hashimoto’s thyroiditis and hyperthyrotropinaemia and looking for possible prognostic factors found that celiac disease, elevated thyroid stimulating hormone and antithyroid antibodies at presentation and a progressive increase in  thyroid stimulating hormone are predictive factors for thyroid failure in Hashimoto’s thyroiditis patients.

Three hundred and twenty-three patients with Hashimoto’s thyroiditis (88 boys and 235 girls) and 59 with hyperthyrotropinaemia (30 boys and 29 girls), mean age 9·9 ± 3·8 years were included in the study. When first examined, 236 of the children with Hashimoto’s thyroiditis had a normal Hashimoto’s thyroiditis (G0) and in 87, it was elevated but less than 100% of the upper limit (G1). All hyperthyrotropinaemia subjects had elevated thyroid stimulating hormone (TSH). Potential risk factors for thyroid failure were evaluated after 3 years and included the presence or familiarity for endocrine/autoimmune diseases, premature birth, signs and symptoms of hypothyroidism, TSH levels, antithyroid antibodies and thyroid volume.

RESULTS: Hashimoto’s thyroiditis (HT): Of those with HT, 170 normal TSH (GO)patients remained stable, 31 moved to G1 and 35 to G2 (hypothyroidism). Thirty-six G1 children moved to G0, 17 remained stable and 34 moved to G2. Of patients with hyperthyrotropinaemia (IH): 23 normalized, 28 remained stable and eight became overtly hypothyroid. In patients with HT, the presence of celiac disease, elevated TSH and thyroid peroxidase antibodies (TPOAb) increased the risk of developing hypothyroidism by 4·0-, 3·4- and 3·5-fold, respectively. The increase in TSH levels during follow-up was strongly predictive of the development of hypothyroidism. In patients with IH, no predictive factor could be identified.⁴

“Autoimmune thyroid disease and celiac disease in children.” This study designed to establish the prevalence of autoimmune thyroid involvement in a large series of pediatric patients with celiac disease (256 patients were following a gluten-free diet, 87 patients were untreated), demonstrated high frequency of autoimmune thyroid disease among patients with celiac disease, both treated and untreated, and concluded these findings may justify a thyroid status assessment at diagnosis and at follow-up evaluation of children with celiac disease. Hypothyroidism was observed in 8.1% of children with celiac disease vs. 3.5% of controls and hyperthyroidism in 1.1% of children with celiac disease vs. none of controls. 15.7% of children with celiac disease had euthyroidism vs. 6% of controls.⁷

“Thyroid-related autoantibodies and celiac disease: a role for a gluten-free diet?” This study evaluating the presence of celiac disease in 100 patients with autoimmune thyroid disease demonstrated that serologic markers became undetectable 6 months after beginning gluten free diet, but thyroid autoantibodies did not positively correlate with gluten free diet.¹⁵

Sources:

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