Prevalence of Congenital Hypothyroidism Current Trends and Future Directions: Workshop Summary ic!ard S. "lne#, Scott D. $rosse and obert %. &ogt, 'r Pediatrics 2010(12)(S31 D"I: 10.1)*2+peds.200-1) 10.1)*2+peds.200-1)/ /
!e online ersion of t!is article, along wit! updated information and serices, is located on t!e orld ide eb at: http://pediatricsaappu!licationsorg/content/"#$/Supplement%#/S&"fullhtml
PDIAI/S is t!e official 4ournal of t!e American Academ# of Pediatrics. A mont!l# publication, publication, it !as been publis!ed publis!ed continuousl# continuousl# since 1*5. 1*5. PDIA PDIAI/S is owned, publis!ed, and trademar6e trademar6ed d b# t!e American American Academ# Academ# of Pediatrics, Pediatrics, 1*1 7ort!west Point Point 8ouleard, l6 $roe &illage, Illinois, 9000. /op#rig!t 2010 b# t!e American Academ# of Pediatrics. All rig!ts resered. Print ISS7: 0031-*00). "nline ISS7: 105-*2).
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Prealence of /ongenital >#pot!#roidism?/urrent rends and %uture Directions: or6s!op Summar# '(TH)*S: ic!ard S. "lne#, =D, =P>, Scott D. a
$rosse, P!D, and obert %. &ogt 'r, P!D b a
a
National Center on Birth Defects and Developmental Disabilities and b National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia +,-
W)*DS
congenital !#pot!#roidism, neonatal screening, epidemiolog#, public !ea lt!, conferences '..*,/0'T0)1S
/>?primar# congenital !#pot!#roidism /D/? /enters for Disease /ontrol and Preention * ? t!#ro@ine S>?t!#rotropin !e ndings and conclusions in t!is article are t!ose of t!e aut!ors and do not necessaril# represent t!e ofcial position of t!e /enters for Disease /ontrol and Preention.
www.pediatrics.org+cgi+doi+10.1)*2+peds.200-1)/ doi:10.1)*2+peds.200-1)/ Accepted for publication 'an 22, 2010
Address correspondence to ic!ard S. "lne#, =D, =P>, 7ational /enter on 8irt! Defects and Deelopmental Disabilities, /enters for Disease /ontrol and Preention, 1900 /lifton d, =ailstop -59, Atlanta, $A 30333. -mail: rolne#Bcdc.go P3DIAI/S CISS7 7umbers : Print, 0031-*0 0)( "n line, 10 5-*2). /op#rig!t 2010 b# t!e American Academ# of Pediatrics F01'1C0'2 D0SC2)S(*,: The authors have indicated the have
no !nancial relationships relevant to this article to disclose"
abstract In response to publis!ed newborn-screening data t!at !ae s!own an increase in t!e incidence Cbirt! prealence rate of primar# congenital !#pot!#roidism C/> in t!e ;nited States, a wor6s!op was !eld in Atlanta, $eorgia, on %ebruar# 2 and 25, 2005, to e@amine t!is issue. opics of t!e meeting included pat!op!#siolog#, medical management, and follow-up of />( transient !#pot!#roidism Cetiolog#, clinical impli- cations, management, and c!anges in prealence( ris6 factors for />( laborator# approac!es to newborn screening for />( state-specic ealuations of trends in incidence rates of />( and concluding discus- sions on future directions to resole outstanding issues. !roug! pre- sentations and discussion, gaps in 6nowledge were identied, suc! as t!e lac6 of consistent denitions for /> and transient !#pot!#roidism and t!e effects of preentable ris6 factors on incidence rates of />. "ne outcome of t!e meeting was a series of accompan#ing articles t!at e@amined C1 trends in t!e incidence rates of /> in indiidual states and nationall#, C2 effects of newborn-screening practices on />incidence rates, C3 t!e contribution of transient !#pot!#roidism to />-incidence rates, and C* future researc! directions. In t!is summar#, we brieE# touc! on t!e topics of t!ese articles and e@amine !ig!lig!ts of ot!er presentations from t!e wor6s!op t!at illuminated t!e secular trends in reported />-incidence rates in t!e ;nited States. Pediatrics 2010(12):S31FS39
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In 200, >arris and Pass 1 publis!ed newborn-screening data from 7ew Gor6 and t!e ;nited States t!at s!owed an increase in t!e incidence Cbirt! prealence rates of primar# congenital !#pot!#roidism C/> oer t!e past 2 decades C7ew Gor6: 1 in 335 to 1 in 1*1* birt!s( ;nited States: 1 in *05 to 1 in 230 birt!s. Seeral potential reasons for t!ese trends in />-incidence rates were discussed in t!eir article, but t!e lac6 of denitie e@planations and t!e need for clarication about an appropriate public !ealt! response, if an#, led to understandable con- cerns among public !ealt! ofcials, clinicians, and ot!ers in t!e newborn- screening communit#. In prelimi- nar# discussions, leading concerns included t!e c!anging and incon- sistent denitions for /> and tran- sient !#pot!#roidism. >oweer, se- eral ot!er factors t!at reHuired furt!er e@amination emerged Ceg, t!e potential effects of ris6 factors wit! c!anging freHuencies in t!e ;S population, suc! as race and et!- nicit# and rates of preterm birt!( eoling screening met!ods( and s!ifting practices related to management of c!ildren identied b# newborn screening. SubseHuentl#, a wor6s!op planning committee was formed and included representaties from t!e 7ational 7ewborn Screening and $enetics esource /enter and 2 federal agencies: t!e >ealt! esources and Serices Administration and t!e /enters for Disease /ontrol and Preention C/D/. !ese groups cosponsored a wor6- s!op t!at was !eld in Atlanta, $eor- gia, on %ebruar# 2 and 25, 2005, en- titled Prealence /ongenital of >#pot!#roidism: rends /urrent and %utur e Directions.J In t!is oeriew we proide a summar# of t!e issues addressed at t!e wor6s!op and brieE# describe t!e presentations, t!e details of w!ic! are largel#
incor-
porated in ot!er articles in t!is sup plemental issue of Pediatrics. =ost notabl#, t!e future researc! directions set fort! b# wor6s!op partici pants are detailed in t!e article b# S!apira et al. 2 !e oerall goal of t!e wor6s!op was to present participants wit! detailed bac6ground information about /> and data on incidence rates to deelop future approac!es to resole t!e Huestions surrounding t!e magnitude of and potential e@planations for t!e increasing />-incidence rates, w!et!er real or artifactual. At t!e outset, t!e wor6s!op organiKers compiled t!e following list of issues to address potential e@planations for t!e reported data trends: L c!anges in practice t!at mig!t !ae
occurred in t!e follow-up and medical management of screen-positie cases identied b# newborn screening, including t!e primar# care proiderMs perspectie( L transient !#pot!#roidism:
etiolog#, clinical implications, management, and c!anges in prealence(
L epidemiolog# and ris6 factors for
/>, suc! as preterm birt!, genetic factors, se@, race and et!nicit#, prenatal iodine inta6e, and autoimmunit# Calso co-occurring trends in t!ese factors oer t!e past 3 decades( and L c!anges in laborator# approac!es
to newborn screening for />, including laborator# met!ods and screening paradigms.
o concentrate on t!ese issues, t!e planning committee drew from a multidisciplinar# group of spea6ers and inited participants Csee t!e list of wor6s!op participants at t!e beginning of t!e supplement, w!ic! included endocrinologists, epidemiologists and public !ealt! professionals, !ealt! serices researc!ers, laboratorians, medical geneticists, primar#
care proiders, and state newbornscreening program professionals. )/,*/0,W )F CH P'TH)PH-S0)2)3-4 5,D0C'2 5'1'3,5,1T4 '1D F)22)W6(P: P*,S,1T'T0)1S .- 50TCH,224 F)2,-4 '1D /'1 5,T,*
7ormal fetal and neonatal t!#roid functions are well establis!ed, and details of t!ese p!#siologic processes !ae been reiewed in a number of articles. 3F) During gestation, t!e fetus relies at least in part on maternal t!#roid !ormone. !ere is t#picall# a surge in t!#rotropin CS> 30 minutes after birt! to a pea6 of 0 mI;+<
S&#
"<73G et al
Cor as !ig! as 0 mI;+< before concentrations decline to normal w!en t!e new- born is 3 to ) da#s of age. o identif# newborns wit! for t!e purpose of earl# /> newborntreatment, screening programs measure S> or t!#ro@ine C* concentrations, or bot!, in dried blood spots obtained from neonates. >#pot!#roidism detected in new- borns can be eit!er permanent or transient, and a discussion of t!e c!allenges in dening and distin- guis!ing t!e 2 forms follows. /on- genital
Cpermanent defects of t!#- roid location or structure, w!ic! affect most newborns wit! />, are c!aracteriKed b# an ectopic gland, an absent gland Ct!#roid aplasia or agenesis, or t!#roid !#poplasia. Scanning studies of newborns wit! /> t#picall# !ae reealed t!at ectopic disorders account for t!e ma 4orit# of suc! defects. 9, D#s!ormonogenesis Can inborn error of metabolism inoles defects in * s#nt!esis and accounts for 10N to 20N of newborns wit! />. "t!er causes, w!ic! could total anot!er 10N of screen-positi e newborns, include resistance to S> Ct!#rotropin receptor defects and t!e causes of
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transient !#pot!#roidism: maternal t!#rotropin-bloc6ing antibodies, e@ posure to maternal antit!#roid medications, iodine decienc#, and iodine e@cess. 7ewborn screening for /> began wit! pilot programs in t!e 10s and t!ereafter s!ortl# became widespread and eentuall# uniersal in t!e ;nited States.) Identication of primar# !#po- t!#roidism, w!ic! is t!e focus of new- born screening for congenital !#po- t!#roidism, is reEected b# eleated S> and low serum free * concen- trations. ransient !#pot!#roidism also inoles an initiall# eleated S> concentration and low or normal * leel but normal * and S> concentrations on subseHuent measurement. /entral !#pot!#roidism can be detected b# newborn-screening programs t!at test * as t!e principal anal#te. =edical management begins wit! conrmator# serum t!#roid-function tests to conrm t!e diagnosis according to establis!ed algorit!ms suc! as t!e
guidelines formulated b# seeral professional organiKations t!at were pub- lis!ed in 2009.) Some clinicians also order t!#roid imaging b# eit!er ultrasound or radionuclide studies. !e goal of earl# identication t!roug! newborn screening and follow-up is to normaliKe t!e * concentration wit!in 2* !ours and t!e S> concentration wit!in 1 wee6.
and free * concentrations( moni- toring of linear growt!( conducting neurops#c!ological ealuations( and, in cases in w!ic! it is not 6nown w!et!er t!e condition is permanent, discontinuing t!erap# on a trial basis
diagnosis, age at diagnosis and onset of t!erap#, dose of leot!#ro@ine, and ad!erence to medication administration and monitoring. Publis!ed guidelines !ae indicated t!at monitoring of t!#roid !ormone concentrations s!ould be performed at specied interals, wit! !ig!er freHuencies at #ounger ages, and after an# c!ange in medication dosage or p!armaceutical source of medication. ) !ere is increasing global interest in e@panding screening of /> to detect central !#pot!#roidism among all newborns, as well as dela#ed-onset /> t!at occurs among preterm infants. is about t!e 6nown b# primar# care proiders( t!e most recent data came from a sure# in isconsin of p!#sicians of record for )00 newborns w!o screened pos- itie during 15* and 15). 10 It is unclear !ow man# primar# care pro- iders interact wit! pediatric endocrinologists, are aware t!at infants s!ould be treated wit! crus!ed tablets slurried in formula, or follow t!e pubw!en t!e c!ild is 3 #ears of age.),5 &ari- ables t!at affect medical and neuro- ps#c!ological outcomes for persons wit! /> include t!e seerit# of /> at
presented t!at indicated wide ariations in t!e freHuenc# of transient !# pot!#roidism between state newbornscreening programs, w!ic! seemed most li6el# to be t!e result of !ow pro- grams tallied cases of transient !#po- t!#roidism ersus normalsJ Cscreen- positie results ultimatel# reported as neit!er true /> nor transient !#pot!#- roidism. Ideall#, suc! classication would be based on a precise denition of transient !#pot!#roidism and prospectie follow-up data collected w!en screen-positie c!ildren are at least 2 or 3 #ears of age, w!ic! is t!e t#pical window for a trial of discontinuation of t!erap# to assess t!e nonpermanence of presumed />. "ne distinguis!ing factor between permanent /> and transient !#pot!#roidism is t!e female-to-male ratio. 7umerous uropean, Australian, and /anadian studies !ae reported a ratio for true /> cases of 2:1,
9,,12F1*
w!ereas t!e ratio among cases of transient is s#stematic !#pot!#roidism 1:1 or low!ae been no er.9,1*,1)!ere lis!ed 2009 guidelines on clinical management. Population-based data also are needed regarding !ow man# affected c!ildren are assessed for educational performance during sc!ool #ears. T*'1S0,1T H-P)TH-*)0D0S5: P*,S,1T'T0)1S .- P'*+S4 3,(*014 '1D 3*)SS,
!e article b# Par6s et al11 e@plores issues and data related to transient !# pot!#roidism, suc! as ariations in denitions, ris6 factors, incidence rates from arious sources, and trends oer time for all of t!ese factors. !is topic was a ma4or focus of t!e wor6s!op because of suspected ariations in t!e relatie freHuencies of true /> ersus transient !#pot!#-
roidism according to state and time period. At t!e wor6s!op, data were
long-term follow-up studies of t!e se@ ratio among newborns wit! ersus permanent transient !#pot!#roidism in t!e ;nited States. idence was presented at t!e wor6- s!op, based on an anal#sis of !ealt! insurance claims data, t!at s!owed t!at man# ;S c!ildren diagnosed wit! and treated for /> stop !aing pre- scriptions lled well before t!e age at w!ic! trial is recomdiscontinuation
mended.19 %urt!ermore, it was re ported t!at t!ose c!ildren w!o stopped treatment comprised roug!l# eHual numbers of bo#s and girls, w!ic! is c!aracteristic of transient !#pot!#roidism.
An alternatie approac! to classif#ing cases of /> is t!roug! t!e s#stematic use of imaging of t!e t!#roid. !is practice is standard in Ouebec, /an- ada, w!ere no increase in t!e inci- dence rate of t!#roid d#sgenesis !as
P3DIAI/S &olume 12), Supplement 2, =a# 2010
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been found. Imaging anal#ses !ae been done in limited clinical settings in t!e ;nited States, wit!out reporting of secular trends in incidence rates.10,1 D'T' )1 *0S+ F'CT)*S F)* CH '1D 2'.)*'T)*- 'PP*)'CH,S: P*,S,1T'T0)1S .- SH'P0*'4 TH,**,224 5,04 H,*T7.,*34 H01T)14 van der H''*4 '1D .2)(1T
!e aut!ors of 3 recent epidemiologic studies from /alifornia, estern Australia, and Ital# !ae proided publis!ed data on ris6 factors for />. aller et al15 reported on ris6 factors in /alifornia from 10 to 15. !e oerall incidence rate was 1 in 2500 birt!s( t!e rate was lower among non- >ispanic blac6+African American new- borns and !ig!er among >ispanic newborns compared wit! t!e rate among w!ite newborns. !e female-to- male ratio was 2:1 among w!ite, >ispanic, %ilipino, and /!inese new borns but lower among ot!er racial and et!nic groups. 7ewborns wit! birt! weig!ts of 2000 or *)00 g were at eleated ris6. !is ;-s!aped cure in incidence rates according to birt!-weig!t categor# was consistent, een w!en t!e data were stratied ac- cording to race+et!nicit# and se@. urincKu6 et al reported on 151F 15 data from estern Australia. 13 !e# e@- cluded patients wit! transient !#po- t!#roidism Canal#King /> onl#, t!e ap- pro@imate incidence rate was 1 in 3*00 birt!s from 151 t!roug! 15. $irls !ad more t!an twice t!e ris6 t!an did bo#s. !e aut!ors also obsered a ;-s!aped cure in incidence rates wit! birt! weig!t and wit! gestational age C 3 or *1 wee6s of gestation. Ap pro@imatel# 10N of affected newborns !ad anot!er birt! defect, w!ic! is ap pro@imatel# twice t!e freHuenc# of birt! defects among t!e general popu- lation. !e ris6 for cardiac defects par-
ticularl# was eleated. %inall#, =edda et al9 e@amined records of 1*0 Italian newborns wit! /> and 1) wit! tran- sient !#pot!#roidism compared wit! t!ose of matc!ed control newborns. !#roid-scan results were aailable for 1N of newborns wit! />, of w!om )5N !ad ectopic glands. Preterm birt!s were more common among newborns wit! transient !#pot!#roidism and t!ose wit! />. A parental !is- tor# of !#pot!#roidism was associated wit! bot! transient !#pot!#roidism and />. =aternal !#pot!#roidism was associated wit! transient !#pot!#roid- ism, and !#pot!#roidism paternal was associated wit! />. =edda et al re ported an eleated female-to-male ratio onl# for />, not for transient !#pot!#roidism.
In t!eir article, >inton et al1 report an anal#sis of secular trends in />incidence rates in t!e ;nited States from 11 to 2000 and in * states C/al- ifornia Q153F200R, e@as Q12F 2009R, 7ew Gor6 Q15F200R, and =assa- c!usetts Q19 F200R according to race and et!nicit#, se@, and low birt! weig!t. At a national leel, from 11 to 2000, />-incidence rates increased signicantl# onl# among w!ite new borns, alt!oug! a limitation of t!is nding is t!at, during t!is time period, an un6nown proportion of infants wit! >ispanic et!nicit# were included in t!e w!ite racial categor#. Studies t!at in- cluded later time periods in /alifornia C2000 F200 and e@as C12F2009, in w!ic! >ispanic infants wit! /> were differentiated from non->ispanic w!ite infants, did s!ow signicant increases in t!e incidence rate of /> among >is- panic infants. !e possible inEuence of c!anges in newborn-screening met!odolog# on />-incidence rates needs to be e@am- ined. Suc! an inEuence was obsered in estern Australia,
w!ere t!e inci- dence rate from 151 to 15 was 1 in
)*) birt!s( !oweer, after screening met!ods c!anged Clower S> cutoff, t!e incidence rate was 1 in 2525 birt!s from 155 to 15.13 In an anal#sis of ;S data from 11 to 2000, detailed in t!e article b# >ertKberg et al,20 c!anges in testing met!ods for t!e * or S> anal#tes did not account for t!e oerall increase in t!e national />incidence rate, alt!oug! t!e increasing rate was associated partl# wit! c!anges in * assa# met!odologies. An effect of c!anging cutoff points for positie screens was not obsered, w!ic! Caccording to /D/compiled data from 1F2000 !ae not aried muc! in aggregate for * or S>. In addition, alt!oug! more
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"<73G et al
state laboratories !ae c!anged to a S> assa# for t!e initial screening test C2 laboratories in compared wit! 12 11 laboratories in 2000, t!is c!ange in screening met!odolog# was not associated wit! t!e increasing />incidence rate. /oncerns !ae been raised about t!e possible inEuence of inadeHuate prenatal iodine inta6e on t!#roid function among offspring. A mar6ed reduction in median urinar# iodine concentrations among pregnant women was obsered in t!e ;nited States between national sure#s con- ducted during 11F
1* and 155 F 1*( !oweer, between t!e latter period and a new sure# conducted during 2001 and 2002, t!e direction of c!ange was stable to slig!tl# upward. 21 !us, no decrease in iodine inta6es was obsered in association wit! recent increases in t!e incidence rate of />, alt!oug! iodine mig!t !ae pla#e d a role in increasing trends obsered before t!e earl# 10s. Anot!er recent publication re ported t!at a ma4orit# of table salt samples ta6en from ;S olunteers !ad iodine measurements below t!e content recommended b# t!e ;S %ood and Drug Administration. 22
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related researc! Huestion is w!et!er perc!lorate e@posure from enironmental sources could affect t!#roid functioning, particularl# in a bac6ground of low iodine inta6es. esearc!ers at /D/ and elsew!ere !ae rened assa#s to measure perc!lorate in dried blood spots and ot!er biologica l samples and found t!at, in a representatie ;S sample, perc!lorate e@posure was widespread but below t!e reference dose. 23F2) Additional studies are needed to determine if common but low-leel perc!lorate e@posures, inadeHuate iodine inta6e, or bot! mig!t be contributing to recent trends in />-incidence rates in t!e ;nited States. A
ST'T,6SP,C0F0C ,/'2('T0)1S )F T*,1DS 01 01C0D,1C, *'T,S )F CH: P*,S,1T'T0)1S .- H'**0S4 P'SS4 ,'T)14 2)*,-4 3,(*014 '1D F,FF,*5'1
Data from indiidual states !ae pro- ided an opportunit# for detailed, record-based anal#ses of trends and ris6 factors for />. ;pdated data from 7ew Gor6 presented at t!e wor6s!op s!owed a persistent increase, as in t!e original publication t!at stimulated t!e 1 meeting. >inton et al1 incorporate detailed information from t!e presen- tations of data from 7ew Gor6, /alifor- nia, =assac!usetts, and e@as. A com- mon but not uniersal pattern in t!ese data was periods of increase wit! in- terals of stable incidence rates. In =assac!usetts, it was reported t!at alt!oug! low birt! weig!t newborns !ad a !ig!er incidence rate of />, in- creases in incidence rates also oc- curred among newborns of normal birt! weig!t. Anot!er important nd- ing, gien t!e increased relatie num- ber of >ispanic birt!s during t!e time period of interest, was conrmation of
!ig!er incidence rates of /> in /alifornia and e@as among >ispanic new borns. %inall#, in some of t!ese * states, c!anges in screening practices occurred, wit! ar#ing inEuence on t!e rates of /> identication.
/linical data from indiidual treatment centers are not population based and, t!erefore, do not proide direct eidence about secular trends( !oweer, suc! data can proide more detailed information about medical aspects of />, suc! as diagnostic imaging and long-term follow-up, t!at mig!t !elp to interpret trend data. !e aiserPermanente =edical /are Program in /alifornia !as proided a uniHue per- spectie b# irtue of t!e large birt! population it seres and its use of coordinated diagnostic, treatment, and preentie serices. 29 Scintigrap!# !as been reported among 200 nort!ern /alifornia newborns wit! />, wit! an oerall proportion of *3N wit! normalappearing t!#roid glands.1 As among t!e statewide population, >ispanic and female newborns !ad !ig!er incidence rates of /> t!an non->ispanic and male newborns, respectiel#. =oreoer, as discussed in t!e >inton et al1 article, abnormal scan results were more freHuent among >ispanic and female newborns, w!ic! reinforces t!e underl#ing !eterogeneit# of /> according to se@ and et!nicit#. ai- ser follow-up data presented from sout!ern /alifornia indicated t!at 1)N of newborns initiall# treated were eentuall# classied as !aing !ad transient !#pot!#roidism, and ini- tial S> alues were not predictie of w!o would turn out to !ae transient !#pot!#roidism. F(T(*, D0*,CT0)1S T) *,S)2/, )(TST'1D013 0SS(,S: P*,S,1T'T0)1 .- TH,**,22 '1D D0SC(SS0)1 2,D .- SH'P0*'
!e concluding presentations and dis- cussions at t!e wor6s!op focused
on 2
main areas: summariKing gaps in 6nowledge and brainstorming about future pro4ects to address t!ese gaps. !e article on t!e concluding session b# S!apira et al 2 proides a detailed reiew of a number of issues t!at re- mained unresoled or in need of up- dated information: L
consistent denitions of and diagnostic criteria for permanent and transient !#pot!#roidism(
L correct classication of transient
!#pot!#roidism and e@clusion of suc! cases from />-incidence-rate calculations( L trends in t!e incidence rate of
and transient /> !#pot!#roid- ism based on strict denitions of t!e screening and conrmator# diagnostic criteria for t!e condi- tions( L
L
effects of modiable and nonpre- entable ris6 factors on t!e inci- dence rate of />( and differences in follow-up and treat- ment of /> based on t!e t#pe of medical proider.
A number
of ideas for future
researc! were offered at t!e wor6s!op, wit! specic mec!anisms for carr#ing out t!ese pro4ects, and discussed b# S!a pira et al2:
L long-term follow-up of infants
wit! /> to ealuate effects on t!e />-incidence rate from maternal or infant factors and to determine t!e number of cases of true /> ersus transient !#pot!#roidism( L ot!er follow-up studies Cprospec-
tie or retrospectie t!at lin6 permanent ersus transient outcomes to initial diagnostic criteria( L ealuation of t!e relation between
newborn and maternal Cprenatal t!#roid-function tests( and L pilot pro4ects to document prac-
tices in conrmation and man-
P3DIAI/S &olume 12), Supplement 2, =a# 2010
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agement of /> b# primar# care pro iders and endocrinologists b# using common data elements. C)1C2(S0)1S At t!e end of t!e 2-da# wor6s!op in Atlanta, t!e inited participants !ad not identied a single cause for t!e reported increases in />-incidence rates. Indeed, t!e# pointed to a num*,F,*,1C,S 1. >arris 8, Pass A. Increase in congenital !#pot!#roidism in 7ew Gor6 State and in t!e ;nited States. #ol Genet #etab" 200( 1C3:295 F2 2. S!apira S, . >#pot!#roidism. Pediatr Clin North Am" 1(29C1:33F)1 *. 8rown S, >uang SA, %is!er DA. !e maturation of t!#roid function in t!e perinatal pe- riod and during c!ild!ood. In: 8raerman <, ;tiger , eds. %erner & 'ng bar (s The Throid) A *undamental and Clinical Te+t . t! ed. P!iladelp!ia, PA: ealt! /ommittee( 8rown S( , &ulsma . 7eonatal detection of congenital !#pot!#roidism of central ori-
ber of factors t!at need furt!er e@amination t!roug! anal#sis of e@ist- ing data or prospectie studies, most notabl# c!anges in diagnostic and treatment practices b# clinicians. Some of t!ese efforts are underwa# alread#. Public !ealt! action to address t!e issue will reHuire a better understanding of trends and identication of conrmed enironmental etiologies or ot!er pre-
gin. , Clin Endocrinol #etab" 200)(0C9: 33)0 F33)
10.
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entable ris6 factors t!at mig!t be re- sponsible for t!e occurrence of />. 'C+1)W2,D35,1TS 2e are indebted to participants at t!e wor6s!op for t!eir contributions, espe- ciall# t!e presenters w!o commented on t!e draft meeting summar# and pro- ided materials t!at formed t!e basis of t!is article.
15. 2aller D, Anderson '<, inton /%, >arris 8, 8orgfeld <, et al. rends in incidence rates of congenital !# pot !# roi di sm rel at ed to sel ec t demo- grap!ic factors: data from t!e ;nited States, /alifornia, =assac!usetts, 7ew Gor6, and e@as. Pediatri cs" 2010(12)C2 suppl:S3FS* 20. >ertKberg &, =ei ', !errell 8<. ffect of laborator# practices on t!e incidence rate of congenital !#pot!#roidism. Ped iat ric s" 2010(12)C2 suppl:S*5 F S)3
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1). Sorcini =, %aKKini /, "liieri A, et al. 7eonatal screening in congenital !#pot!#roidism in Ital#. !e 7ational egistr# Qin ItalianR. Ann 'st .uper .anita" 1*(30C3:2)F25 19. emper A, "u#ang <, $rosse SD. Discontinuation of t!#roid !ormone treatment among c!ildren in t!e ;nited States wit! congenital !#pot!#roidism: ndings from !ealt! insurance claims data. B#C Pediatr" 2010(10C1. In press 1. Sc!oen ', /lapp 2, o 00, %ireman 8>. !e 6e# role of newborn t!#roid scintigrap!# wit! iso- topic iodine C123I in dening and managing congenital !#pot!#roidism. Pediatrics" 200*( 11*C9. Aailable at: www.pediatrics.org+cgi+ content+full+11*+9+e953
23. Gu <, /!eng O, /anas ', &alentin-8lasini <, 8lount 8/, Anderson . /!allenges in determining perc!lorate in biolog ical tissues and Euids: implications for c!aracteriKing perc!lorate e@posure. Anal Chim Acta" 2009( )9C1:99 F 2 2*. 8lount 8/, &alentin-8la sini <, "sterlo! 'D, =auldin 'P, Pir6le '<. Perc!lorate e@posure of t!e ;S population, 2001F2002. , E+po .ci Environ Epidemiol" 200(1C*:*00 F *0 2). "tero-Santos S=, Delins6# AD, &alentin8lasini <, Sc!iffer ', 8lount 8/. Anal#sis of perc!lorate in dried blood spots using ion c!romatograp!# and tandem mass spectrometr#. Anal Chem" 200(51C):131F139 29. Sc!oen ', %efferman . Screening for con- genital !#pot!#roidism. , Pediat r" 150( 9C1:11F12
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Prevalence of Congenital Hypothyroidism Current Trends and Future Directions: Workshop Summary ic!ard S. "lne#, Scott D. $rosse and obert %. &ogt, 'r Pediatrics 2010(12)(S31 D"I: 10.1)*2+peds.200-1)/ (pdated 0nformation Services
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