Graves’ Disease in Pediatrics
Graves’ disease is a common cause of an
overactive thyroid. It occurs in about 1 in
5000 children and teens. It occurs more
often in females than males. This booklet is
designed to help you learn more about
Graves’ disease. After reading it, please feel
free to ask your nurse or doctor any
questions you may have about Graves’
Before we can discuss what it means to have
this disease, we need to back up and take a
look at the main body organ involved in
Graves’ disease: the thyroid gland.
What is the thyroid gland?
The thyroid is a butterfly-shaped gland
found in the front of the neck. It is part of
the endocrine system. This means it makes
hormones and sends them into the
bloodstream. Then they can act on certain
parts of the body called target organs.
The thyroid uses iodine and other building
blocks to make two hormones: thyroxine
(called T4) and triiodothyronine (called
T3). Your thyroid makes more T4 than T3,
but in other parts of the body some T4 is
changed to the more active T3.
Thyroid hormones affect almost every tissue
and organ system. They act on a number of
target organs to aid in growth, body and
brain development, and normal metabolism.
Thyroid hormone acts like the body’s “gas
pedal,” because it affects the rates of
growth, muscle contraction, metabolism,
and protein building.
The thyroid is controlled by two centers in
the brain called the hypothalamus and the
pituitary gland. The pituitary gland is a
pea-shaped organ at the base of the brain
and the hypothalamus lies just above it.
When the body needs more T3 or T4, the
hypothalamus sends a message (thyroid
releasing hormone or TRH) to the pituitary
telling it to release thyroid stimulating
hormone (TSH). TSH causes the thyroid to
raise the body’s level of thyroid hormones.
The hypothalamus and the pituitary gland
detect this increase and stop sending TSH
messages when the thyroid has produced
enough of the hormone.
What do hyperthyroidism and
When your thyroid is working as it should
and it makes the right amount of thyroid
hormone, you are euthyroid (eu- meaning
“normal”). If you produce too much thyroid
hormone, it is called hyperthyroid (hyper –
meaning “too much”). Low levels of
thyroid in the body cause you to be
hypothyroid (hypo – meaning “too little”).
You need to know the symptoms of hyper-
and hypothyroidism because both may occur
in the course of treating Graves’ disease.
Symptoms of Hyperthyroidism (too much
T3 and T4)
▪ Feeling hot when nobody else does
▪ Having moist or sweaty skin
▪ Feeling nervous or restless, having
trouble falling or staying asleep
▪ Short attention span
▪ Normal or increased growth rate, but
▪ Increased appetite
▪ Rapid heart beat
▪ Muscle weakness or tremors
▪ Fine hair
Symptoms of Hypothyroidism (too little
T3 and T4)
▪ Feeling cold when nobody else does
▪ Cool, dry skin
▪ Slowed growth and weight gain
▪ Poor appetite
▪ Having a calm or quiet nature
▪ Coarse, dry, thin hair
What Causes Graves’ Disease?
Graves’ disease is an autoimmune (auto –
meaning “self”) disease. Every person has
an immune system which will produce
antibodies (also called immunoglobulins)
that help the body fight disease. An
antibody connects to a foreign particle in the
body and helps destroy it. But when the
immune system makes antibodies against
things that are not foreign to the body, but
are part of the body, autoimmune disorders
like Graves’ disease occur.
In Graves’ disease, the body’s immune
system makes antibodies that affect the
thyroid in the same way TSH would. Like
TSH, these antibodies, called thyroid-
stimulating immumoglobulins or TSI, act
as a message that turns the thyroid “on” and
tells it to produce thyroid hormones. But,
unlike TSH, TSI is not controlled by thyroid
hormone levels, and the result is
The reason the body begins to produce
antibodies against the thyroid is not fully
known. Research seems to suggest that
some peoples’ genes make them more prone
to making autoantibodies
What will the doctor do to decide if I have
Your doctor relies on your health history,
physical exam, and blood tests to decide if
you have Graves’ disease. The list below
describes many of the things your doctor
may do or order during your clinic visit.
Look for signs of Graves’ disease by
▪ Weight loss or rapid growth.
▪ Resting pulse rate of greater than 100
beats per minute.
▪ Blood pressure with a large gap
between the high (systolic) and low
▪ Fast reflexes.
▪ Moist or oily skin and hair.
▪ Enlarged thyroid gland (called a
goiter). In hyperthyroidism due to
Graves’ disease, the thyroid is
enlarged because stimulation of the
thyroid by TSI causes it to grow.
▪ Prominent eyes called
exophthalmos. This gives you a
wide-eyed staring look. This is
caused by autoantibodies and is not a
result of hyperthyroidism. Other
changes in the eyes may include
excess tearing, aching, or burning
behind the eye, a feeling as if grit or
sand is in the eye, or being bothered
▪ Nervous system signs such as
tremors, feeling restless, muscle
weakness, and sleep problems.
Your doctor will also order some lab tests.
The main things your doctor wants to
1. TSH levels in people with Graves’ are
very low because their T3 and T4 are
high enough that the pituitary does not
need to send TSH to the thyroid to make
it produce T3 and T4.
2. Free T3 and Free T4 tests find that T3
is high when a person is hyperthyroid.
T4 may be normal or high. Since
Graves’ speeds up the change of T4 into
T3, normal levels of T4 can occur with
high levels of T3.
3. TSI is sometimes, but not always, seen
when Graves’ disease is the problem.
4. Thyroid Scan gives a picture of how
your thyroid uses iodine. It can be used
to decide whether it is Graves’ disease or
some other cause of hyperthyroidism.
This test is rarely used in children.
How is Graves’ disease treated?
If hyperthyroidism is not treated, it can be a
severe problem. As a result, if patients have
symptoms, they should receive medical,
radiation, or surgical treatments.
Tapazole® (methimazole) acts on the thyroid
to reduce its production of thyroid
hormones. As a result, less thyroid hormone
is produced. These drugs also slow down
the change of T4 to T3.
Another group of drugs called beta-
blockers (e.g., propanolol), do not act on
the thyroid and do not affect thyroid
hormone levels, but block the effects of the
thyroid hormones in the body. For instance,
this type of drug might be used when
Graves’ is first diagnosed and the heart rate
is very rapid.
In children, most doctors use Tapazole®
(methimazole) as the first treatment for
Graves’ disease. We will adjust the dose to
bring thyroid hormone levels into the normal
range. Knowing the signs of hypo – and
hyperthyroidism will allow you to tell your
doctor that a change in dose may be needed.
About 5% of Graves’ disease patients
getting drug treatment have side effects such
as skin rashes, liver problems, joint pain,
and fever. Rarely, problems with white
blood cell production can cause high fever
and throat or mouth infections. You must
call your doctor or the endocrinology
nurse if you have any of these signs or
symptoms. You will need blood tests done
to watch for any of these side effects.
Even though drug treatment works well to
lower thyroid hormone levels, it does not
shrink the size of the thyroid gland or
prevent other problems of Graves’ disease
such as eye problems. Treatment is often
needed for two or more years. But we
cannot predict the course of Graves’ disease
and sustained use of drug therapy may not
be the best option. At that time, we may
need to think about other forms of treatment.
Radioablation can be used to permanently
treat the hyperthyroidism of Grave’s disease.
Because iodine is a crucial building block of
thyroid hormones, the thyroid will take up
radioactive iodine, which then destroys the
thyroid cells. The risk of getting cancer or
having children with birth defects is not
increased for patients who have received
radioablation, but it is expected that
hypothyroidism will result and this can be
treated with thyroid hormone supplement.
More than one treatment with radioiodine
may be needed.
Overactive thyroid tissue can also be
removed by surgery (thyroidectomy). In
the hands of a skilled surgeon, side effects
rarely occur. The risks include: not enough
of the thyroid gland is removed, damage to
the nearby parathyroid glands, or damage to
the nerve that controls the vocal cords. To
reduce some of these risks, drug treatment
may be needed before surgery to lower
thyroid hormone levels.
Drugs are most often used as the first type of
treatment for children and teens. But each
case varies and so will the treatment choices.
Either radioablation or surgery can destroy
the tissue that is causing too much thyroid
hormone to be produced. Because of its
ease, lower cost, and safety, radioablation
may be the preferred treatment for patients
with long-term, unstable Graves’ disease.
Thyroidectomy is the best choice for
patients with a large thyroid who have failed
medical treatment and do not want
After surgery, hypothyroidism would be
expected. The patient would then need to be
on thyroid hormone replacement. This is a
once daily tablet.
All of these treatments control the
hyperthyroidism part of Graves’ disease by
bringing down hormone levels, but they do
not cure the disease. It is best to discuss
with your doctor whether drug treatment,
radioablation, or surgery would be the best
option for you.
How long will my Graves’ disease last?
We cannot predict how long you will have
Graves’ disease because each case is unique.
Some people respond well to drug treatment
and their Graves’ disease goes into
remission after the first 18 to 24 months of
treatment. For most people, longer
treatment is needed. When radioablation is
used, symptoms decrease after a few
months. With surgery, the results are seen
sooner. Since the TSI can persist after
hyperthyroidism is gone, ask your doctor
what this might mean for you.
What can I do to help?
One of the best things you can do is to learn
more about the thyroid and Graves’ disease.
By knowing the symptoms of hypo – and
hyperthyroidism, what your medicines are,
and how to use them, you can help us take
good care of you.
Follow your treatment plan by taking your
medicine as prescribed. Do not miss doses.
This is the best thing you can do to ensure
success. Regularly scheduled clinic visits
and blood tests will also help your doctors
and nurses work with you to keep you
healthy. Feel free to ask your doctor or
nurse any questions you may have. For
further information, you can contact these
Graves Disease and Thyroid Foundation
P.O. Box 2793
Rancho Santa Fe, CA 92067
The American Thyroid Association
Kappy, Michael S; Allen, David B. and Geffner, Mitchell E.
Principles and Practice of Pediatric Endocrinology (2005). Springfield, IL: Charles C. Thomas, Publisher, LTD.
Rivkees, S. Optional treatment for Graves' Disease J CLIN ENDOCRINOLOGY METABOLISM 2007 March
Spanish Version of this HFFY is #7503
Your health care team may have given you this information as part of your care. If so, please use it and call if you
have any questions. If this information was not given to you as part of your care, please check with your doctor. This
is not medical advice. This is not to be used for diagnosis or treatment of any medical condition. Because each
person’s health needs are different, you should talk with your doctor or others on your health care team when using
this information. If you have an emergency, please call 911. Copyright © 3/2014. University of Wisconsin Hospital
and Clinics Authority. All rights reserved. Produced by the Department of Nursing. HF#6653