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4 Treatment Î Of the established instruments used to measure hypothyroid symptoms, data are lacking regarding their sensitivity and specificity in the ''everyday'' clinical setting to recommend their routine clinical use. (S-M) Note: Further studies are needed to determine if and how to combine general psychological screening instruments, hypothyroidism-specific tools, and laboratory assessment of thyroid function to measure the impact of levothyroxine replacement therapy on psychological well-being, treatment satisfaction, and preference in clinical practice. Î A minority of patients with hypothyroidism, but normal serum TSH values, may perceive a suboptimal health status of unclear etiology. Acknowledgment of the patients' symptoms and evaluation for alternative causes is recommended in such cases. (W-L) Note: Future research into whether there are specific subgroups of the population being treated for hypothyroidism who might benefit from combination therapy should be encouraged. Hypothyroidism in Pregnant Women, Infants, and Children Î Pregnant women with overt hypothyroidism should receive levothyroxine replacement therapy with the dose titrated to achieve a TSH concentration within the trimester-specific reference range. Serial serum TSH levels should be assessed every 4 weeks during the first half of pregnancy in order to adjust levothyroxine dosing to maintain TSH within the trimester-specific range. Serum TSH should also be reassessed during the second half of pregnancy. For women already taking levothyroxine, two additional doses per week of the current levothyroxine dose, given as one extra dose twice weekly with several days separation, may be started as soon as pregnancy is confirmed. (S-M) Î In infants, levothyroxine replacement at a dose of 10-15 μg/kg/d should be initiated once newborn screening is positive, pending the results of confirmatory testing. Higher doses may be required for infants with severe congenital hypothyroidism. (S-H) Note: The aim of therapy is to maintain the serum thyroxine in the mid- to upper half of the pediatric reference range and the serum TSH in the mid- to lower half of the pediatric reference range. The target should be to normalize serum thyroxine approximately 2-4 weeks after initiation of therapy. Once the proper dose is identified, surveillance testing with a serum TSH and thyroxine should be performed every 1-2 months during the first year of life with decreasing frequency as the child ages. Î All children with overt hypothyroidism should receive levothyroxine replacement therapy to normalize their biochemical parameters and reverse their signs and symptoms of hypothyroidism. (S-H)

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