大龄婴儿、儿童以及青少年甲状腺功能
婴幼儿时期,甲状腺质量、TSH受体数量、Tg和碘甲状腺原氨酸储备以及T4合成率均随着年龄的增长,呈现进行性的增加。在碘充足地区,未成年人甲状腺的生长与体型发育大致平行。既往研究通过超声测量未成年人甲状腺质量变化,确认出生时甲状腺平均质量为1.0g,10岁时为5g,而成年后可增长至20g。而同一时期,甲状腺碘含量则从出生时0.3mg,增长到青少年及成年时期的16mg。但在碘缺乏地区,新生儿甲状腺重量为2~3g,而碘含量则低至40ug。婴儿甲状腺碘清除率约是成人的3倍,其肾脏碘清除率也随着年龄的增长而递减。
儿童和青少年对放射性碘的吸收和清除,受到饮食和碘摄取的影响。有研究观察指出,20岁之前其吸收和清除率保持相对稳定。但是,欧洲、澳大利亚等低碘地区的研究结果,则显示儿童和青少年摄碘率与清除率呈进行性减低。因而学界推论,多项研究之间的差异可能是受到碘摄入量的影响。
自儿童期开始,血清TBG水平进行性降低,至15~16岁,达到并维持在成人水平。因此,未成年人血清T3和T4水平,也随着年龄的增长而逐渐降低,而血清中甲状腺转运蛋白的浓度则发生相反的变化。
多项研究通过免疫法检测血清FT4水平,观察到儿童在5岁之前血清FT4水平逐渐降低,而后维持稳定。但是,有研究通过平衡渗析法测量血清FT4水平,则发现婴幼儿血清FT4水平仅在出生后5~6个月之内表现为进行性减低,而后便维持相对稳定直到20岁。新生儿期后,足月儿、儿童以及青少年之间,血清FT4水平非常接近。出生2周后,血清TSH水平开始下降,同时TSH/FT4也逐渐变小,提示T4对TSH分泌负反馈调节的调定点也在不断调整。
随着T4降解率和Tg水平的下降,儿童和青少年甲状腺激素的代谢速率也在不断降低。目前认为1~2岁后,儿童和青少年T4合成率大约是2μg/(kg·d)。但是,对无甲状腺婴幼儿行T4替代治疗时,通常新生儿的口服剂量为8~12μg/(kg·d),婴儿为6~8μg/(kg·d),1~3岁时为3~4μg/(kg·d),之后为2~3μg/(kg·d),直至20岁。这一现象可能是因为口服T4吸收率通常仅为60%~70%,所以替代治疗的T4剂量,通常要高于同一时期正常个体的T4合成率。
进行性的T4合成和甲状腺摄碘率的减低,提示甲状腺功能的逐渐下降。血清TSH浓度的下降,则反映了TSH/FT4调定点的轻微变化。儿童和青少年时期,血清rT3主要来源于外周组织对T4的脱碘作用,其水平通常维持稳定或轻度提高。有研究发现,血清rT3/T4,以及游离rT3/FT4均随着年龄进行性升高,提示儿童和青少年期T4向rT3的转化逐渐增加。而血清T3/rT3,以及游离FT3/rT3则随着年龄减低,提示未成年人T4向T3的转化逐渐减少。
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