Sign up for our daily newsletter


Athyreosis congenital hypothyroidism cretinism: Congenital hypothyroidism

Santana-da-Silva, Does the polymorphism in the length of the polyalanine tract of FOXE1 gene influence the risk of thyroid dysgenesis occurrence? Weber, D.

Matthew Cox
Tuesday, November 3, 2020
  • In countries where newborn screening programs take place, all infants with CH are diagnosed after detection by newborn screening tests.

  • Neurodevelopmental outcomes in congenital hypothyroidism: Comparison of initial T4 dose and time to reach target T4 and TSH. Bole-Feysot, L.

  • Effect of different starting doses of levothyroxine on growth and intellectual outcome at four years of age in congenital hypothyroidism. Trends in incidence rates of congenital hypothyroidism related to select demographic factors: Data from the United States, California, Massachusetts, New York and Texas.

  • La Franchi SH.

Add new comment

In the developed countries, almost all instances of CH are detected by a newborn screening program which hypothyroidsm based on measurements of thyroxine T 4 or TSH on the 2nd or 3rd day of life. There are also a few uncommon symptoms which can be characterized by appearance: yellow skin, puffy face, hands and feet, enlarged tongue. Persani, A.

Persani, S. Galazzi, M. A 7-year experience with low blood TSH cutoff levels for neonatal screening reveals an unsuspected frequency of congenital hypothyroidism CH. Persani, I.

J Clin Endocrinol Metab Oct;96 10 Recent advances in fetal imaging techniques ultrasonography and fetal hormonology have made it athyreosis congenital hypothyroidism cretinism to identify thyroid function disorders in the fetus that could potentially be treated in utero by administering drugs to the mother. The initial screening in an affected twin may be normal; a second screening in same sex twins should be considered. TD is considered a sporadic disease. Rose SR. The underlying etiology of thyroid dysgenesis remains largely unknown.

Definition and classification

Cretinism of this danger, it is important to start treatment as soon as possible after birth. One pitfall of scintigraphy is lack of isotope uptake despite the presence of thyroid tissue. CrossrefMedlineGoogle Scholar 8. Thyroid scanning ultrasound, and serum thyroglobulin in determining the origin of congenital hypothyroidism.

How to evaluate fetal thyroid function and to manage nonautoimmune fetal cretinism have been described in the CH concensus guidelines 1. Re-evaluation is essential in subjects who were preterm or sick during the neonatal period Endocrinology — It is unclear whether the thyroid cancer is gene-specific or related to goiter development.

Therefore, in TSH-based neonatal screening programs, their screening result may be false negative 29 In addition, an expert on the development of evidence-based guidelines was recruited to serve in an advisory capacity. Catherine E. Disease severity, as judged by very low initial levels of thyroid hormones due to the absence or loss of function of the thyroid gland and by severely delayed bone age, has also been shown to be an important predictive factor for neurodevelopment 4982 — Permanent congenital hypothyroidism may be due to primary or secondary central causes. One may also find evidence of maternal autoimmune thyroid disease or an iodine deficient diet.

Login to your account

As the child grows up, these levels are checked regularly to maintain the right dose. Hypoparathyroidism Hypoparathyroidism Pseudohypoparathyroidism Pseudopseudohypoparathyroidism. August J Paediatr Child Health ;

Syndromic CH is mostly caused by mutations in genes encoding transcription factors or involved in early thyroid development. Eur J Pediatr. Although triiodithyronine T3 is the biologically active form of the hormone, most T3 in the brain is formed from local deiodination of T4; thus, T3 replacement is not needed for normal neurologic functioning. These further diagnostics and intervention should only be done by an experienced multidisciplinary team in a specialized center of prenatal care after a careful benefit—risk evaluation.

Most children born with congenital hypothyroidism and correctly treated with thyroxine grow and develop normally in all respects. Ardissino, G. Results of screening tests could guide further tests required for confirmation diagnosis and urgency of replacement therapy. Lyons, R. Show related SlideShares at end. Trubiroha, R. Macroglossia 1 7.

Navigation menu

Effect of different starting doses of levothyroxine on growth and intellectual outcome at four years of age in congenital hypothyroidism. Clin Endocrinol Oxf — Barakat syndrome Tricho—rhino—phalangeal syndrome. Acta Paediatr Suppl.

For goitrous nonimmune fetal hypothyroidism leading to hydramnios, we recommend intra-amniotic injections of LT4 to decrease the size of the fetal thyroid gland. Treatment should be initiated in any infant with a positive screening result, right after confirmatory tests are drawn but before results are available [ 8283 ]. Acta Paediatr. Thyroid hormone is also important in the formation and maturation of bone [ 1516 ]. Normal T4 and elevated TSH values Infant with an elevated serum TSH level and a normal free T4 or total T4 have either a transient or permanent thyroid abnormality[ 22 ] or delayed maturation of the hypothalamic-pituitary axis.

  • Transient CH in newborn may be due to maternal thyrotropin receptor-blocking antibodies, exposure to maternal antithyroid medications, iodine deficiency and iodine excess.

  • Oostdijk, E. Porazzi, C.

  • Detection of thyrotropin binding inhibitory activity in neonatal blood spots. Choreoathetosis - hypothyroidism - neonatal respiratory distress NKX2.

  • Infant with athyreosis congenital hypothyroidism cretinism elevated serum TSH level and a normal free T4 or total T4 have either a transient or permanent thyroid abnormality[ 22 ] or delayed maturation of the hypothalamic-pituitary axis. Immunoglobulin superfamily member 1 gene IGSF1 mutations are the molecular cause of a recently described X-linked syndrome, including mild-to-moderate central CH.

Van Vliet G, Deladoey J. Even mild or subclinical attack hypothyroidism is considered to adversely affect fertility. Age based reference values must be followed in interpreting the results. Gruters, D.

Heart malformations, variable expressivity. Table 3 gives genes implicated in thyroid cretinism. A report from the U. Findings may guide treatment decisions in infants with borderline serum test results, e. Pediatr Int. In one study done on hypothyroid neonates, ectopic thyroid tissue was found inferior and superior to the hyoid bone, and above the thyroid cartilage [ 30 ]. Help Learn to edit Community portal Recent changes Upload file.


Neurologia — There is no evidence for a one optimal follow-up scheme. Experience with intraamniotic thyroxine treatment in nonimmune fetal goitrous hypothyroidism in 12 cases. Psychometric testing in infants both treated and not treated antenatally, however, may provide useful information. Hear Res —

  • Intellectual and motor development of young adults with congenital hypothyroidism diagnosed by neonatal screening.

  • Government General Hospital. Along with this, the normal postnatal increasing in the TSH levels can pose as an issue when the affected infants are discharged earlier.

  • While some patients with Pendred syndrome may develop hypothyroidism at birth [ 75 ], the majority are clinically and biochemically euthyroid. If the serum T4 or freeT4 and TSH remain normal, the presumed diagnosis is transient congenital hypothyroidism and treatment is no longer needed.

  • Mansouri, A. Congenital hypothyroidism CH occurs in to births worldwide.

  • Google Scholar PubMed.

Weber, D. Schoenmakers, Comprehensive screening of eight known causative genes in congenital hypothyroidism with gland-in-situ. You are commenting using your WordPress. HR Atrichia with papular lesions.

De Angelis, H. Congenital hypothyroidism by Ravindra Sharma views. Thyroid 26 6— Apart from the above mentioned causes, CH may also occur sporadically due to some idiopathic factors. Clipping is a handy way to collect important slides you want to go back to later.

Change Password

In the absence of thyroid tissue in the normal location, small hyperechoic structures of approximately the same echogenicity as fat are found laterally on both sides of the trachea, mimicking the appearance of a thyroid gland. Randomized controlled trials addressing this question have not been performed. A study has shown cost-effectiveness of the programme in UK. This is measured in umbilical cord serum to be percent of normal [ 10 ].

In this study, the infants with hypothyroidis, athyreosis congenital hypothyroidism cretinism hypothyroidism achieved the highest intellectual scores when started at the highest dose [ 90 ]. Finally, prolonged heat exposure may reduce the efficacy of l-thyroxine tablets. Variable hypopituitarism associated with septo-optic dysplasia or pituitary stalk interruption syndrome. Adverse effects of long-term LT4 treatment are rare or absent if adequately prescribed. Further, if a pregnant woman inadvertently receives radioactive iodine RAI after weeks gestation, the fetal thyroid will trap the RAI, resulting in thyroid ablation and hypothyroidism. Mothers should be investigated for TRB-Ab in cases of recurrent congenital hypothyroidism in siblings. Following are examples of typical cutoffs for T4 and TSH:.

Secondary or Central hypothyroidism Congenital secondary or central hypothyroidism generally results from defects of Cretinism production; most commonly, it is part of a disorder causing congenital hypopituitarism. Toni Torresani. Therefore, lifestyle interventions, including diet and physical exercise, should be encouraged to avoid metabolic abnormalities 1. The goal of therapy is to render the patient euthyroid, with a normal TSH concentration.

Clinincal features

Cancer Biomark — A detailed description of the grading scheme has been published elsewhere 7. MedlineGoogle Scholar Heyerdahl SOerbeck B. In preterm newborns, the TSH surge and the blood levels of T4 and T3 are lower than those in term neonates.

Bas, L. Porazzi, C. Szinnai, A. White, P. It is also used to treat thyroid cancer along with surgery and other medicines. Most of these children eventually ended up in institutional care. Apart from the above mentioned causes, CH may also occur sporadically due to some idiopathic factors.

In the era before newborn screening, less than half of cases of severe hypothyroidism were recognized in the first month of life. Louzada, M. Boelen, E. Secondary Hypothyroidism — It originates at the pituitary gland. Many have speech delays as well as some other behavior problems.

Summary of Recommendations

Thus, an exact cause for the vast hypothyroidism cretinism of cases of thyroid dysgenesis remains unknown. Grasberger H, Athyreeosis S. Diagnostic algorithm: the diagnosis of congenital hypothyroidism begins with either abnormal newborn screening test results or a clinical suspicion of hypothyroidism, leading to serum thyroid function tests typically TSH and free T4 to confirm the diagnosis.

Santana-da-Silva, Does the polymorphism in the hyppothyroidism of the polyalanine tract of FOXE1 gene influence the risk of thyroid dysgenesis occurrence? Medical College, Tirupati 5. In adults, cretinism results in mental deterioration, swelling of the skin, loss of water and hair. Issue Date : March Ovulation is impeded and infertility is common. A diagnostic protocol starting with an ultrasonography of thyroid and serum thyroglobulin levels can aid identify the probable underlying etiology and dictate the cases requiring scintigraphy or genetic tests. Laros, M.

ALSO READ: Toe Cramps And Hypothyroidism

Non-immune goiter and hypothyroidism in a week fetus: a plea for conservative treatment. In the study by Oron et al. Of these several defect, mutations in thyroid peroxidase TPO gene are the most prevalent causes of inherited defects in CH. This has been illustrated in studies done in both Europe, the United States and Canada [ 8085 ][ 87 - 89 ]. However, I is specifically taken up by the thyroid gland and gives a clearer scan than 99m Tc

Cretinism revisited. Treatment for congenital hypothyroidism: athyreosis congenital hypothyroidism cretinism alone or thyroxine hypothyoridism triiodothyronine? Neither test approach will detect infants with defects of thyroid transport, metabolism, or action. Family structure and parental involvement are important for preventing and tackling this problem. Other programs, however, have not found an effect of age of onset of treatment. GH and PRL deficiency, prominent forehead, midface hypoplasia, depressed nose. Recently, DUOX2 mutations have also been reported in patients with thyroid ectopy; however, further studies are needed to confirm and explain this striking finding

Access options

Catherine E. Only a few studies have evaluated the impact of long-term L-T 4 treatment on bone mineral density. Risk factors for neurodevelopmental deficits in congenital hypothyroidism after early substitution treatment. J Pediatr Endocrinol. Table 2.

Thyroid scintigraphy and perchlorate test after recombinant human TSH: a new tool for the differential diagnosis of congenital hypothyroidism during infancy. In some cases, athyreosis congenital hypothyroidism cretinism was already present and thyroid nodules isolated or multiple developed despite apparently adequate LT4 treatment. Norms have been established as a function of GA. The absence of one or both knee epiphyses has been shown to be related to: 1 T 4 concentration at diagnosis; and 2 IQ outcome, and is thus a reliable index of intrauterine hypothyroidism 47 The first treatment goal in neonates with primary CH is to rapidly increase the circulating amount of TH, reflected by normalization of serum TSH; therafter, TSH should be kept within the reference interval. One specific disorder, Pendred's syndrome consists of sensorineural deafness, goiter, and impaired iodide organification.

J Med Imaging Radiat Oncol — Netrin is part of a family of laminin-related proteins, involved in cell migration and possibly in cognenital development of pharyngeal vessels Eur J Epidemiol. European Journal of Endocrinology. Returning user. Athyreosis congenital hypothyroidism cretinism on current outcome data, an immediate treatment should be initiated, and it appears necessary to maintain adequate L-T 4 treatment throughout the lifespan for most patients, with a particular emphasis on treatment in the first years of life and of treatment optimization in pregnant women with CH. On the other hand, all of the infants with milder hypothyroidism did well except the group treated with the lower dose and later age of onset, which had an IQ points lower than the other groups [ ].

Navigation menu

Infants born with congenital hypothyroidism may show no effects, or may display mild effects that often go unrecognized as a problem. Fugazzola, N. Hovens, A.

Mechanisms of disease: psychomotor retardation and high T3 levels caused by mutations in monocarboxylate transporter 8. It is, therefore, hypothyroidsm possible to formulate guidelines from current data. Thyroid ultrasonography can confirm a large gland, suggestive of dyshormonogenesis. Familial forms of thyroid dysgenesis among infants with congenital hypothyroidism. Causes of congenital hypothyroidism include iodine deficiency and a developmental defect in the thyroid glandeither due to a genetic defect or of unknown cause. How to evaluate fetal thyroid function and to manage nonautoimmune fetal hypothyroidism have been described in the CH concensus guidelines 1.

  • Is the incidence of congenital hypothyroidism really increasing?

  • Porazzi, S.

  • Dyshormonogenesis leads to goitrous hypothyroidism; however, this is rarely seen in babies detected by newborn screening [ 45 ]. The evidence-based guidelines were graded with the Grading of Recommendations, Assessment, Development and Evaluation system, describing both the strength of recommendations and the quality of evidence.

  • Abstract Congenital hypothyroidism CH is the one of the most common preventable cause of mental retardation.

Thus, the use of iodine-containing disinfectants is yypothyroidism in preterm babies, since exposure to topical iodine may cause transient neonatal hypo- or hyperthyroidism as summarized in a systematic review hypothyroidims Treatment should be started promptly and infant should be rendered euthyroid as early as possible, as there is an inverse relationship between intelligence quotient IQ and the age at diagnosis. Therefore, additional measurement of TSH and fT4 around the age of 3 to 4 weeks should be considered. In addition, a certain percentage of affected patients has morphological abnormalities of the pituitary gland or hypothalamus, or other neurological defects 25 Transient primary CH can be defined as an increase in TSH levels during the neonatal period, with normal TFT results obtained off treatment at a later stage. In summary, if a patient is detected with congenital hypothyroidism and imaging studies show some form of thyroid dysgenesis, the families can be counseled that the recurrence risk appears small, around 2 percent. Indian J Pediatr.

Hypothyroidism due to deficient transcription factors involved athyreosiw pituitary development or function. Treatment for weight gain due to hypothyroidism treatment, there may have been factors other than age of onset of treatment that influenced IQ outcome, such as initial starting dose. Thyroid dysgenesis: hypothyroidism due to a developmental anomaly. Follow-up of newborns with low thyroxine and nonelevated thyroid-stimulating hormone-screening concentrations: Results of the year experience in the Northwest Regional Newborn Screening Program. It is important to bear in mind, however, that the degree of hypothyroidism is not simply related to the size of the residual thyroid gland. This syndrome has been recently referred to as Bamforth-Lazarus Syndrome [ 35 ].

Method for Developing Evidence-Based Recommendations

Tharian, J. Fugazzola, F. Hypofunction Diabetes mellitus types: type 1 type 2 MODY 1 2 3 4 5 6 complications coma angiopathy ketoacidosis nephropathy neuropathy retinopathy cardiomyopathy insulin receptor Rabson—Mendenhall syndrome Insulin resistance.

Individuals with CH require monitoring throughout their lives, particularly during early childhood and pregnancy. This represents the path taken by the developing thyroid as it descends from the base of the tongue to its final location in the neck [ 2829 ]. Figure 1. Bibcode : Chmsp. Because of this danger, it is important to start treatment as soon as possible after birth. In none of the studies T3 was administered.

  • Severely affected children may benefit from a higher initial dose of L-T 4leading to the more rapid normalization of thyroid hormone levels and potentially resulting in a better intellectual outcome 88 —

  • Treatment consists of a daily dose of thyroxineavailable as a small tablet.

  • In addition, some forms of CH are associated with defects in other organ systems; these are classified as syndromic hypothyroidism. Scintigraphy is the most accurate diagnostic test for determining the etiology of CH, especially in case of TD.

  • A gland in the wrong place is referred to as ectopicand an ectopic gland at the base or back of the tongue is a lingual thyroid. Among specific defects are thyrotropin TSH resistance, iodine trapping defect, organification defect, thyroglobulinand iodotyrosine deiodinase deficiency.

  • CASR Familial hypocalciuric hypercalcemia.

Although the condition has been observed in all populations throughout the world, it is hypothyroidism cretinism more prevalent among the Hispanic group. Heinen, M. The dose increases as the child grows. Early identification and intervention is important as Thyroid dependent brain development is complete by 3 years of age. Gaujoux, F. Neurological impairment may be mild with reduced muscle tone and coordination. Raynaud-Ravni, P.

Schmitt, C. Start on. Kempers, L. Felice, A mouse model demonstrates a multigenic origin of congenital hypothyroidism. Are you sure you want to Yes No. Partial thyroidectomy may be needed in such cases.

Publication types

Biebermann, H. London: Blackwell Science; Nongoitrous congenital hypothyroidism has been described as the "most prevalent inborn endocrine disorder". Bole-Feysot, L. Kilinska, M.

Other drugs that may cause hypothyroidism include amiodarone, interferon alpha, interleukin-2 athyreosis congenital hypothyroidism cretinism thalidomide. Oostdijk, E. The developmental quotient DQ, as per Gesell Developmental Schedules of children with hypothyroidism at age 24 months that have received treatment within the first 3 weeks of birth is summarised below:. Naveen Kumar Cheri. Dreschler, O. Caiulo, R.

  • The expert panel recognizes that crushing tablets is an off-label procedure, but that it has been done this way succesfullly for many years. Thus, an exact cause for the vast majority of cases of thyroid dysgenesis remains unknown.

  • Kant, C. Ardissino, G.

  • The remaining sections and tables were written by SL. Corresponding Author: Dr.

  • If such infants are not treated, measurement of FT4 and TSH should be repeated at 2 and 4 weeks and treatment should be initiated promptly if the FT4 and TSH concentrations have not normalized. This syndrome is caused by a genetic defect in the transmembrane protein pendrin encoded on 7q31which acts as a chloride-iodide transporter in both in the thyroid gland and the inner ear.

  • Table 2: Syndromic associations of congenital hypothyroidism Click here to view. The L- thyroxine tablet should be crushed, mixed with breast milk, formula, or water and fed to the infant.

  • Motor and cognitive development in children with congenital hypothyroidism: a clngenital evaluation of the athyreosis congenital hypothyroidism cretinism of neonatal treatment. Antenatal diagnosis As congenital hypothyroidism is most commonly not a heritable disorder, and the majority of cases are sporadic, it is not possible to identify a population of pregnant women who are at high risk for fetal hypothyroidism.

Polak, P. It can also be related to increased stress. Bas, L. Cancel Save. Losekoot, L. Procedures Drugs calcium balance corticosteroids oral hypoglycemics pituitary and hypothalamic thyroid.

If the child zthyreosis delays in some specific areas of speech or learning, it athyreosis congenital hypothyroidism cretinism be possible to arrange for additional help. Endocrinology 3— Google Scholar In the developed world, nearly all cases of congenital hypothyroidism are detected by the newborn screening program. We provide an overview of recent genetic causes of primary and central CH.

Navigation menu

Endocrinology 1— Mnif, L. Download references. In certain cases, the gland might be smaller in size than usual or not located in its proper place. Soleimani, T.

In case the thyroid gland is absent, a baby cannot produce any of his or her own thyroid hormone. Retrieved 22 May No Downloads. It can be so severe that the person cannot stand or walk. Bonaldi, V. Bas, L. Diagnostic re-evaluation of children with congenital hypothyroidism.

ALSO READ: Symptoms Central Hypothyroidism

Method for Developing Evidence-Based Recommendations. Therefore, lifestyle interventions, including diet and physical exercise, should be encouraged to avoid metabolic abnormalities 1. Goiter, variable hypothyroidism, conserved iodide uptake, partial defect at perchlorate discharge, high serum Tg. Effect of different starting doses of levothyroxine on growth and intellectual outcome at four years of age in congenital hypothyroidism. Transient hypothyroxinemia of the preterm neonate is a frequent finding, often aggravated by general illness of the preterm neonate and it is due to an immature HPT function.

Normal Cretinism and elevated TSH values Infant with an elevated serum TSH level and a normal free T4 or total T4 have either a transient or permanent thyroid abnormality[ 22 ] or delayed maturation of the hypothalamic-pituitary axis. The etiology of the most common cause of CH, thyroid dysgenesis, is largely unknown as the increase incidence of CH. Therefore, LT4 treatment should be started only after a normal adrenal function test result or after glucocorticoid treatment has been started Testing for specific genetic mutations generally is only considered after other studies point to a specific defect, e.

  • MedlineGoogle Scholar 9. Only a few studies have evaluated the impact of long-term L-T 4 treatment on bone mineral density.

  • Lethargy 1 4. The L- thyroxine tablet should be crushed, mixed with breast milk, formula, or water and fed to the infant.

  • Table 1. Young adults with severe congenital hypothyroidism: cognitive event related potentials ERPs and the significance of an early start of thyroxine treatment.

  • Published online Jun Variable hypopituitarism, anterior pituitary hypoplasia with ectopic posterior pituitary, Arnold—Chiari syndrome, hypoplasia of the corpus callosum.

Persistence of severe, untreated hypothyroidism resulted in severe mental impairment, with an IQ below 80 in the majority. Philadelphia: Elsevier Saunders; Grueters, H. Fugazzola, Genetics and management of congenital hypothyroidism.

RevEndocr MetabDisord. Therefore, additional measurement of TSH and fT4 around the age of 3 to 4 weeks should be considered. Categories : Athyreosis congenital hypothyroidism cretinism disease Congenital disorders of endocrine system Intellectual disability Cell surface receptor deficiencies. Congenital hypothyroidism detected by neonatal screening: relationship between biochemical severity and early clinical features. Extensive genetic analysis of a large group of affected patients revealed novel variants, expanding BLT syndrome phenotype

Search form

Volume 31 Issue creginism Mar As described under confirmatory serum thyroid testing aboveresults will lead to a diagnosis of primary congenital hypothyroidism, subclinical hypothyroidism, and, in some programs, secondary or central hypothyroidism. The immature HPT axis in the extreme preterm neonates is characterized by i a markedly attenuated TSH surge, ii a T4 decrease instead of an increase, and iii a clearly lower and shorter T3 increase within the first 24 hours of life. Thyroid Scintigraphy.

Courtesy Dr. FZD4 Familial exudative vitreoretinopathy 1. Universal newborn screening for congenital hypothyroidism. Wolff — Chaikoff effect. J Trop Pediatr ;

Muzza, L. Genetics of congenital hypothyroidism. Bartolucci, R. There are also a few uncommon symptoms of athyreosis congenital hypothyroidism cretinism athyreoosis be characterized by appearance, such as yellow skin, puffy face, hands and feet, enlarged tongue. Iodine is an essential element, necessary and primary for the synthesis of thyroid hormones. Galazzi, M. Kariyawasam, M.

Bakker, G. Pediatr Radiol ; Arch Pediatr Adolesc Med ; Prenat Diagn ;

Bole-Feysot, P. Amiel, D. Hypothyroidism cretinism, C. Almaghamsi, C. Early intervention programs can be availed which are present in most developed countries to provide support to young children before they attain school age. An 8 month old infant with a homozygous mutation in the TTF-2 gene locus leading to congenital hypothyroidism.

Also, recently, NGS studies in crftinism of CH patients screened for mutations in sets of CH genes revealed that a significant proportion of these patients has multiple athyreosis congenital hypothyroidism cretinism in more than one thyroid-specific gene 89, In addition, the nonaffected twin should be followed up for possible TSH elevation later in life Anti-thyroid antibodies Maternal autoimmune thyroid disease may be associated with production of a thryotropin receptor blocking antibody TRB-Ab. In countries with newborn screening programs in place, infants with CH are diagnosed after detection by screening tests.