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Thyroid disease in children is very rare and the occurrence of Graves' disease even more so. It has been estimated that Graves' disease (GD) accounts for approximately 10-15% of hyperthyroidism in children. Graves' disease in children and adolescents accounts for approximately 1-5% of all cases of Graves' disease.

Children may have the same symptoms as adults, but may not complain about them. Sometimes the most prominent symptom may be extreme restlessness and short attention span leading to difficulties at school and at home.

The modalities of treatment for children and adults are the same, namely antithyroid drugs, radioiodine treatment or surgery. Many pediatricians initiate treatment with antithyroid drugs and if improvement is not seen, another modality is chosen. Antithyroid drugs are usually not given long term to children since only 30-40% of children respond. In addition, the side effects in children can be severe, and the relapse rate of Graves' disease is high. Studies also indicate that the risk of thyroid carcinoma in children and adolescents increases with time and is higher following antithyroid treatment than following radioiodine treatment. Some children are best managed by removing the thyroid gland once the hyperthyroidism is under control.

Radioiodine treatment does not thus far appear to cause any increase in the risk of thyroid carcinoma in children and adolescents. Further investigation regarding long-term outcomes is needed. Some doctors prefer to consider RAI as an option for failed antithyroid drugs before they consider surgery.

In children, surgery may be considered under the following conditions:

• Large thyroid gland
• Severe Graves' ophthalmopathy
• Poor response to antithyroid drugs

The success rate of thyroidectomy in children has been estimated at approximately 95%. There is ongoing debate regarding the long-term advantages of total versus subtotal thyroidectomy in children and adolescents. As with adults, the success of surgery is highly dependent on the skill of the surgeon. Complications of surgical thyroidectomy, (e.g., hypoparathyroidism and laryngeal nerve injury) are estimated at approximately 4%.

When subtotal thyroidectomy is performed on children, the remnant left in the patient is usually smaller than that of an adult patient because the risk of recurrence of hyperthyroidism is higher than for an adult. With the minimal thyroid tissue left in children, the risk of recurrence is reduced to approximately 10% and the risk of developing hypothyroidism is approximately 40%.

With RAI and thyroidectomy, permanent hypothyroidism is common and requires life long thyroid replacement therapy.