Gastric Perforation Associated with Congenital Diaphragmatic Hernia in a Neonate

and hypertension. Annual report of the American Association of Poison Control Centers' National Poison Data System of 2008 revealed that out of 9,006 unique exposures to thyroid preparations only 3 cases had major adverse outcome and there were no deaths[4]. It has been documented that there is no correlation between the amount of levothyroxine ingested and the onset and severity of the symptoms as well as the serum concentrations of both triiodothyronine (T3) and thyroxine (T4)[2,5-7]. In study by Golighty et al one child with massive ingestion (13mg) never developed any complications whereas ingestion of 1.8mg developed tachycardia[5]. Serum T4 levels can help only in verifying the occurrence of the ingestion[5,6]. In many pediatric levothyroxine ingestion study series either they did not develop symptoms or showed only minimal symptoms[2,36]. In a study by Livotiz et al only four out of 78 children developed symptoms and T4 levels in three of these four children were 32.8, 30 and 26.4 μg/dl, respectively[2] which were similar to T4 levels in our child. Literature has supported a conservative management based on minimal symptoms[2,5,6]. T4 values cannot be used to guide treatment, and prompt clinical monitoring and evaluation is necessary[5]. Propranolol is used in the presence of features of toxicity[3,5]. Julio Pardo opines thyroxine overdose needs very close monitoring after gastrointestinal decontamination and conser-vative treatment like propranolol, prednisone, etc should be started as soon as the patient becomes symp-tomatic to avoid the development of a thyroid storm[7]. In children with overdosage of levothyroxine, there is production of reverse T3 which is inactive, thereby protecting from the toxicity and this pathway is enhanced by steroids supporting addition of steroids to the treatment regimen[3,8]. To conclude although pediatric levothyroxine overdose rarely leads to serious toxicity, any symptoms should be managed accordingly as they arise.