The prevalence of transient and permanent congenital hypothyroidism in infants of Kurdistan Province, Iran (2006-2014)

Abstract

Background: Congenital hypothyroidism (CH) is the most common endocrine diseases and one of the major causes of preventable mental retardation. This study was conducted to investigate the prevalence of transient and permanent congenital hypothyroidism in Kurdistan province, Iran. Materials and Methods: In this cross-sectional study, all registered congenital hypothyroidism neonate of health centers of cities covered by Kurdistan University of Medical Sciences during 2006 to 2014 entered to study. Demographic and laboratory information of CH neonates was collected and entered into the Stata-12 and was analyzed using student t-test and Chi-square statistic and P- value less than 0.05 was considered. Results: Overall incidence rate during 2006 to 2014 for province was 1.8, 2.3, 3.2, 4.3, 3.3, 4.0, 3.6, 4.6 and 2.7, respectively per 1000 neonates in this period. The number of diagnosed patients was 855 cases including 519 (60.7%) boys and 336 (39.3%) girls who 516 (60.4%) cases were from urban areas. Of the total patients, 202 (22.6%) were permanent. There was no significant difference between gender, location, type of childbirth, and season of birth with transient and permanent types of disease (P > 0.05); while, there was a significant statistical relationship between consanguineous marriages and congenital hypothyroidism (P < 0.05). Conclusion: The prevalence of congenital hypothyroidism in Kurdistan province is significantly higher than the global and country levels that emphasize the continuation and reinforcement of screening program of infants. Therefore, complementary studies are research priorities of the health system in Kurdistan province in order to clarify the environmental and genetic factors related.

Full text

Int J Pediatr, Vol.5, N.2, Serial No.38, Feb.2017 4309
Original Article (Pages: 4309-4318)
http:// ijp.mums.ac.ir
The Prevalence of Transient and Permanent Congenital
Hypothyroidism in Infants of Kurdistan Province, Iran (2006-2014)
Zaher Khazaei1, Elham Goodarzi2, Ebrahim Ghaderi1, Salman Khazaei3, Alireza Alikhani4,
Saeeid Ghavi5, Kamyar Mansori6, Erfan Ayubi7, Behzad Gholamaliee8, Reza Beiranvand9,
Seyedeh Leila Dehghani10, Nahid Ghotbi11, Sairan Nili12
1
1Social Determinants of Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran. 2Social
Determinants of Health Research Centre, Medical School, Rafsanjan University of Medical Science, Rafsanjan,
Iran. 3Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical
Sciences, Tehran, Iran. 4Deputy of Medical Education Development Center, Kermanshah University of Medical
Sciences, Kermanshah, Iran. 5Social Determinants of Health Research Center, Department of Public Health,
Birjand University of Medical Sciences, Birjand, Iran. 6Social Development and Health Promotion Research
Center, Gonabad University of Medical Sciences, Gonabad, Iran. 7PhD Candidate of Epidemiology, Department of
Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 8Msc in
Health Education, Hamadan University of Medical Sciences, Hamadan, Iran. 9MSc Department of Health and
Community Medicine, Faculty of Medicine, Dezful University of Medical Sciences, Dezful, Iran. 10Department of
Public Health, Behbahan Faculty of Medical sciences, Behbahan, Iran. 11Associate Professor, Cellular & Molecular
Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran. 12PhD Student of Epidemiology,
Kerman University of Medical Sciences, Kerman, Iran.
Abstract
Background: Congenital hypothyroidism (CH) is the most common endocrine diseases and one of the
major causes of preventable mental retardation. This study was conducted to investigate the
prevalence of transient and permanent congenital hypothyroidism in Kurdistan province, Iran.
Materials and Methods: In this cross-sectional study, all registered congenital hypothyroidism
neonate of health centers of cities covered by Kurdistan University of Medical Sciences during 2006
to 2014 entered to study. Demographic and laboratory information of CH neonates was collected and
entered into the Stata-12 and was analyzed using student t-test and Chi-square statistic and P- value
less than 0.05 was considered.
Results: Overall incidence rate during 2006 to 2014 for province was 1.8, 2.3, 3.2, 4.3, 3.3, 4.0, 3.6,
4.6 and 2.7, respectively per 1000 neonates in this period. The number of diagnosed patients was 855
cases including 519 (60.7%) boys and 336 (39.3%) girls who 516 (60.4%) cases were from urban
areas. Of the total patients, 202 (22.6%) were permanent. There was no significant difference between
gender, location, type of childbirth, and season of birth with transient and permanent types of disease
(P˃0.05); while, there was a significant statistical relationship between consanguineous marriages and
congenital hypothyroidism (P<0.05).
Conclusion: The prevalence of congenital hypothyroidism in Kurdistan province is significantly
higher than the global and country levels that emphasize the continuation and reinforcement of
screening program of infants. Therefore, complementary studies are research priorities of the health
system in Kurdistan province in order to clarify the environmental and genetic factors related.
Key Words: Congenital hypothyroidism, Hypothyroidism, Neonate, Iran.
*Please cite this article as: Khazaei Z, Goodarzi E, Ghaderi E, Khazaei S, Alikhani A, Ghavi S, Mansori K, et
al. The prevalence of Transient and Permanent Congenital Hypothyroidism in Infants of Kurdistan Province
(2006-2014). Int J Pediatr 2017; 5(2): 4309-18. DOI: 10.22038/ijp.2016.7902
*
Corresponding Author:
Sairan Nili. Dept of Epidemiology, Kerman University of Medical Sciences, Kerman, Iran.
Email: nele_sayran@yahoo.com
Received date Nov.03, 2016; Accepted date: Dec 12, 2016

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Int J Pediatr, Vol.5, N.2, Serial No.38, Feb. 2017 4310
1- INTRODUCTION
Hypothyroidism is the result of decrease
in thyroid hormone synthesis or deficiency
in activity of thyroid hormone receptors.
The most common cause of congenital
hypothyroidism is disorder of complete or
partial development of the thyroid gland or
disorder of inappropriate replacement of
thyroid during the fetal period (Entopic
Gland) (1). CH is one of the major causes
of preventable mental retardation in
infants. Hypothalamic-pituitary-thyroid
axis starts its activity in the middle of fetal
life and evolves until birth of term infant.
Existence of hypothyroidism in the fetus
leads to some disorders in major organs
including the central nervous system and
the skeleton (2). Most infants seem quite
normal at birth, but children with signs of
precocious puberty and short stature and
delayed bone age should be sought for
hypothyroidism (3). Currently, almost all
the industrialized countries of the world
carry out the screening program for
neonatal hypothyroidism systemically (4).
Developing countries also gradually carry
out the screening program for neonatal
hypothyroidism at different scales. Its
implementation has also started in Iran
since 1997 (5). Before beginning screening
programs, early diagnosis of the disease is
usually conducted with delay due to the
low and non-specificity of signs and
symptoms in the first days of life, and this
issue is associated with the loss of
Intelligence Quotient (IQ) to various
degrees in patients (6). Congenital
hypothyroidism disease can lead to the
most important and major problems in
patients including failure to weight gain,
physical growth slowdown, delay in the
overall growth of the body and growth
failure of these children that is often
remained unknown (7). Congenital
hypothyroidism can be referred when
Thyroid-Stimulating Hormone (TSH) is
greater than 5mu/l of heel sample in
infants 3-5 days on filter paper (S&S 903
paper) and confirmation with venous blood
samples TSH is greater than 10mu/l and
thyroxine (T4) less than 6.5gr/dl (8).
Congenital hypothyroidism is divided into
two groups as permanent and transient.
The transient type is automatically
improving, while; the person has to take
medicine for the rest of his life in the
permanent type (9). Transient
hypothyroidism is thyroid symptoms at the
time of birth which are disappeared
spontaneously and thoroughly within a few
weeks or months (9). The most common
cause of transient hypothyroidism has been
reported iodine deficiency in the world.
Other causes of excessive consumption of
iodine are consumption of anti-thyroid
medications or presence of antibodies
against the thyroid during pregnancy (10).
In general, the incidence rate of disease in
the world has been estimated 1 in every
3,000-4,000 live births. According to
research conducted, prevalence spectrum
of CH in the world varies from 7.14 per
1000 births in Nigeria (2) to 14 per 1000
births in Japan (9). Based on studies
conducted in Iran, the incidence of this
disorder has been reported about 1 in 400
to 1 in 900 live births which is much
higher than the global average (10).
Results of studies from other countries
have shown that the prevalence of this
disease is 1 in 650 in Turkey (12), 1 in
1000 in France (13), 1 in 800 in Greece
(14), 1 in 2,372 in America (15), 1 in
2,640 in India (16), and in several studies
this amount is about 1 in 400 to 1 in 900
live births (17). National studies had
different results in this regard, so that
prevalence of this disease was ranged from
1 in 1000 in Tehran, 1 in 370 in Isfahan
(18), and 1 in 303 in Kashan (19), to 1 in
1433 live births in Shiraz (20). The
incidence of this disease in Kurdistan
province which is one of the western
provinces of Iran and a mountainous area
is higher and about 1 in 400 live births
(10).

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Int J Pediatr, Vol.5, N.2, Serial No.38, Feb. 2017 4311
Given the relatively high prevalence of this
disease in Kurdistan province and its
importance in the creation of mental
retardation in children, we decided to
investigate the prevalence of congenital
hypothyroidism in Kurdistan province
during 2006 to 2014.
2- MATERIALS AND METHODS
2-1. Study Design and Population
This cross-sectional study was
conducted on children with neonatal
hypothyroidism. In this we used the data
collected from the CH screening in
Kurdistan Province, Iran, from August
2006 to August 2014. National screening
program for early detection of CH was
conducted by Iranian Ministry of Health
and Medical Education (MOHME) in all
provinces in 2005 and has been in progress
up to now. Kurdistan is located in west of
Iran, and according to National Census, in
2011 population of Kurdistan province
was 1,493,645 out of which 66% lived in
urban area. The capital of Kurdistan
province is the city of Sanandaj and other
counties are Marivan, Baneh, Saqqez,
Qorveh, Bijar, Kamyaran, Dehgolan,
Diwandarreh and Sarvabad.
2-2. Methods
According to the neonatal hypothyroidism
screening program, a few drops of blood
from the baby's heel is poured onto the
filter paper by the Lancet on the third to
fifth day of birth, and will be sent to the
newborn screening laboratories in the
provincial capitals by express post after
being dried which usually takes 3 hours.
After testing and determining the amount
of TSH, if it is less than 5 mu/L, it will be
known as a healthy infant otherwise as
suspected cases. And if amount of TSH is
5-9.9, the second filter paper is taken and
if it is more than 10, it will be referred to
the focal point in order to conduct serum
tests and approve or reject the disease.
Start treatment is ideal about 2 weeks to 3
weeks after birth (21). Treatment of
infected infants starts with a dose of 10 to
15 μg / mg levothyroxine medication.
After 3 years of treatment, in order to
determine whether permanent or transient
disease, treatment is discontinued for 2-4
weeks and tests are repeated. If the
transient disease is normal, treatment will
be discontinued otherwise it is permanent
and medication must be consumed until
the end of life (22).
In this program, heel prick blood samples
have been taken on Whatman filter papers
for infants by trained staff, mostly within
3-5 days of birth. They dry and
immediately transfer to the reference
screening laboratory of the province by
express mail service. Thyroid stimulating
hormone (TSH) test using the enzyme
linked immunosorbent assay (ELISA)
method. In this study according National
screening program TSH less than 4mu/l
and 5mu/l were considered normal for 3-7
day-old and ≥ 8 day- old neonates,
respectively. Then, the neonates with TSH
more than normal were selected. In order
to distinguish between permanent and
transient cases of CH, levothyroxine (LT4)
therapy was discontinued for 4 weeks in
children who were ≥ 3 years old, after
which time thyroid function tests (T4 and
TSH) were evaluated by the same
laboratory methods and the same
enzymatic kits. If the thyroid function tests
showed a high TSH with low T4, the
patient was diagnosed to have permanent
CH.
2-3. Measuring tools
We used registered data for each patient
which exists in Kurdistan deputy of health.
Information including gender (boy/girl),
location (rural/urban), county, date of
birth, parental consanguinity
(present/absent), delivery type
(Natural/cesarean section), birth weight,
length of infant and TSH and T4 level at
first measurement (mIU/L) were extracted
from this checklist.

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2-4. Eligibility criteria
Eligibility for including in this study were
cases had CH diagnosed by a newborn
screening program and confirmed by
venous blood samples, and also if they had
been treated with levothyroxine, and were
followed up closely in the first three years
of life.
2-5. Ethical considerations
Data were obtained with the consent of the
Kurdistan Deputy Health. And data were
in possession of researchers without a
patient's name.
2-6. Data analyses
Incidence rates were calculated per 1,000
live births by county for each year from
2006 to 2014. The average annual rate of
reduction (increase) (AARR [I]) was
calculated using a regression analysis to
quantify the rate of change of the
incidence from 2006 to 2014. In this
regression model, the incidence rate for
each county was considered as dependent
and the year as independent variable.
Then, using the coefficient (B) obtained
the AARR/I was calculated by the
following formula: AARR= 1-exp (B).
By using GIS software, map location of
CH cases in the province was drowning.
Frequency, mean and standard deviation
(SD) for demographic data according CH
type (permanent/transient) in neonates
were estimated. Qualitative variables were
compared using the Chi-square test and
quantitative variables were compared by t-
test. In this study, P-values less than 0.05
were considered significant. Statistical
analyses were performed using the Stata
software, version 12.0 (Stata Corp, College
Station, TX, USA).
3- RESULTS
According CH register data available in
Kurdistan deputy of health, 855 CH
patients were registered during 9 years
period (March 2006 to March 2014).
Among 855 neonates with CH, 202
(22.6%) of them were permanent CH and
544 (63.6%) were transient CH, 519
(60.7%) were boy and 336 (39.3%) were
girls (boy: girl ratio 1.54:1). 516 (60.4%)
of them were lived in urban areas. Chi-
square test showed no statistically
significant relation between gender
(P=0.1) and location (P=0.67) with CH
type. Neonates with the consanguine
parents had the significantly higher
proportion of permanent CH (29.7%)
compared parents without consanguinity
(20.8%) (P=0.03).
608 (71.1%) of neonates were born natural
and 247 (28.9%) were born with cesarean
section; there was no significance relation
between delivery type and CH type
(P=0.3). 239 (28%) and 178 (20.8%) of
children were born in spring and autumn,
respectively. There was no significance
relation between season of birth and CH
type (P=0.24) (Table.1).
The trends of incidence rate (per 1000 live
births) for CH cases are shown in Table.2.
The overall incidence rate for province
was 1.8, 2.3, 3.2, 4.3, 3.3, 4.0, 3.6, 4.6 and
2.7, respectively per 1000 neonates in this
period. This rate was increasing (1.8 in
2006 to 2.7 in 2014; 6.7% increase per
each year in this period). This trend only
for Gorveh and Sarvabad were decreasing;
but significance trend were shown only for
Divandareh with the 26.9% increase per
increase in these 9 years (P<0.05).
As shown in Figure.1, a geography
disparity was observed across Kurdistan
province because the spatial distribution of
incidence rate of CH varies at county level.
Generaly incidence rate of CH was higher
in North counties. Higher incidence rate of
CH were observed in Divandarreh County
in Nnorth and lowest in Qorveh County in
Southeast of Kurdistan province,
respectively. The mean birth weight of
permanent CH and transient CH neonates
was 3160 ± 613.7 and 31540 ± 599.5
grams, respectively. The mean TSH levels

Kaheni et al.
Int J Pediatr, Vol.5, N.2, Serial No.38, Feb. 2017 4313
at first measurement in permanent were
significantly higher than transient CH
cases (14.1±17.6 vs. 11.3±16.2 mIU/L)
(P=0.04). Also, mean T4 levels at first
measurement in permanent CH cases were
8.8 ± 10.8 mIU/L and 11.4 ± 16 mIU/L in
transient CH cases. As shown in Table.3
and there was a significance differences
between T4 levels at fist measurement
permanent and transient CH patients
(P=0.04).
Table-1: Demographic and geographic distribution of CH neonates according CH type
Variables
Total (%)
Permanent CH
No (%)
Transient CH
No (%)
P-value
Unknown
No (%)
Gender
Boy
519(60.7)
133(25.6)
322(64)
0.1
64(12.3)
Girl
336(39.3)
69(20.5)
222(62.1)
45(13.4)
Residency
Urban
516(60.4)
124(24)
324(62.8)
0.67
68(13.2)
Rural
339(39.6)
79(23.1)
219(64.8)
41(12.1)
Parental
consanguinity
Absent
700(81.9)
146(20.8)
460(65.7)
0.03
94(13.4)
Present
155(18.3)
46(29.7)
94(60.7)
15(9.7)
Delivery Type
Normal vaginal
delivery
608(71.1)
139(22.9)
395(65)
0. 3
74(12.2)
Cesarean section
247(28.9)
63(25.5)
149(60.3)
35(14.2)
Season of birth
Spring
239(28.0)
47(19.7)
155(64.8)
0.24
37(15.5)
Summer
203(23.8)
58(28.6)
123(60.1)
22(10.8)
Autumn
178(20.8)
44(24.9)
112(63.3)
21(11.9)
Winter
235(27.4)
52(22.2)
153(65.3)
30(12.4)
Table-2: Trend of incidence rate (per 1000 live births) for Congenital Hypothyroidism in Kurdistan
province by county (2006-2014)
County
2006
2007
2008
2009
2010
2011
2012
2013
2014
AARR(I)
P-
value
Baneh
Fre
6
5
8
5
7
10
10
12
7
+2.2
0.49
IR
2.4
2.0
2.8
1.8
2.2
3.0
3.0
3.4
1.9
Bijar
Fre
3
3
4
4
6
9
4
3
3
+2.3
0.7
IR
2.0
1.5
2.7
2.6
4.2
6.2
2.7
1.9
1.9
Dehgolan
Fre
2
2
2
1
2
2
3
2
3
+2.42
0.55
IR
1.9
1.9
1.9
0.9
1.8
1.7
2.5
1.7
2.2
Diwandarreh
Fre
4
5
5
13
7
18
28
23
3
+26.9
0.003
IR
2.9
3.3
3.3
8.9
4.9
12.9
19.8
15.5
2.0
Qorveh
Fre
2
3
2
2
3
2
1
3
2
-3.6
0.44
IR
0.8
1.2
0.8
0.8
1.2
0.8
0.4
1.1
0.7
Kamyaran
Fre
5
14
12
5
9
14
12
9
22
+9.25
0.16
IR
2.7
7.8
6.2
2.6
4.7
7.5
6.3
4.9
11.0
Marivan
Fre
7
3
8
14
3
19
15
9
17
+11.1
0.23
IR
2.2
0.9
2.5
4.0
0.9
5.4
4.1
2.3
3.8
Saqqez
Fre
6
14
19
33
17
13
14
31
11
+4.9
0.5
IR
1.6
3.4
4.7
8.1
4.4
3.4
3.7
7.6
2.5
Sanandaj
Fre
10
10
24
38
33
20
13
40
14
+3.1
0.68
IR
1.5
1.4
3.4
5.0
4.4
2.6
1.6
4.9
1.6

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Sarvabad
Fre
3
2
2
3
2
1
1
2
2
-4.1
0.35
IR
3.4
2.4
2.5
3.6
2.6
1.6
1.4
2.8
2.7
Total
Fre
48
61
86
118
89
108
101
134
84
+6.7
0.1
IR
1.8
2.3
3.2
4.3
3.3
4.0
3.6
4.6
2.7
Fre: Frequency, IR: Incidence Rate per 1000 birth, AARR (I): average annual rate of reduction (increase).
Positive sign for AARR (I) represent increasing trend and negative sign represent decreasing trend.
Fig.1: Spatial distribution for CH mean incidence rate according counties in Kurdistan province
Table-3: Biochemical and anthropometric measures of CH neonates according CH type
Variables
Permanent CH
(mean± SD)
Transient CH
(mean ± SD)
P-value
Birth Weight (gr)
3160.1±613.7
3154.0±599.5
0.9
Length at Birth (cm)
49.5±5.97
48.3±7.6
0.3
TSH level at first measurement
(mIU/L)
14.13±17.6
11.3±16.2
0.04
T4 level at first measurement
(mIU/L)
8.8±10.8
11.4±16.0
0.04
Age at start of treatment (day)
21.15±13.2
21.44±14.1
0.8
4- DISCUSSION
The results of this study showed that
during the years 2006 to 2014, the number
of 855 infants were diagnosed with CH,
that 519 (60.7%) were boy and 516
patients (60.4%) were lived in urban areas.
202 (22.6%) of them were with permanent
hypothyroidism and 519 (63.6%) were
transient hypothyroidism. The number of
cases with transient hypothyroidism has
been more than permanent hypothyroidism
cases during the years 2006 to 2014.

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Int J Pediatr, Vol.5, N.2, Serial No.38, Feb. 2017 4315
The mean age of start of treatment was
21.29 + 0.328 days in our study that was
21.15 + 0.027 days in permanent type and
21.44 + 0.142 days in transient type, and
no statistically significant difference was
found between age of start of treatment
and the type of hypothyroidism (transient
and permanent) that was consistent with
the study of Hashemipoor in Isfahan (23);
while, the mean age of start of treatment
was 38 days in the study of Kusdal in
Turkey that they have not seen it
appropriate and have mentioned delay in
conducting and receiving test results as the
reason (24).
In this study, the mean of weight and
height of infants with congenital
hypothyroidism were 3160 + 0.326 grams
and 49.5 + 0.028 cm, respectively, and
there was no statistically significant
relationship between weight and height of
infants with congenital hypothyroid
whereas was not consistent with the study
of Abedi et al. in Sanandaj in 2013 (25).
Investigation of annual incidence rate of
congenital hypothyroidism showed that
Divandareh city had the highest average of
annual incidence (+26.9) and this trend has
increased during the years 2006 to 2014
(P=0.003). Thus, the need for educational
programs in the field of prevention of
congenital hypothyroidism in this city
should be prioritized.
It seems that initially, doctors of
Divandarreh city were identified TSH
above 5 (instead of TSH above 10) as
patient and treated them which has been
lead to the increase in the prevalence of
this disease in this city that this criterion
has changed in recent years and TSH
above 10 has been defined as a patient.
The results of study showed that
congenital hypothyroidism was higher in
boys than girls and a significant
relationship between consanguineous
marriage and incidence of congenital
hypothyroidism disease was obtained.
In the study of Beheshti et al. in 2015 in
Mazandaran, the number of cases of
transient hypothyroidism was more than
permanent type (38.1% vs. 56.7%), which
was consistent with the results of our study
(11). In the study of Dareh et al. (2013) in
Markazi province- Iran, 122 patients were
with permanent hypothyroidism (29.5%)
and 113 patients were with transient
hypothyroidism (27.3%) of the total
patients (12). Disease incidence (transient
and permanent) in the province Kurdistan
is higher than the national average (1 in
300 vs. 1 in 414); of course, disease
incidence in the country is also higher than
many other countries which genetic and
environmental factors can be it causes due
to the high percentage of transient
hypothyroidism and that iodine deficiency
is the most common cause of incidence of
the transient type (13).
The prevalence of hypothyroidism is
variation in different regions in the world.
The difference between contractual criteria
which are considered in order to definitive
diagnosis of congenital hypothyroidism,
iodine deficiency in some areas of the
world and racial differences can be
mentioned as the causes of variety of the
prevalence of hypothyroidism in different
parts of the world (14); so that, it is 1 in 67
in Nigeria, and 1 in 781 live births in
Pakistan. Several studies in Iran show that
the prevalence amount of congenital
hypothyroidism was reported 1 in 950
births in Tehran, in Isfahan 1 in 342 live
births in 2002 and 1 in 333 live births in
2009, 1 in 1000 in Kerman, 1 in 446 in
Qazvin, and 1 in 397 live births in
Boroujerd (26). These statistics indicate
that the prevalence of congenital
hypothyroidism in Kurdistan province
compared to the global average (1 in 3,500
to 4,500 live births) is much higher and
almost in the average level of Statistics of
Iran (1 in 400 to 1 in 900 live births) (9).
The results of our study showed that 519
(60.7%) infants with hypothyroidism were

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Int J Pediatr, Vol.5, N.2, Serial No.38, Feb. 2017 4316
boy and 336 (39.3%) are girl. In the
majority of research conducted, the
prevalence of the disease in females are
more than males (21), but in the present
study, sexual prevalence ratio of female
was obtained less than male (1 to 1,41),
although this difference was not
statistically significant. In the study
conducted in Isfahan, the prevalence in
females was less than males (1 to 1, 45),
which is consistent with the results of our
study (27).
In the study of Zitalzadeh et al., the
prevalence of congenital hypothyroidism
in boys were more than girls, but this
difference was not statistically significant
(P=0.38) (21). Recent years studies in Iran
show that hypothyroidism is slightly more
in boys (11, 28).The results of this study
showed that hypothyroidism is 516
(60.4%) in urban areas and 339 (39.6%) in
rural areas that this difference was not
statistically significant. In the study of
Mohammadi et al. (2012) in Kerman, the
prevalence of congenital hypothyroidism
in the village was significantly higher than
the city (20) that was not consistent with
our study. In the present study, the ratio of
consanguineous marriage to non-
consanguineous marriage in parents of
hypothyroidism infants was 20 to 80
percent. These ratios do not introduce the
effect of consanguineous marriage, but this
ratio was 70 to 30 percent in the study of
Tehran and Damavand. In the study of
Siami et al., the ratio of consanguineous
marriage to non- consanguineous marriage
in parents of hypothyroidism infants was
25 to 75 percent (29).
In the present study, the highest prevalence
of congenital hypothyroidism was seen in
spring and winter and the lowest in
summer and autumn which this difference
was not statistically significant (P=0.24).
In the study which was conducted in
Japan, most cases of congenital
hypothyroidism were in spring and winter
(30), which was consistent with the results
of our study. In another study in Yazd, the
highest prevalence of congenital
hypothyroidism has been in spring and
summer and the lowest in autumn and
winter, respectively (25). The seasonal
differences in the incidence of congenital
hypothyroidism indicate that several
factors such as genetic and environmental
factors can play a role in creating it (31).
The results of our study showed that TSH
range of infants was 11.3 mU/L in
transient type and 14.13 mU/L in
permanent type, and T4 level was 8.8
mu/L in permanent type and 11.4 mU/L in
transient type, and there was a significant
relationship between congenital
hypothyroidism and level of TSH and T4
(P=0.04). In the study of Beheshti et al.,
the mean of TSH was 24.19 mU/L (21).
In the study of Siami et al., the mean and
standard deviation of TSH and T4 in
hypothyroidism infants were 36.05±33.35
and 8.82±9.55, respectively (29). In the
present study, 71.7% of childbirth was
natural and 28.9% were cesarean, and no
significant relationship between the types
of childbirth and catching the transient and
permanent types of disease was obtained.
In the study of Beheshti et al. unlike our
study, the ratio of natural childbirth to
cesarean was (35.8% vs. 64.2%) (11).
4-1. Limitations of the study
Failure to accurately document existing
data in the health centers of cities of the
province can be mentioned as the
limitation of this study.
5- CONCLUSION
Given the high prevalence of congenital
hypothyroidism in Kurdistan and the
importance of this disease in creation of
mental retardation, informing people and
health care personnel in order to encourage
parents to participate in the screening
program of congenital hypothyroidism is
essential to be able to take preventive
interventions by a more detailed planning.

Kaheni et al.
Int J Pediatr, Vol.5, N.2, Serial No.38, Feb. 2017 4317
Given that the prevalence of this disease
has been higher in Divandarreh city and
generally has an increasing trend in
Kurdistan province counties except
Sarvabad and Qorveh during recent years,
it emphasizes the need for further trainings
and the implementation of measures
planned for reducing the disease in the
city. Higher incidence rate of CH were
observed in Divandarreh county in North
and lowest in Qorveh County in Southeast
of Kurdistan province, respectively.
Complementary studies can provide a
clearer picture of the risk factors of this
disease in infants of the province for the
researchers.
6- CONFLICT OF INTEREST: None.
7- ACKNOWLEDGMENT
We offer our sincere appreciation for all
respected colleagues in the department of non-
communicable diseases and Healthcare
Department of Kurdistan University of
Medical Sciences and subsidiary cities that
assisted us in this research.
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