Open AccessSubclinical hypothyroidism (SCH), defined by a normal total or free T4 level and a mildly elevated TSH (typically 5–10 mU/L), is common in children, but there is currently no consensus on management. Several recent pediatric studies indicate that progression of SCH to overt hypothyroidism (OH) is uncommon and that over a period of several years, elevated TSH usually either normalizes or persists but does not increase. The etiology appears to be multifactorial, with some cases representing minor developmental abnormalities, some related to obesity, some to mild autoimmune thyroiditis, and some associated with mutations in the gene for the TSH-receptor. There are no pediatric studies showing clinical benefit of treating these children with thyroid hormone, but additional studies in this area are needed. Since few cases of pediatric SCH progress to OH, treatment can be deferred, and periodic follow-up testing may be the preferred strategy, with elevated thyroid antibodies or a goiter being considered risk factors for eventual OH.