Signs of early puberty can be deceiving and recognition of true early onset of puberty can help primary care providers make appropriate referrals to pediatric endocrinologists, according to a new guide to evaluation of children with these symptoms.
Most children with symptoms that appear to indicate early puberty simply show benign variations in typical growth and development that do not require testing or interventions, wrote Dr. Paul Kaplowitz and his colleagues with the American Academy of Pediatrics Section on Endocrinology.
“The most common of these signs of early puberty are premature adrenarche (early onset of pubic hair and/or body odor), premature thelarche (nonprogressive breast development, usually occurring before 2 years of age), and lipomastia, in which girls have apparent breast development which, on careful palpation, is determined to be adipose tissue,” wrote the investigators (Pediatrics 2015 Dec 14. doi:10.1542/peds.2015-3732).
Although there has been a decrease in the age of puberty onset, this trend stabilized in the 1950s, and currently, precocious puberty refers to onset before 8 years old in girls and before 9 years old in boys, though ethnicity and body weight can play a significant role in variation. Black girls appear to enter puberty earlier than white girls on average, for example. “Thus, the evaluation of girls with signs of early puberty has to take into account increased [body mass index] as well as race/ethnicity,” the authors wrote. Penile or testicular enlargement before age 9 in boys is concerning enough to warrant a referral, they suggested.
Early pubic hair growth and/or body odor without clitoromegaly, penile growth, or testicular enlargement may occur with increased levels of dehydroepiandrosterone sulfate (DHEA-S), typically 30-150 mcg/dL, but usually does not require referral or additional testing. A radiograph with cautious interpretation of bone age may help rule out early puberty.
Similarly, genital hair in infancy without genital enlargement or crossing of growth percentiles generally does not require any labs and has become somewhat less rare in recent years. It’s less clear with premature thelarche – palpable glandular tissue in girls under 2 year old – how much testing and follow-up is needed, but “it seems reasonable to hold off on hormonal testing and pelvic ultrasonography in most girls” when it does not increase and no crossing of growth percentiles occurs, the authors wrote.
Prepubertal vaginal bleeding – once potential trauma or tumors have been ruled out – is generally benign unless it becomes recurrent or continuous. In overweight and obese girls with apparent early breast development, a clinical exam can rule out progressive precocious puberty if no firm glandular tissue is found under the areolae and no estrogenic stimulation around the nipples and areolae exists.
A central precocious puberty (CPP) diagnosis may be considered in girls with “progressive breast development and who cross percentiles upward on the linear growth chart,” the authors wrote. Rarer in boys, the diagnosis may be considered with testicular and penile enlargement before age 9.
“The typical evaluation includes obtaining a family history, because CPP is occasionally inherited from the parents; menarche in the mother at 10 years or younger or a growth spurt in the father before 12 years of age are suggestive of autosomal-dominant inheritance,” the researchers noted. Questions to the family should include the child’s possible exposure to birth control pills, transdermal estrogen creams or testosterone gels, certain essential oils such as lavender and tea tree oil, and other potential exogenous sources of sex steroids.
“The family should also be asked about any [central nervous system] symptoms, including severe frequent headaches or recent visual deficits, and a history of disorders associated with CPP, including brain tumor, meningitis, CNS trauma, cranial irradiation, hypoxic-ischemic injury, histiocytosis, and neurofibromatosis,” the investigators wrote.
Diagnostic evaluation of central precocious puberty generally includes a bone age determination, baseline lab testing of follicle-stimulating hormone, luteinizing hormone, and estradiol or testosterone levels, and possibly pelvic ultrasonography, though most of this would be done by a pediatric endocrinologist.
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