Early pubic hair, breast, or genital development may result from normal but early maturation or from several abnormal conditions. Early puberty which is normal in every way except age is termed idiopathic central precocious puberty. It may be partial or transient. Central puberty can also occur prematurely if the inhibitory system of the brain is damaged, or a hypothalamic hematoma produces pulsatile gonadotropin-releasing hormone (GnRH). Secondary sexual development induced by sex steroids from other abnormal sources (gonadal or adrenal tumors, congenital adrenal hyperplasia, etc.) is referred to as peripheral precocious puberty or precocious pseudopuberty.

Clinical significance

Early sexual development deserves evaluation because it may :

induce early bone maturation and reduce eventual adult height,
cause significant social problems, or
indicate the presence of a tumor or other serious problem.

Measures

No single age limit reliably separates normal from abnormal processes, but the following age thresholds for evaluation will minimize the risk of missing a significant problem:

Pubic hair or genital enlargement in boys with onset before 9 years.
Breast development in boys before appearance of pubic hair and testicular enlargement.
Pubic hair before 8 or breast development in girls with onset before 7 years.
Vaginal bleeding in girls before 10 years.

Suggested causes: Environmental estrogens, sedentary lifestyle, and obesity

Other notes

Medical evaluation is sometimes necessary to recognize the few children with serious conditions from the majority who have entered puberty early but are still medically normal.

Children (esp. girls) who are obese are more likely to physically mature earlier.

Precocious puberty can make a child able to conceive when very young. Both sexes have become parents before age 10. The youngest mother on record is Lina Medina, who gave birth at the age of 5 years, 7 months and 21 days.

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Reassessing the Age Limit of Precocious Puberty in Girls
From American Family Physician, 3/15/00 by Grace Brooke Huffman

Standard textbooks usually define precocious puberty as "development of secondary sexual characteristics" in girls less than eight years of age. However, puberty seems to be occurring earlier now than in the past. Kaplowitz and colleagues reviewed existing data and issued some guidelines for evaluation and treatment of girls with possible precocious puberty.

Breast tissue development is the most accurate physical sign of puberty (activation of the pituitary-gonadal axis) in girls. Pubic hair usually appears at about the same time breast tissue development begins. Age estimates of onset of puberty are usually based on a 1969 study in which it was found that Tanner stage 2 breast development and stage 2 pubic hair development occurred at 11.15 [+ or -] 1.1 years and at 11.69 [+ or -] 1.21 years, respectively. Current studies, however, seem to indicate that these stages are now reached earlier (approximately one year earlier in white girls and two years earlier in black girls). Therefore, the youngest ages at which development will occur (and below which evaluation is needed) are lower than the new means.

Based on evaluation of available studies, the following recommendations have been made about when an evaluation is needed. First, a white girl who has breast or pubic hair development before age seven or a black girl who has this development before age six should be referred for further evaluation. Premature adrenarche (a normal variant) will be the most likely diagnosis in girls who present with pubic hair development but no breast development before age eight. Girls who exhibit evidence of other androgen production (e.g., rapid growth, clitoral enlargement or early onset of acne) will need to be evaluated for other virilizing disorders.

The second recommendation for further evaluation concerns patients with breast development beginning after age seven in white girls or age six in black girls who also have the following additional conditions: (1) a bone age more than two years ahead of their chronologic age and a predicted height that is at least two standard deviations below their genetic predicted height (for girls: the father's height [in inches] + the mother's height - 5 inches / 2); (2) a new onset of headaches, seizures or focal neurologic findings or a pre-existing neurologic problem; or (3) behaviors suggesting that puberty progression is adversely affecting emotional development. Obtaining a bone age determination would be appropriate in girls who are not above the 50th percentile in height or in whom breast development and puberty seem to be accelerated. This determination could help guide a decision about the use of gonadotropin-releasing hormone (GnRH) agonist therapy. If the girl's status is unclear, a re-examination in three to six months is reasonable. No good evidence exists to prove that the use of GnRH agonists in girls meeting these criteria (nonaccelerated puberty and an acceptable predicted adult height) improves adult height.

The committee made no changes to lower the age-limit recommendations about evaluation of boys with precocious puberty because a significant trend toward earlier maturation in males has not been evident.

GRACE BROOKE HUFFMAN, M.D.

Kaplowitz PB, et al. Reexamination of the age limit for defining when puberty is precocious in girls in the United States: implications for evaluation and treatment. Pediatrics October 1999;104:936-41.

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