Signs of Early Sexual Maturation Are Benign in Most Cases

Diana Swift

December 17, 2015

Most often, signs of early sexual maturation in children are benign and do not signal the arrival of puberty, according to an American Academy of Pediatrics clinical report published online December 14 in Pediatrics.

"Although a small number of such children have a disorder that requires thorough testing and treatment, the great majority of patients have benign, normal variants of puberty, some of which can be followed by the primary care provider without immediate testing or referral," write the report's authors, Paul Kaplowitz, MD, PhD, senior pediatric endocrinologist at the Children's National Health System in Washington, DC, and Clifford Bloch, MD, a pediatric endocrinologist in Greenwood Village, Colorado.

The most common form of early puberty is premature adrenarche, which includes pubic and axillary hair, axillary odor, and sometimes mild acne. The authors note, however, that as long as a child continues on a normal growth curve, then the child is unlikely to have true central precocious puberty and can be managed by observation in the course of primary care without tests such as laboratory assays and bone age radiographs.

According to Dr Kaplowitz, however, in 10% of children with early maturation signs, a serious hormonal condition is triggering precocious puberty, and these patients should be referred to a specialist such as a pediatric endocrinologist, gynecologist, or urologist. "But even among this 10%, not all of them will actually need treatment," said Dr Kaplowitz in an interview with Medscape Medical News.

Markers of true central precocious puberty include progressive breast development over the course of 4 to 6 months or progressive penile and testicular enlargement, especially when accompanied by rapid linear growth.

"Children exhibiting these true indicators of early puberty need prompt evaluation by the appropriate pediatric medical subspecialist. Therapy with a gonadotropin-releasing hormone agonist may be indicated," the authors write.

One reason for treatment is the preservation of height potential "because untreated [central precocious puberty] may result in premature cessation of growth and resultant short stature," the authors explain. A predicted adult height, based on bone age, of less than 5 feet in a girl and less than 5 feet 5 inches in a boy is an indication for intervention, although improved height appears to be greater in those treated for puberty onset before age 7 years.

Other reasons for treatment include preventing early menarche in emotionally immature girls and preventing aggressive or sexual behavior in boys. "The main reason parents request treatment is to prevent early periods in young girls, although some girls handle this well if there is adequate reassurance and preparation from the parents," Dr Kaplowitz said. He added that it takes at least 2 years from the onset of breast development for menses to begin.

The report also notes that variations in the onset of pubertal signs are associated with ethnicity and weight. A 2010 report by Biro and colleagues, for example, found that in a three-city longitudinal study of girls aged 7 and 8 years, breast development was observed in 23% of blacks, 15% of Hispanics, and 10% of whites. And in addition to being a risk factor for early pubertal signs, obesity can also make it difficult to see whether a child really has true breast tissue development, rather than adipose tissue in the breast area. "And obesity is not the whole story, because not all of these children are overweight," Dr Kaplowitz cautioned.

There is also some concern that exposure to estrogen-like chemicals in the environment may foster early breast development. "But I don't think endocrine disrupters interacting with estrogen receptors are driving this, because we would see more breast development in boys," he said.

The report was undertaken for the academy 2 years ago to provide an up-to-date information summary and clinical guidance to the pediatricians and primary care physicians seeing growing numbers of children with early pubertal signs. "Some of them don't feel comfortable in distinguishing between the benign scenarios that could be followed in their offices and the more serious scenarios that really do require prompt referral to specialists," Dr Kaplowitz told Medscape Medical News.

The guide takes clinicians through the generally benign variants: premature adrenarche, premature thelarche (palpable glandular breast tissue in patients younger than age 2 years), genital hair in infancy, and lipomastia (nonglandular adipose breast tissue). Although increasing numbers of overweight girls are being referred because of lipomastia,"[i]f the breast examination is inconclusive, the patient is unlikely to have progressive precocious puberty," the authors write.

A much rarer benign phenomenon discussed in the guide is prepubertal vaginal bleeding, which studies have shown generally resolves in one to six episodes. Heavy, recurrent, or continuous bleeding is cause for referral to a specialist.

The authors note that historically, the age of menarche onset declined over the course of the last 200 years, but stabilized in the 1950s.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online December 14, 2015. Full text

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