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    AAP offers guidance on evaluating early puberty

    CP-eConsult-Issue_2640.jpg

    Early signs of puberty can be concerning for parents, and pediatricians may not always know which signs warrant further testing and referral and which are benign.

    In new guidance, the American Academy of Pediatrics (AAP) outlines methods for evaluating and referring to specialists children with early pubertal development.

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    Paul Kaplowitz, MD, PhD, endocrinologist at Children’s National Health System, in Washington, DC, helped develop the guidance and says pediatricians should be able to recognize the common and benign scenarios that look like precocious puberty but are not—particularly pubic hair and body odor development before age 8 years and breast development before age 2 years.

    “In most cases, they can avoid ordering tests and try to reassure rather than worry parents,” Kaplowitz says. “[Pediatricians] should be able to monitor many of these benign cases in their practice and refer to the specialist the ones that are atypical (eg, if there is rapid progression or growth acceleration) or when the parents are very anxious.”

    Early pubertal development is a common source of parental anxiety and a leading cause of referrals to pediatric endocrinologists, but only a small number of children truly have disorders that warrant testing and treatment. The majority of cases are benign and can be handled within the pediatric primary care office without immediate action, according to the report.

    “Although there is a chance of finding pathology in girls with signs of puberty before 8 years of age and in boys before 9 years of age, the vast majority of these children
with signs of apparent puberty have variations of normal growth and physical development and do not require laboratory testing, bone age radiographs, or intervention,” according to the report.

    Commonly, early puberty manifests as premature adrenarche (early onset of pubic hair and/or body odor), premature thelarche (non-progressive 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.

    Sign that sexual maturation may in fact be taking place include progressive breast development over 4 to 6 months, or progressive penis and testicular enlargement—particularly when accompanied by rapid linear growth.

    Children exhibiting these signs of early puberty need evaluation by pediatric medical subspecialists and may require therapy with gonadotropin-releasing hormone (GnRH) agonists, according to the report.

    As more studies confirm that the onset of puberty is occurring earlier than was previously considered normal, many primary care physicians are facing confusion about the timing of puberty and benign normal variants versus central precocious puberty (CPP).

    Puberty is triggered by increased secretion of peptide GnRH by the hypothalamus. The GnRH stimulates the production of the 2 gonadotropins—follicle-stimulating hormone (FSH) and luteinizing hormone (LH).

    Follicle-stimulating hormone promotes the development of oocytes and spermatozoa, and increases the size of gonads, while LH causes the ovaries to secrete estradiol resulting in breast enlargement, growth spurts, and bone advancement; and the testes to secrete testosterone resulting in pensile enlargement, pubic hair growth, and growth spurts. These processes activate the hypothalamic-pituitary- gonadal (HPG) axis, referred to
as gonadarche.

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    Rachael Zimlich, RN
    Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare ...

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