Puberty

Please remember there is a Paediatric Clinical Mailbox that can be used for any non-urgent queries: clinical_paediatrics_crosshousehospital@aapct.scot.nhs.uk

Definitions

• Lower age of onset of puberty (‘pubarche’): boys 9yrs, girls 8yrs. Above this age considered normal variation.
• Upper age of onset of puberty: boys 14yrs, girls, 14yrs.
• Upper age of menarche (onset of menstrual periods) 16yrs, average age 12yrs.
• Adrenarche: the phase of growth characterised by appearance of pubic hair growth, axillary hair, body odour and acne - caused by the effects of adrenal androgens. Usually coincides with puberty.
• Premature adrenarche: appearance of adrenarche before the expected age of puberty. No treatment or investigations required. Benign and no long term effects.

Background

Parents/ children most often seek medical advice in the following situations:

Boys

• Delayed onset of puberty – Likely to be constitutional delay in growth and puberty (puberty delayed, but will happen in due course). Consultation is usually instigated by boy due to issues of self-consciousness etc, particularly about height and lack of growth spurt.
  • Useful checks: parental height, genital exam (testes start enlarging before appearance of pubic hair, appearance of any pubic hair is reassuring).
  • Consider re-checking in 6 months before referring: Refer if no changes / progress, and over 14yrs.

Girls

• Onset of pubic hair growth below age 8 – likely to be premature adrenarche, if no other signs (especially if no breast growth); reassure or review in 6 months. Adrenarche is associated with greasy skin/acne (androgen effect)
• Onset of “true puberty” before the age of 8: breast enlargement, growth spurt, pubic hair: refer to paediatrics for consideration of investigation for precocious puberty.
• Breast enlargement in toddler – may be premature thelarche – self-resolving, seen in toddlers - refer to paediatrics, non-urgent. Older than toddler –look for other signs of puberty and consider precocious puberty.

Re-assurance can be given in many cases without investigations or onward referral.

History

• Note age of onset of changes – breast growth, pubic hair growth, menstruation.
• Family history of early or precocious puberty, maternal menarche.
• Any learning difficulties – may be associated with early puberty e.g. autism, hydrocephalus
• Recent growth spurt or always tall?
• History of being overweight? In overweight / obesity associated with adrenarche, encourage family to take part in ‘Jumpstart’ (see Resources below)

Examine

• Measure child’s height and weight and accurately plot them on growth and BMI chart (eg ‘red book’, WHO charts, or iGrow if available). Compare these measurements to those done previously in child’s ‘red book’ or medical records – has a growth spurt happened?
• Document presence of pubic hair (wiry, darker; not downy, soft), breast enlargement, axillary hair, appearance of genitalia (pre-pubertal or enlarged)

Referral should be considered if the signs are prominent or changing fast over last few weeks or months.  Consider reviewing child again in several months to re-assess.

Referrals to Paediatrics should be made via the SCI Gateway.

Please note, these are vetted in a timely manner so the priority status of a referral may change upon review.

• Usually no investigations are necessary before referral.
• Symptoms suggesting hypothyroidism/strong family history of hypothyroidism – check TFTs.
• Boys with signs of pubic hair / penis enlargement before age 9yrs is very unusual and more likely to have a pathological cause.
• Girls with delayed puberty or amenorrhoea – consider eating disorder – Check BMI.

NHS Scotland. Parent information booklet. Adrenarche.

NHS Ayrshire & Arran. Jumpstart leaflet. Do you have concerns that your child could be above a healthy weight?