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Precocious puberty – Quick review card

PRECOCIOUS PUBERTY Precocious puberty is early onset of puberty and secondary sexual characteristics in children < 8 in girls and < 9 in boys Challenging condition as the cause can range from benign conditions to serious cause as malignancy

 

Central – gonadotrophin dependent ( GDPP ) premature activation of the HPG axis follows normal pattern ( sequence ) of pubertal development sexual characteristics are isosexual ie they are consistent with the child’s gender in girls the most common cause is idiopathic whereas in boys usually there is an underlying pathology Idiopathic precocious puberty is the commonest cause of GDPP CNS related causes as tumours , infections , trauma , cranial irradiation , hydrocephaly , cerebral palsy Genetic syndrome as neurofibromatosis type 1 , tuberous sclerosis Environmental Familial precocious puberty.

 

Peripheral- gonadotrophin independent independent of GnRH pulsatile secretion due to production of sex steroids from exogenous or endogenous sources Due to causes as
○ adrenal ( e,g congenital virilising congenital adrenal hyperplasia Cushing’s )
○ Gonadal – Mc Cune ALbright syndrome , ovarian tumors
○ HCG producing tumors
○ primary hypothyroidism ( longstanding )
○ iatrogenic

 

Other variants of precocious puberty include premature thelarche , premature pubarche , isolated premature menarche
 Premature thelarche -isolated development of breasts which may regress over a period of time ie non-progressive ( typically before age 2 ) Premature adrenarche – due to mildy elevated levels of androgens leading to early onset of pubic hair & or body odour Lipomastia -obese and overweight girls ,it may appear that they have breast tissue with no true glandular breast tissue which can be sometimes difficult to ascertain -an observation over 4-6 months can be reassuring.

 

type of changes ( which signs of puberty ) progression , sequence , changes consonant or disconsonant ? ( pattern same as in normal puberty 
or not ? ) any recent change in height ( rapid linear growth in last 6-12 months ) symptoms suggestive of a neurological problems / infections / trauma / visual field defects / cranial irradiation / brain tumour / meningitis ingestion of sex hormones or exogenous exposure ( food , topical , drugs , COCP , testosterone gels etc ) family history – pubertal onset in parents , h/o ambiguous genitalia ,

 

Sensitive topic – can be hard for children and families to discuss Helpful tools – show Tanner stages of development
( Google search or look under resources )- a formal staging is usually undertaken in 2ary care but it may help in communicating about the issue RCPCH height charts ( links )

 

Height / weight / BMI Register on a growth chart RCPCH charts marked with puberty lines -indicating normal age limits for the phases of puberty Examine abdomen for any masses Neurological exam & visual field defects Palpate testes to assess size If a decision to refer to secondary care has been taken a comprehensive physical examination may not yield additional information & can be distressing / unexpected Safety net to discuss- seek help if they get worried , new symptoms develop while waiting for 2ary care apt . Refer suspected precocious puberty cases to a paediatric endocrinologist.

 

These tests may be considered but are not obligatory prior to referral- LH , FSH , Serum oestradiol and testosterone, TSH, 
Hand and wrist radiography , Pelvic US in girls

REFERENCES

  1. Bradley S HLawrence NSteele CMohamed ZPrecocious puberty doi:10.1136/bmj.l6597 Precocious puberty | The BMJ
  2. Pallavee, Palai and Rupal Samal. “Precocious puberty: a clinical review.” International journal of reproduction, contraception, obstetrics and gynecology 7 (2018): 771.
  3. Kota AS, Ejaz S. Precocious Puberty. [Updated 2021 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544313/
  4. Berberoğlu, Merih. “Precocious puberty and normal variant puberty: definition, etiology, diagnosis and current management.” Journal of clinical research in pediatric endocrinology vol. 1,4 (2009): 164-74. doi:10.4274/jcrpe.v1i4.3
  5. BMJ Best Practice Precocious puberty: summary Precocious puberty – Symptoms, diagnosis and treatment | BMJ Best Practice

 

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