Published online January 3, 2005
PEDIATRICS Vol. 115 No. 1 January 2005, pp. 194-195 (doi:10.1542/peds.2004-1766)

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Navigating Recent Articles on Girls' Puberty: Where Should Our Patients Go for Evaluation?

Jill D. Jacobson, MD
L. Kurt Midyett, MD
Wayne V. Moore, MD
Children's Mercy Hospital,
University of Missouri-Kansas City School of Medicine,
Kansas City, MO 64108

To the Editor.—

This letter is written in response to the Herman-Giddens et al commentary "Navigating the Recent Articles on Girls' Puberty in Pediatrics: What Do We Know and Where Do We Go From Here?"¹ We disagree with the authors on several key points.

These authors state that we have made the "erroneous assumption that a girl needs to have both breasts and pubic hair to be considered as having true precocious puberty."^1(p914) Pubic hair development and breast development accompanied by a growth spurt has long been the conventional definition of true precocious puberty.² We maintain that this traditional definition is clinically very helpful, because the development of all 3 before the age of 8 years should be viewed with concern. Traditionally, endocrine referral of girls with these characteristics has been recommended.

The danger in not using this definition of sexual precocity was exemplified by the 1997 article by the Pediatric Research in Office Settings (PROS) network, wherein numbers of girls with premature adrenarche, premature thelarche, and true precocious puberty were simply added together.³ The authors suggested that 27.2% of black girls and 6.7% of white girls had begun to develop by age 7 years. Those data were used to argue that we needed to redefine the normal age of puberty. Based on this publication, the Drug and Therapeutics Committee of the Lawson Wilkin's Pediatric Endocrine Society issued new recommendations to lower the age of sexual precocity to age 6 years in black girls and 7 years in white girls.⁴ Much controversy ensued. Many pediatric endocrinologists wrote commentaries and letters to editors disagreeing with the new guidelines.^5–7 We subsequently published an article in Pediatrics demonstrating a high incidence of endocrine pathology in black girls 6 to 8 years old and white girls 7 to 8 years old.⁸

The PROS authors claim that endocrine evaluation of all girls with signs of puberty before the age of 8 would be too costly and that "each endocrinologist [in the country] would have to see, on average, 300 of these girls."^1(p915) We maintain that most patients with partial or formes frustes of sexual precocity may be managed by careful observation by the general pediatrician who is watchful for pathologic signs, which may include growth spurts, acanthosis nigricans/obesity, and or advancing bone ages. The work-up for incomplete forms of precocious puberty can be accomplished in an office-based setting. Growth rates, bone ages, and skin changes can certainly be monitored closely by pediatricians.

The association of isolated premature adrenarche in girls and the development of the insulin-resistance syndromes in adolescence and adulthood is well documented. Pediatricians need to be aware that premature adrenarche, obesity, and acanthosis nigricans may be the prodrome of an insulin-resistance syndrome (metabolic syndrome, syndrome X, polycystic ovarian syndrome). Patients with this constellation of findings will require additional medical attention without regard to cost issues.

The PROS authors claimed that we made a mistake in our calculations. We stand behind our original calculations. We noted that only 22 patients in the entire cohort of 17077 girls included in the PROS study actually met the traditional definition of true precocious puberty. This is, as we stated, 0.1% of their entire population. Our article was written in an effort to guide the general pediatrician in the management and referral of these girls, which is why we pointed out that a very small percentage of a pediatrician's entire practice would need immediate referral (assuming that the PROS practice accurately reflects a referral base). Even if one restricts the referral base to the ages and races in question (6–8 years for black girls and 7–8 years for white girls), only 1.6% of this group of girls would require immediate endocrine referral.

REFERENCES

1. Herman-Giddens ME, Kaplowitz PB, Wasserman R. Navigating the recent articles on girls' puberty in Pediatrics: What do we know and where do we go from here [commentary]? Pediatrics. 2004;113 :911 –917[Free Full Text]
2. Lee PA. Normal ages of pubertal events among American males and females. J Adolesc Health Care. 1980;1 :26 –29[CrossRef][Medline]
3. Herman-Giddens ME. Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings. Pediatrics. 1997;99 :505 –512[Abstract/Free Full Text]
4. Kaplowitz PB, Oberfield SE; Drug and Therapeutics and Executive Committees of the Lawson Wilkins Pediatric Endocrine Society. Reexamination of the age limit for defining when puberty is precocious in girls in the United States: implications for evaluation and treatment. Pediatrics. 1999;104 :936 –941[Abstract/Free Full Text]
5. Pathomvanich A, Merke DP, Chrousos GP. Early puberty: a cautionary tale. Pediatrics. 2000;105 :115 –116[Free Full Text]
6. Rosenfield RL, Bachrach LK, Chernausek SD, et al. Current age of onset of puberty. Pediatrics. 2000;106 :622 –623[Free Full Text]
7. Chumlea WC, Schubert CM, Roche AF, et al. Age at menarche and racial comparisons in US girls. Pediatrics. 2003;111 :110 –113[Abstract/Free Full Text]
8. Midyett LK, Moore WV, Jacobson JD. Are pubertal changes in girls before age 8 benign? Pediatrics. 2003;111 :47 –51[Abstract/Free Full Text]

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PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics

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This article has been cited by other articles:

				L. S. Nield, N. Cakan, and D. Kamat A Practical Approach to Precocious Puberty Clinical Pediatrics, May 1, 2007; 46(4): 299 - 306. [PDF]

This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Jacobson, J. D. Articles by Moore, W. V. Search for Related Content PubMed PubMed Citation Articles by Jacobson, J. D. Articles by Moore, W. V. Related Collections Office Practice Social Bookmarking                         What's this?