PEDIATRICS Vol. 115 No. 1 January 2005, pp. 195 (doi:10.1542/10.1542/peds.2004-2191)
Navigating Recent Articles on Girls' Puberty: Where Should Our Patients Go for Evaluation?: In Reply
Paul Kaplowitz, MDDepartment of Endocrinology,
Children's National Medical Center,
Washington, DC 20010
Marcia Herman-Giddens, PA, DrPH
Department of Maternal and Child Health,
School of Public Health,
University of North Carolina,
Chapel Hill, NC 27599-7400
North Carolina Child Advocacy Institute,
Raleigh, NC 27601
Richard Wasserman, MD
Department of Pediatrics,
University of Vermont College of Medicine,
Burlington, VT 05401
Drs Jacobson, Midyett, and Moore responded to our critique of their article largely by restating the very positions we felt were in error. Regarding the "traditional" definition of precocious puberty, although it is certainly common for girls with true precocious puberty to have both breast development and pubic hair, reflecting activation of both ovarian estrogen and adrenal androgen production at about the same time, this is not always the case. The best recent data come from the study of Chalumeau et al,1 in which 197 girls with hormonally proven central precocious puberty from a single center in Paris, France, were examined retrospectively. In all, 37 (19%) had stage 1 pubic hair and 159 (81%) had stage 2 or greater pubic hair. Interestingly, in the 11 patients with central nervous system abnormalities, 64% did not have pubic hair. Thus it is difficult to argue that the presence or absence of pubic hair defines whether a girl with breast development has true precocious puberty. Hence, following their suggestion to calculate the "true" incidence of precocious puberty in the Pediatric Research in Office Settings study based solely on the number of girls with both breast and pubic hair development would be inaccurate. A much greater inaccuracy, however, would arise from their insistence on using the entire cohort of girls in the PROS study (17077) as the denominator in a calculation of the prevalence of precocious puberty. The youngest age groups (between 3 and 5 years old; a total of 
8000 girls) were overrepresented in PROS (presumably because they were seen more often for well-child visits), and as expected, very few had signs of puberty. There were many fewer 6- to 8-year-olds ( 4400). The 4800 girls between 9 and 12 years old are irrelevant to this discussion but are also included in their 17077 denominator. To demonstrate the fallacy of including the entire cohort as the denominator, had the PROS study included another 8000 girls between 0 and 2 years old, very few of whom would have had breast and pubic hair growth, the prevalence of true precocious puberty by the Jacobson et al method of calculation would have been even smaller. This demonstrates why the appropriate denominator for any calculation on the incidence of a condition, in this case precocious puberty, must be specific to the potentially affected population.
On one point we agree with Drs Jacobson, Midyett, and Moore. Partial forms of sexual precocity such as girls with only pubic hair (premature adrenarche) or breast development without other signs of puberty (premature thelarche) can often be managed by careful observation by the general pediatrician who can alert the specialist in the event of pathologic signs such as a growth spurt. However, this is different from the position taken in their article, in which they stated "Our findings suggest that all girls with any secondary sexual development before 8 years of age deserve at the minimum a bone age assessment and close longitudinal follow-up, especially when one considers that breast and pubic hair development can be asynchronous in the early stages of precocious puberty."2(p50) It is that position, we believe, that leads to the costly and unnecessary referral of many normal young girls.
REFERENCES
- Chalumeau M, Chemaitilly W, Trivin C, Adan L, Breart G, Brauner R. Central precocious puberty in girls: an evidence-based diagnosis tree to predict central nervous system abnormalities.
Pediatrics. 2002;109
:61
–67
[Abstract/Free Full Text] - Midyett LK, Moore WV, Jacobson JD. Are pubertal changes in girls before age 8 benign?
Pediatrics. 2003;111
:47
–51
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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