Endocrinology and Diabetes
Precocious Puberty At Stanford Medical School with Morgan Theis talking to Dr. Laura Bachrach talking about precocious puberty
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- i'm here at stanford medical school
- with Morgan Theis and Dr. Laura Bachrach
- and they're going to teach us some things.
- Okay, so what are we going to learn about today?
- I'd like to talk about precocious puberty
- it seems to be on the minds of many parents these days
- they worry that their child is developing too early,
- they worry their child is going too small as a result,
- they worry their child is going to get picked on,
- and they worry they might have done something wrong.
- Fed the child the wrong food, or exposed them to the wrong videos,
- to cause this all to happen.
- So could we just talk about what precocious puberty means,
- it almost sounds like they've done something too soon,
- is that correct?
- It's exactly true.
- The normal process of puberty, in a girl, we think,
- we used to think, started around the aged of 10,
- with a little bit of breast development.
- And around 6 months later, the girls would get
- a little bit of pubic hair,
- and around the age of 12 and 3/4 to 13
- they'd get their first period.
- In boys, we used to think,
- the process was starting a little later,
- at about 11 and a half.
- The boys would get some enlargement of the testes.
- They'd get some pubic hair about a year later.
- And by age 15 or so, they'd be mature.
- We have a definition of what's precocious,
- uh, when there's signs of puberty before 8, in a girl,
- or before 9, in a boy.
- Ok. So, 8 or less in a girl, would be precocious,
- and that's for the breast development?
- For any signs of puberty:
- the breasts, the pubic hair or the period
- would be precocious if it happened before the age of 8 in a girl.
- And in a boy, before the age of 9.
- Now this has become a little bit controversial
- because there was one very large pediatric study
- that involved over 17 000 girls
- that found that as many as 25% of african american
- girls would have sign of puberty before 8,
- and as many 7% of the white girls had some
- signs of puberty before age 8.
- But we're still basically using these guidelines.
- Not to say that this is definetely abnormal, but
- this is something we're going to evaluate.
- If we see signs of puberty before those age landmarks.
- Ok, so it sounds like there's a lot of variability,
- it's kind of hard to know in any individual case,
- whether it's normal or not, but we have to have
- some kind of threshold for which we're going to
- work someone up to make sure everything is normal.
- You hit on a really important word.
- And that is variability.
- And a lot of this variability, uh, is determined by genetics.
- So part of what we always need to know is
- the timing of development in the family.
- So when did mom get her first menstrual period,
- when did dad get his puberty and growth spurt?
- So that's part of it, genetics,
- and we need to know that, take that into account:
- If mom had her first period at 10 and started
- her breasts at 8
- it might be perfectly normal for her daugher.
- If mom's period were at 14 and her daughter has
- breast development at 7 and a half
- it's more worrysome.
- Ok, the second factor that seems to be contributing,
- is the overnutrition of our young people.
- Oh, yes.
- And in the particular study that I mentioned to you,
- where they looked at over 17 000 children,
- at least for the white population,
- the could explain the earlier signs of puberty
- as an association with a high body mass index.
- So it looked as if, if you overnourish your child
- you may speed along their growth, and eventually,
- potentially, speed along the onset
- of puberty.
- Now, this did not hold up as an association in the
- african american population, so there's other factors
- going on there.
- But that's something that we rtake into account.
- THe bottom line is,
- the child may present with some signs of early puberty,
- mom or dad get worried,
- they go to the pediatrician,
- and the pediatrician has to decide what's going on.
- Ok, now, JUST Backing up a little bit, is this a problem?
- I mean, what's the problem with, say, a 7 year old girl
- starting puberty, or, uh, an 8 year old boy
- starting puberty early?
- I imagine there could be some social implications
- (as you mentionened)
- but what are sort of the things
- we worry about?
- Well, that's an importand question,
- because it comes up not only how far do we go to
- evaluate them, but how far do we go
- to treat them?
- So, one of the concerns parents have,
- relates to their final height.
- So, if they start their growth spurt early in life,
- and close it off early in life,
- are them gonna cheat themselves
- out of some final height?
- So height is a concern.
- And its impact really depends upon how young the child is.
- A three year old going into puberty
- is definetely going to end up short
- if we don't do something.
- A seven and a half old girl is
- probably not going to be altered by this
- in terms of height.
- The second concern is definetely what you
- brought up, in terms of social concern.
- Parents worry their child may behave in an older way,
- or be treat in a way that
- they're not quite ready for.
- They mey get unwarranted attention
- from people because they look older.
- And there is even potential concern for abuse,
- sexual abuse.
- Um, right.
- So those are the usual parental concerns
- for why they bring the child in.
- The other concern they have is, often
- "what am I doing wrong".
- There are a lot of questions about
- "should I have fed my child organic food?"
- "what about the soap i was using?"
- "what about the soap operas my child was watching?"
- You know, they're really
- concerned about something they might have done.
- And they worry about these additives in ourplastics,
- in our theeth sealants, etc...
- They worry about evils inour environment.
- So things that you address in the visit that
- you have with them are definetely
- some of the, the concerns that parent have
- about what they could have done differently.
- Exactly. We start out, assessing
- in a sort of a systematic way.
- The first question we want to know, is
- when did this all start?
- And what did they notice.
- And it's really important
- to break down the signs of puberty,
- because different hormones contribute to
- the different signs.
- For example, in a girl, if she is presenting with
- some body odor, some acne, and some pubic hair,
- but no signs of any breast development,
- that leads us down the road to
- worry about what we call her androgens
- or her male hormones.
- If a girl comes in with just breast development
- but none of the body hair
- or body odor, we think, aha! she's been
- exposed to estrogens.
- And so we get a lot from the physical exam in
- terms of thinking what hormones to go after.
- okay, so even though the definitions of precocious
- is just any of these
- different physical developments happening
- too soon, the combination that you see
- is going to direct what yo uthing is going on
- wit hthem clinically.
- It will make us more or less worried
- and it will take us down one avenue or another,
- thinking about what could be wrong,
- what level of abnormality in the hormone system is at work.
- Ok. Can I ask you a question, just curious, so
- what are the most common diagnosis given
- to people coming in with their kids, that are
- concerned for precocious puberty?
- The common diagnosis, is "variations are normal".
- There is a condition called
- "isolated premature adrenarche" which is a
- fancy doctor way of saying
- the adrenal glands producting their
- hormones, we see pubic hair, underarm hair, and acne.
- Uh... We also can see isolated
- breast development in little toddler girls
- that's not concerning.
- So that would just go away, or?
- Yes. Typically that begins between
- six months and two years and
- goes away.
- But even within the more full blown cases,
- where we're seeing breast and the pubic hair
- in a girl, or the enlagrement of the testes
- and the pubic hair in a boy, where's it's full on,
- full blown puberty, it may be idiopathic,
- or not pathological.
- We think that in girls,
- who develop fully, 95% of the time, even if they
- have the full blown puberty,
- it's idiopathic, or not pathological.
- Whereas in boys, about 50% of the time, there is pathology.
- So the condition is less common on boys, but
- when it occurs in boys, it's more worrisome.
- Oh, interesting.
- So it's less common for boys to have any signs of
- precocious puberty, but when it does happen you worry more.
- Because it's more likeyl to be something bad.
- So I'm guessing as an endocrinologist,
- once you've sort of ruled out the normal things, then you start th
- then you start thinking more about
- sort of what's going on in terms of all the
- different hormones that are controlling the
- things, which maybe is something that
- we'll talk about in a different
- is there any other sort of general things
- that you wanted to adress when
- we'll just talking about...
- I think the general advice I would give to a parent
- if see signs of puberty in their child,
- before 8 in a girl, before 9 in a boy,
- they should at least question their pediatrician
- about it, uh, and the pediatrician should do
- a complete exam, and the
- other factor that needs to be looked at carefully is growth,
- because a child who is truly in puberty will have a growth spurt.
- So, those are things that parents can be
- aware of at home, but I think it's
- important that the parent asks the pediatrician about it,
- if they are concerned.
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