-Caveat Lector- New York Times November 30, 1999 Yesterday's Precocious Puberty Is Norm Today By JANE E. BRODY A friend who runs the child care program at a Brooklyn high school reports that one of the newly enrolled mothers, a freshman, is 13. Her baby's father is 14. While children having children is not a new phenomenon, the ever-dropping age of puberty is. Many parents become worried when their 7- or 8-year-old daughters begin to develop breasts or grow pubic hair. They wonder, is this normal? Will the surge of sex hormones adversely affect the girls' behavior, moods or physical growth? Can girls who are still emotionally and socially immature adjust well to early physical maturation? And when should more explicit sex education and cautions about birth control begin? What's Normal? Two years ago, Dr. Marcia E. Herman-Giddens and colleagues described the results of physical examinations of 17,077 American girls, which revealed that white girls were showing bodily signs of sexual maturity an average of one year earlier than previous studies had indicated, and black girls two years earlier. On the average, breast development was notable before age 10 in white girls and before age 9 in black girls, and the growth of pubic hair generally occurred about a year later. But even at age 7, 27 percent of black girls and nearly 7 percent of white girls had begun to grow breasts, pubic hair or both. The findings, she and others suggest, should prompt a redefinition of the ages at which puberty is considered precocious. Current medical textbooks state that just 1 percent of girls younger than 8 show signs of puberty. In a new review of existing data, in the Oct. 4 issue of the journal Pediatrics, Dr. Paul B. Kaplowitz, Dr. Sharon E. Oberfield and members of the Lawson Wilkins Pediatric Endocrine Society, concluded that "the onset of breast development between 7 and 8 years of age in white girls and between 6 and 8 years in African-American girls may be part of the normal broad variation in the timing of puberty and not, in most cases, a pathological state." Breast development is stimulated by estrogen, which is released from the ovaries upon a hormonal signal from the pituitary gland. The growth of pubic hair, however, is a result of stimulation by androgen, the so-called male sex hormone, also produced by the ovaries. There has been much speculation about why earlier maturation may be occurring in girls, especially because there has been no apparent advance (and no racial difference) in the onset of puberty in boys. For girls, better nutrition over all and fewer infectious diseases no doubt play a role, because these trends result in more consistent growth. The increase in childhood obesity may also be a factor, because fatty tissue is a source of the sex hormone estrogen. Another suggested possibility is increased exposure to certain plastics and insecticides that degrade into substances that have estrogenlike effects. But whatever the reasons, the phenomenon is real and, to many parents, worrisome. The new report by Dr. Kaplowitz of the Medical College of Virginia and Virginia Commonwealth University, Dr. Oberfield of Columbia University College of Physicians and Surgeons and members of the endocrine society should prove reassuring. Effects of Early Maturity Parents of adolescent girls know all too well that life can be an emotional roller coaster, with unpredictable outbursts of temper and outrageous or infuriating behavior. Indeed, precocious puberty has been associated with behavioral problems. In one study of 33 early-maturing girls, as a group, they appeared to be more depressed, socially withdrawn, aggressive and moody than a comparable group of girls who had not yet entered puberty. But another study that followed girls with precocious puberty to age 17 1/2 found that they suffered no lasting psychological effects, except a tendency toward excessive psychosomatic complaints. Although girls undergoing early sexual maturation may be far from their teenage years, parents would probably do well to read up on how to cope with an adolescent and what is considered the range of normal behavior for this often volatile time of life. Another common concern involves the ability of girls as young as 7 or 8 to cope with menstruation. Dr. Kaplowitz and his colleagues point out that a 7-year-old who is developing breasts will not undergo the start of menstrual cycles, or menarche, for another two years. That time gap should give parents and pediatricians enough time to prepare. Also, once a girl starts menstruating, she is potentially able to become pregnant and needs explicit sex education. Adults who wait too long end up with pregnant 13-year-old girls. But the main concern for pediatricians and for some parents is the effect that hormones might have on the child's growth. Estrogen is known to cause the growth plates in long bones to close, which can slow or shut down linear growth. Concerned parents and pediatricians sometimes wonder whether early-maturing girls should be given a hormone that blocks the pituitary stimulus of the ovaries and would presumably allow such girls to grow taller. Here, the new evidence is most reassuring. Dr. Kaplowitz and his co-authors point out that "the younger the age at onset of puberty, the longer the duration of puberty," meaning that the adolescent growth spurt occurs for a longer time in early-maturing girls. This in part offsets the loss of adult height that might occur when the skeleton matures earlier. Indeed, girls who undergo early menarche tend to grow somewhat more than girls whose menarche occurs later. The end result is little if any difference in adult height. Thus, the authors state, the concern that girls who enter puberty "between 6 and 8 years of age will become very short adults without intervention is overstated, because adult height within the normal range is reached in the majority of cases." Only if the onset of puberty occurs before age 6 has hormonal therapy been shown to make a meaningful difference in a girl's height. Who should undergo evaluation for early puberty? The authors recommend that white girls younger than 7 and black girls younger than 6 who show breast or pubic hair development should be examined to be sure they have no disorder that involves an excess production of hormones that could distort their development. Too much androgen, for example, would cause masculinization and could result in infertility. Girls who have any of the following conditions should be fully evaluated: o An unusually rapid progression of puberty that would cause rapid skeletal maturation and a predicted height four inches less than their genes might dictate or less than 4 feet 11 inches. o The presence of any newly developed problem involving the central nervous system, including headaches, seizures or neurological deficits. o Behaviors suggesting that the girl's emotional state, or the family's emotional state, is being adversely affected by the progression of puberty. Finally, the authors say, parents of boys would be wise to seek medical evaluation if evidence of excessive androgen production (other than the growth of pubic hair) occurs before age 9. Such signs might include enlargement of the penis and scrotum, acne and very rapid growth. Boys who mature too rapidly, the authors say, often have a central nervous system disorder. 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