"I just stumbled across your website while trying to prepare for a doctor's appointment with my daughter this week. I feel like a million pounds have been lifted off of my shoulders. I am NOT losing it and I am NOT crazy! I have brought up concerns before to our doctor and I felt like they blew me off! [...] I feel so much better prepared now for our appointment on Friday. I am trying to educate myself so I can be an advocate for my only child." Heather D.
Precocious Puberty or Central Precocious Puberty can be very confusing and truly unexpected. After all, who knew children could go into puberty too early? There are treatments for this condition! Early puberty is not healthy for children for many reasons. Often, children with Precocious Puberty look older (they are taller and more physically developed than other children the same age). They are expected to act as old as they look and this is confusing for children. This in combination with other factors leads to a time of great stress. We are here to help parents!
NOTE: Recent news reports have stated that Central Precocious Puberty is becoming more frequent. Many factors may contribute to children who exhibit signs of (early) precocious puberty.
The Pituitary Gland
The pituitary gland, which is often referred to as the “master gland”, regulates the release of most of the body’s hormones (chemical messengers that send information to different parts of the body). It is a pea-sized gland that is located underneath the brain. The pituitary gland controls the release of thyroid, adrenal, growth and sex hormones. The hypothalamus, located in the brain above the pituitary gland, regulates the release of hormones from the pituitary gland.
Chemical messengers that carry information from one cell to another in the body. Hormones are carried throughout the body by the blood and are responsible for regulating many body functions. The body makes many hormones (e.g., thyroid, growth, sex and adrenal hormones) that work together to maintain normal bodily function. Hormones involved in the control of puberty include:
GnRH: Gonadotropin releasing hormone, which comes from the hypothalamus and controls the release of luteinizing hormone (LH) and follicle stimulating hormone (FSH) from the pituitary gland.
LH: Luteinizing hormone, a pituitary hormone that in conjunction with FSH stimulates male/female sex hormone production in the testicles/ovaries.
FSH: Follicle stimulating hormone, a pituitary hormone that in conjunction with LH stimulates sperm/egg development.
Testosterone: A male sex hormone (an androgen), which is made by the testicles in boys. It is also present in smaller amounts in girls. Other androgens from the adrenal glands (located near the kidneys) produce pubic and axillary hair at the time of puberty.
Estrogen: A female sex hormone, which is responsible for breast development in girls. It is made mainly by the ovaries, but is also present in boys in smaller amounts.
Sex Hormones: Responsible for the development of pubertal signs as well as changes in behavior and the ability to have children.
Precocious Puberty means having signs of puberty (e.g., pubic hair or breast/ testicular enlargement) at an earlier age than usual (prior to age 8 in girls and age 9 in boys).
There is a wide range of ages at which individuals normally start puberty. Girls usually develop breasts and then pubic hair between the ages of 8 and 13 years. Menstrual periods typically start at 12 to 13 years of age. Girls will often experience moodiness and become more irritable during puberty. Boys normally develop testicular enlargement and then pubic hair between the ages of 9 and 14 years. Underarm and facial hair, as well as deepening of the voice, typically occurs between the ages of 13 and 16 years.
Your child may be taller than the other children in his/her class. This is because the hormones that increase at the time of puberty also cause a spurt in growth.
Causes of Precocious Puberty
In the majority of cases of precocious puberty, the cause is unknown. In some instances, the pituitary signals the ovaries and testicles to make female and male hormones at an earlier than usual time. In other cases, signs of puberty occur prematurely because of abnormalities in the ovaries, testicles, pituitary, or adrenal glands.
Tests are usually necessary to determine whether the cause of precocious puberty is in the brain or in another area of the body.
Treatment for Precocious Puberty
If your child’s doctor determines that treatment is necessary, your child may receive a medication (analog or modified form of GnRH). The goals of treatment with this drug are to temporarily stop puberty and to decrease the rate of bone maturation. Rapid bone maturation will cause your child’s adult height to be shorter than his/her potential height. After the first couple of months of treatment, your child’s rapid growth should slow, and his or her pubertal stage will remain the same or possibly regress. Many children are too young to deal with the psychological aspects of early puberty, and by stopping further advances, your child may feel more like his or her friends.
GnRH analogs are given by injection every 3 or 4 weeks or as an implant placed just under the skin of your child's inner arm every 12 months. If your child receives the medication once a month, your local physician or a visiting nurse will most likely give the injection; in some cases, you may be trained to administer the injection at home if you prefer. Your child will receive medication until it is appropriate for puberty to resume. Research to date indicates that when treatment is stopped, puberty should resume and advance normally.
LUPRON DEPOT-PED® is available in 3-month dosing options (once every 3 months) and 1-month dosing options (once per month). With 3-month dosing, your child will get 4 injections per year instead of the 12 required with monthly dosing. If your child receives a LUPRON DEPOT-PED injection every 3 months, injections may be scheduled to coincide with his or her regular doctor visits and allow for more flexibility to fit your schedule.
SUPPRELIN® LA is the only once-yearly treatment for central Precocious Puberty. A single dose of SUPPRELIN® LA provides 1 full year of medication in 1 implant to help provide hormone suppression through month 12 after the first month of therapy.
Possible Treatment Side Effects
During the first 6 weeks of treatment, your child may experience the following side-effects: Girls may have mood changes, acne, an increase in breast size, and menses. Boys may have an increase in pubic hair and testicular development as well as acne. These effects are only temporary and should be controlled by the seventh week of treatment. Other side effects your child may experience include redness and slight pain at the injection site. Rarely, a sterile abscess may occur. Use of a filter needle to reconstitute the depot form of the analog will help prevent this.
Follow Up Clinic Visits
It will be important for your child to be seen every 3 - 6 months. This will allow the doctor to ensure that your child's puberty is appropriately suppressed. Your child’s height will be measured in order to determine his or her growth rate. If treatment is successful, your child’s growth rate should decrease. A physical exam will be done at each visit to evaluate development, and a bone age X-ray will be done at least once a year. Hormone levels occasionally need to be checked.
Due to early puberty, your child may be taller than other children of his/her age. It is important to treat children according to their actual age rather than their size or apparent age, since children tend to develop self-esteem and behave according to how they are treated. Parents of children with precocious puberty should remind teachers, relatives, and friends about this important relationship.
Your child may feel embarrassed by the physical effects of puberty. All children want to look and act like their friends. It is helpful to emphasize to your child that all girls and boys normally experience puberty, but in his or her case, it has occurred sooner than usual. It is important to tell your child that the changes in his/her body are normal. Your child should be allowed to participate in his/her usual activities, which may include spending the night with a friend, athletics and extracurricular activities. Encourage your child to discuss with you worries that he/she may be having.
Precocious Puberty Questions
Q. How should I explain this disorder to my child?
A. Your child may have several questions regarding early puberty and its treatment. It is often helpful to reassure your child that the pubertal changes in his/her body are normal, and that most individuals will eventually have these changes, but that in his/her body they happened sooner than usual.
Grady Bear is a children’s book designed to help parents, like you, explain central precocious puberty (CPP), and its effects, to their child. The narrative, written from the perspective of a child confiding in her teddy bear, touches upon the physical and emotional changes that a child diagnosed with CPP may experience. Friendly illustrations and a conversational tone make this a read that is reassuring for parents and children alike.
Click here for an electronic version of Grady Bear, written by Deborah Rotenstein, M.D., pediatric endocrinologist
Q. What should we tell friends and relatives?
A. It is not necessary to tell anyone about your child’s problem; if, however, they ask about the problem and you wish to discuss this with them, explain that your child is perfectly normal but has started puberty at an earlier than normal age. If your child is receiving injections, you can explain that they are given to temporarily stop puberty, which assists these children in achieving an acceptable adult height.
Q. What will my child’s final adult height be?
A. Final adult height depends on multiple factors. Parental heights play a significant role in the height of a child. The relationship between bone age and chronological age is also important since excessive skeletal maturation for age provides less time for growth. If puberty was detected at an early stage, then your child will have a better chance of reaching his/her expected height. If, however, puberty was detected at a later stage, then his/her bones will be more advanced, and this will limit the time remaining for growth and, therefore, final adult height.
Q. I still have questions about Precocious Puberty. Is there any other information that can help me better understand the disorder?
A. Click here for another link that will provide additional information on Precocious Puberty.
Brian Bordini, M.D.
NorthShore University Health System
Sonya's Personal Story
“Central Precocious WHAT!”
That was my reply four years when my daughter Sydney was diagnosed. I still can recall my disbelief when the endocrinologist said those words. Central Precocious Puberty (CPP) or Precocious Puberty (PP) as it is sometimes called, is a condition that affects approximately 1 in 5,000 to 10,000 children. I soon learned that PP symptoms include all of the normal signs of puberty. However, with PP those typical signs appear well in advance of the typical pre-teen years. Although children are maturing at a faster rate than in previous generations, PP is even a step beyond the trend we have seen in recent years. PP is defined as the onset of puberty prior to the age of eight in girls and prior to the age of nine in boys. PP even sometimes occurs in children younger than two years of age.
My daughter was three when I first noticed changes in her physical development that were abnormal for her age. After bringing my concerns to her pediatrician, he consulted with an endocrinologist. The endocrinologist recommended that we monitor her growth over the next six to twelve months and make note of any changes that were not developmentally in line with her age. By this time Sydney was about four and-a-half years old and the tallest person in her pre-kindergarten class. All of her symptoms escalated: she had an increase in pre-teen body hair, extreme moodiness, adolescent body odor, and advanced physical developments all seemed to be occurring at the speed of light. These changes got us a referral to a pediatric endocrinologist and the diagnosis process began.
For the majority of children with PP there is no known cause. There are some cases however, in which the child might have a brain tumor that is stimulating the pituitary gland. Hence the reason an MRI is one of the screening tests if a child is suspected of having PP. Along with the MRI, Sydney had blood work done to determine her levels of estrogen and other hormones related to puberty. In addition, she had a bone age test and a test we PP parents call the “stim” test. She did not have a brain tumor but all of Sydney’s screening tests confirmed that she indeed had PP and so our journey began.
There are two main types of treatment for PP-monthly injections or an implant that is placed in the upper arm. Both treatments contain medications that allow for puberty to be “placed on hold” until an age appropriate time. After getting a second opinion at Duke University, I decided that the implant was the best option for Sydney. In addition to the obvious physical changes in appearance, children with PP can be impacted emotionally as well. If PP is untreated there can be long term health problems and children are less likely to reach their adult height.
My Sydney is a left-handed, creative, out spoken, dancer. She has a kind soul and she plans one day to have a line of fashion clothing. She will have her fourth Supprellin implant this summer and will continue treatment for two more years. At times it is challenging to help others understand all that is Sydney. At the beginning of each school year I have a conference with her teacher and the school nurse to explain PP and to review her 504 plan. This plan outlines accommodations like a quiet place to calm down if she needs an emotional break or the ability to make up work due to doctor appointments. Parenting a child with PP is never boring! I so appreciate the support I find in sharing this journey with the other Magic Foundation parents who are part of our PP Facebook Page. If you are a parent of a child with PP please consider joining our community!
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