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Letter to the Editor |
Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tiqva, 49202 Israel; and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, 69978 Israel
Address correspondence to: Liat de Vries and Moshe Phillip, Institute of Endocrinology and Diabetes, Schneider Children’s Medical Center of Israel, 14 Kaplan Street, Petah Tiqva 49202, Israel. E-mail: liatd{at}clalit.org.il.
To the editor:
In his recent article in JCEM, Kaplowitz (1) reports the frequency of different diagnoses in children referred for signs of early puberty. Among the 104 children consecutively referred over a 3-yr period, the two most common diagnoses were premature adrenarche (46%) and premature thelarche (18%). Only 9% were thought to have true precocious puberty. These findings differ from our recently published data on 453 children consecutively referred for signs of early puberty between January 1, 1997 and December 31, 2000 (2). In both studies, the majority of patients referred were female. In contrast, we found more than half of our patients to have either idiopathic central precocious puberty (34%) or early puberty (20%). Other diagnoses included idiopathic precocious adrenarche (22%), premature thelarche (13%), obesity associated with pseudothelarche (4%), and "others" (6%). Among the girls with premature thelarche, 21 (5%) were under 3 yr of age and 37 (8%) were older. The group of patients with "other diagnoses" warrants attention, because it included nine patients (2%) with significant pathology: nonclassical 21 hydroxylase deficiency in three patients, aromatase excess in two siblings, and functioning adrenal tumor, hamartoma of tuber cinereum, craniopharyngioma, and pituitary adenoma in one patient each. This pathology was disclosed after endocrine work-up for precocious secondary sexual characteristics. The rest of the "others" subgroup had previously diagnosed central nervous system disorders (eight patients) or hypertrichosis (nine patients) suspected by the referring physician to be adrenarche.
The difference between our findings (2) and those presented by Kaplowitz (1) could have several plausible explanations. The analysis in the majority of children in the latter study was based on a single visit. By contrast, all of our patients were followed for a minimum of 2 yr, and when the clinical picture was not obvious, the diagnoses were deferred for at least 6 months. In addition, the Kaplowitz study (1) was done in a clinic by a single observer, whereas ours was performed in a tertiary care center.
The extent of the work-up required in a child with precocious puberty or precocious adrenarche is controversial; most endocrinologists recommend obtaining data on pubertal progression, growth velocity, and/or bone age. Yet, in the study of Kaplowitz (1), previous growth records were available in only 61% of cases. In the absence of such critical information, caution is necessary, and bone age as well as growth velocity should be assessed over a couple of months. Indeed, girls with premature thelarche or early breast development may progress to precocious puberty (3), and girls with true precocious puberty may have a progressive course and subsequent compromised final height (4).
Presuming that the patients who did not return to the clinic have benign normal variants may result in overlooking endocrine pathology or undertreatment leading to markedly diminished growth potential (5). Furthermore, parents may have been falsely reassured by the fact that their child was seen by a specialist and discharged, leading them to be less attentive to further clinical changes.
We believe that the majority of children referred for precocious puberty warrant endocrine evaluation, including growth velocity data, and follow-up. The extent of evaluation and follow-up should be tailored to identify endocrine disorders expected in each subtype and age group of early sexual development.
Received September 21, 2004.
References
This article has been cited by other articles:
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  L. S. Nield, N. Cakan, and D. Kamat A Practical Approach to Precocious Puberty Clinical Pediatrics, May 1, 2007; 46(4): 299 - 306. [PDF]
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