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Author’s Response: Children Referred for Signs of Early Puberty Warrant Endocrine Evaluation and Follow-Up

Department of Endocrinology, Children’s National Medical Center, Washington, D.C. 20010-2970

Address correspondence to: Paul Kaplowitz, M.D., Ph.D., Department of Endocrinology, 111 Michigan Avenue NW, Washington, D.C. 20010-2970. E-mail: pkaplowi{at}cnmc.org.

To the editor:

I thank Drs. de Vries and Phillips (1) for sharing their recently published experience with referrals for precocious puberty in Israel between 1997 and 2000. Their findings are similar to those of Bridges et al. (2) from the United Kingdom who also found that between 1975 and 1990, the most common diagnosis among their referrals was true precocious puberty (40%), with only 10% diagnosed with premature adrenarche. Thus, it is likely that the proportion of different diagnoses varies from region to region based in part on the different mix of ethnic and racial groups, and it may not be possible to generalize from the type of patients seen in one city in the United States to other countries.

There is no question that within the population of patients referred for signs of early puberty, there are a few patients with significant pathology. Although the Israeli sample, which was four times larger than mine (3), included an adrenal tumor, three central nervous system lesions, and three cases of nonclassical congenital adrenal hyperplasia, the percentage of such cases was still quite small. I do not think that the time of follow-up is the critical difference between their findings and mine, because if a patient I had seen and diagnosed with a benign variant later developed a central nervous system tumor or other serious complication within 1 or 2 yr of my seeing them, he or she would have been referred back by the primary care physician. This did indeed happen in the one child initially diagnosed with premature adrenarche who subsequently was diagnosed with an astrocytoma. I still believe that the majority of the small number of children with serious pathology can be spotted at the first visit as being at higher risk due to more advanced pubertal development and growth acceleration, and these children need testing and close endocrine follow-up. It should be noted that the majority of children diagnosed in my review as normal variants had had breast or pubic hair development for at least 6 months before their first endocrine visit, and had had no or very slow progression of findings in that interval, suggesting a very small probability of finding a problem requiring intervention.

As to whether premature thelarche sometimes progresses to true precocious puberty, the article cited by Pasquino et al. (4) defined premature thelarche as any girl under age 8 with breast development who did not meet the criteria of true precocious puberty, and the 14 girls out of 100 who progressed had a mean age of 5.1 yr at the time of thelarche. I defined premature thelarche as girls with nonprogressing breast development who were less than 3 yr old, and I have yet to see one that young who evolved to true precocious puberty. Girls who start their breast development between ages 3 and 7 are certainly at higher risk and need to be monitored more closely. I agree with Drs. de Vries and Phillips that all patients should have follow-up, but the question is whether it needs to be done by a pediatric endocrinologist when the initial impression is premature adrenarche or premature thelarche. Given the shortage of pediatric endocrinologists in many parts of the United States, one needs to make priorities in terms of which patients one decides to see at regular intervals for up to 2 yr. I believe it is reasonable to provide clear guidelines to the parents and to the primary care physician as to when such a child should be referred back for a second visit.

Received October 13, 2004.

References

1. de Vries L, Phillip M 2005 Children referred for signs of early puberty warrant endocrine evaluation and follow-up. J Clin Endocrinol Metab 90:593 (Letter)
2. Bridges NA, Christopher JA, Hindmarsh PC, Brook CGD 1994 Sexual precocity: sex incidence and aetiology. Arch Dis Child 70:118–120
3. Kaplowitz P 2004 Clinical characteristics of 104 children referred for evaluation of precocious puberty. J Clin Endocrinol Metab 89:3644–3650[Abstract/Free Full Text]
4. Pasquino AM, Pucarelli I, Passeri F, Segni M, Mancini MA, Municchi G 1995 Progression of premature thelarche to central precocious puberty. J Pediatr 126:11–14[CrossRef][Medline]

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