pubertyŠtiming is everything! - semantic scholar · pubertyŠtiming is everything! belinda...
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Page 1 of 17
PubertyTiming is everything
BELINDA PINYERD PhD RN
Central Ohio Pediatric Endocrinology and Diabetes Services
Columbus OH
WILLIAM B ZIPF MD FAAP
Central Ohio Pediatric Endocrinology and Diabetes Services
Columbus OH
BWResearchcolumbusrrcom
T 614840-0535
F 614840-0536
Page 2 of 17
ABSTRACT
Puberty is a dynamic period of physical growth sexual maturation and psychosocial
achievement that generally begins between age 8 and 14 years The age of onset varies as a
function of gender ethnicity health status genetics nutrition and activity level Puberty is
initiated by hormonal changes triggered by the hypothalamus Children with variants of
normal pubertal developmentboth early and late pubertyare common in pediatric
practice Recognizing when variations are normal and when referral for further evaluation is
indicated is an important skill
INTRODUCTION
Puberty derived from the Latin pubertas meaning adulthood is not a de novo event but a
process leading to physical sexual and psychosocial maturation (Blondell Foster amp Dave
1999) Puberty differs from adolescence in that it is just one change (maturation of the
reproductive system) that occurs during adolescence From a biological perspective puberty
is the stage of development during which an individual first attains fertility and is capable of
reproduction Physical changes that occur during puberty include somatic growth primary
sexual organ development (gonads and genitals) and the appearance of secondary sexual
characteristics (breasts and pubic hair) This paper reviews the hormonal processes
responsible for inducing puberty clinical indicators and staging of normal puberty and
psychosocial changes that accompany the physical maturation Abnormal puberty patterns
and guidelines for assessment are also reviewed
OVERVIEW REGULATION OF PUBERTY In normal puberty hormone secretion changes dramatically Central to the process is a
section of the brain called the hypothalamus which produces a substance called gonadotropin
releasing hormone (GnRH) During childhood GnRH secretion is minimal but with the onset
of puberty secretion of GnRH is enhanced The primary function of GnRH is to regulate
the growth development and function of the testes in the male and the ovaries in the
female GnRH signals the pituitary gland to secrete luteinizing hormone (LH) and follicle-
When its time to change you have to rearrange - Peter Brady
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stimulating hormone (FSH) (also known as gonadotropins) In boys LH stimulates
testosterone production and FSH promotes sperm production In girls both LH and FSH
are necessary for ovulation (rupture of follicle and release of egg from the ovary) while FSH
stimulates development and maturation of a follicle in one the ovaries
HORMONAL CHANGES Two processes contribute to the physical manifestations of puberty gonadarche the ovary or
testes component of puberty and adrenarche the adrenal gland component of puberty These
two components may seem to occur simultaneous and be a consequence of the same
phenomena but they are separate and distinct events
Gonadarche is initiated by cells of the hypothalamus that secrete GnRH During childhood
prior to the onset of puberty the hypothalamus gonadostat is exquisitely sensitive to very
low concentrations of sex steroids (androgens and estrogens) As a result GnRH secretion is
suppressed preventing LH and follicle-stimulating hormone FSH release from the pituitary
At the end of childhood the hypothalamus is released from the suppressive effects of the
sex steroids resulting in increased GnRH release and increased release of LH and FSH In
boys LH stimulates testosterone production and FSH supports sperm maturation In girls
FSH and LH stimulate ovary production of estrogen progesterone and testosterone all
necessary for normal menstruation (Lee 2003)
Adrenarche can occur separate from and without other signs of sexual development The
physical signs of adrenarche include the development of adult body odor increase in
testicular size and early changes in body growth axillary hair growth and development of
pubic hair (pubarche) Biochemically adrenarche actually begins earlier then these signs
Studies have shown that in both boys and girls at approximately six years there is an increase
production of adrenal hormones by the adrenal gland The stimulus of adrenarche has not
yet been determined but it is separate from the onset of pituitary secretion of LH and FSH
(Lalwani Reindollar amp Davis 2003)
While adrenarche begins biochemically in boys and girls at the same time pubarche (onset of
sexual hair development) occurs 6 to 12 months later in boys than girls In females the signs
Page 4 of 17
of adrenarche occur approximately six to 12 months after the onset of gonadarche
Physically it is observed that shortly after the onset of the first signs of breast development
(a sign of ovarian estrogen secretion) a young girl will then show signs of adrenal androgen
secretion For some girls this sequence is reversed Recently there is greater attention being
given to this component of puberty because abnormalities in the timing of adrenarche have
been shown to be associated with irregular menstrual cycles obesity insulin resistance and
increased risks for diabetes (Ibanez et al 1998) In boys the physical signs of adrenarche
cannot be distinguished from the signs of gonadarche However the presence of pubarche
without a change in testicular size is usually a sign that gonadarche has not yet begun
STAGING AND TIMING The pubertal sequence of events follows a certain pattern (accelerated growth breast
development adrenarche menarche) on average requiring a period of 45 years (range 156
years) with girls beginning puberty earlier than boys In fact most information available
about the timing of puberty is for girls as breast development and onset of menstruation
(menarche) are more overt and recordable than changes in penis and testicle size in boys
Several factors in addition to gender and ethnicity impact the timing of puberty including
genetics dietary intake and energy expenditure Genetic factors play an important role as
illustrated by the similar age of menarche in members of an ethnic population and in
mother-daughter and sibling pairs (Meyer et al 1991) Type of protein consumption (animal
versus vegetable) amount of dietary fat and total calories has also been related to onset of
puberty (Grumbach amp Styne 2003) Puberty often begins earlier in heavier children of both
sexes (Qing amp Karlberg 2001) whereas excessive exercise and psychiatric illnesses (eg
anorexia nervosa) are associated with hypogonadotropic states that can delay or arrest the
onset of puberty (Warren amp Vu 2003)
What specifically triggers the onset is still debated The attainment of a particular proportion
of fat mass has long been argued to be requisite for the onset of puberty in girls (Plant
2002) Interest in this theory has intensified recently as a result of delayed puberty noted in
athletic girls and girls with eating disorders (Georgopoulos et al 1999 Warren amp Fried
2001)
Page 5 of 17
Females
The first visible sign of sexual maturation is the appearance of breast buds generally
around age 10 or 11 years of age Full breast development takes 3 to 4 years and is generally
complete by 14 years of age In approximately 20 percent of girls pubic hair may be the first
sign of puberty (Lalwani Reindollar amp Davis 2003) As mentioned pubic and axillary hair
growth is primarily due to a pubertal increase in adrenal androgen (adrenarche) Over the
next three years the pubic hair becomes darker curlier and coarser and spread to cover a
larger area Hair also develops under the arms on the arms and legs and to a slight degree
on the face
The most dramatic sign of sexual maturity in girls is the onset of menstruation which usually
occurs at an average age of 128 years (range 1113) Initial menstrual cycles are usually
anovulatory which is associated with irregular and often painful periods After
approximately one to two years the menstrual cycles become ovulatory and more regular
(Zacharias Rand amp Wurtman 1976
Males
For boys an increase in testicular size occurs at 95135 yr (average 12 yr) of age which is
followed by the growth of pubic hair (Marshall amp Tanner 1970) The testes and scrotum
begin to grow and the scrotum thins darkens and becomes pendulous The penis lengthens
and widens taking several years to reach full size Sperm production coincides with testicular
and penile growth generally occurring at age 13514 years Facial hair appears about three
years after the onset of pubic hair growth first in the mustache area above the upper lip and
later at the sides of the face and on the chin The density and distribution of hair growth
varies considerably among adult men and is correlated more with genetic factors than with
hormone levels (Lee 2003) Gynecomastia (visible breast tissue) occurs in approximately
two-thirds of males some time during puberty Onset may coincide with the onset of puberty
but primarily begins at ages 1314 before testosterone levels have reached adult levels Most
commonly it persists for 1824 months then regresses by age 16 years (Zosi et al 2002)
Page 6 of 17
OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES Growth Spurt
During puberty females and males experience a growth velocity greater than at any postnatal
age since infancy The pubertal growth spurt in girls is usually observed along with the first
signs of puberty (breast development and pubic hair) Peak growth occurs when breast
development is between Tanner stages 2 and 3 Because girls reach peak height velocity
about 13 years before menarche there is limited growth potential after menarche most girls
grow only about 25 cm in height after menarche although there is a variation from 1 to as
much as 7 cm (Grumbach amp Styne 2003) In contrast to females the peak growth spurt in
males occurs during midpuberty (Tanner stages 34) when testosterone levels are rapidly
rising Peak growth velocity in boys is generally at 1415 years of age Boys attain 28 to 31
cm of growth during the pubertal growth spurt whereas girls attain 275 to 29 cm of growth
(Abbassi 1998)
In both males and females the ages at menarche and peak height velocity are not good
predictors of adult height because the duration of pubertal growth is the more important
determinant of final height Nonetheless extremely early onset of puberty can diminish
ultimate adult stature (Bourguignon 1988) and prolonged delay of puberty (Haumlgg amp
Juranger 1991) can increase stature
Acne
Comedones acne and seborrhea of the scalp appear as a result of the increased secretion of
gonadal and adrenal sex steroids Early-onset acne correlates with the development of severe
acne later in puberty Acne vulgaris the most prevalent skin disorder in adolescence occurs
at a mean age of 122 years plusmn 14 years (SD range 915 years) in boys and progresses with
advancement through puberty However acne vulgaris can be the first notable sign of
puberty in a girl preceding public hair and breast development
Mood and depression
During puberty young girls frequently exhibit a negative self-image Prepubertal boys and
girls demonstrate an equal frequency of depression although there is a more frequent
occurrence in girls at stage 3 This change in the prevalence of depression appears more
Page 7 of 17
related to serum sex steroid concentrations than to LH or FSH values or the physical
changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide
increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-
to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually
committed suicide during puberty had the onset of their depression in childhood or early
puberty even though the act of suicide occurred later in puberty (Rao et al 1993)
Body image
An important aspect of puberty is the development of body image Body image is a persons
inner conception of hisher physical appearance As obvious from the previous discussion
adolescence is a time of great physical and social change Adolescents are critical and
embarrassed about their bodies during puberty either because they are maturing too early
too late or they are not developing according to societals standards of attractiveness
Adolescent girls appear to be particularly vulnerable to developing a negative body image
especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis
1999) Adolescents with severe body image distortions are vulnerable to developing
psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
Psychosocial changes
Puberty includes a profound social change from the sheltered single-classroom environment
of elementary school to the multiple classrooms and teachers of middle school (Mayer amp
Carter 2003) There is exposure to new peers often with different life experiences and
behavior patterns Risk-taking behaviors often increase including sexual precocity and
alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child
entering puberty develops maturing abstract thought and decision-making processes Other
psychological and psychosocial changes that occur during this time include the ability to
absorb the perspectives or viewpoints of others the development of personal and sexual
identity the establishment of a system of values and increasing autonomy from family
(Remschmidt 1994)
Page 8 of 17
ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years
recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the
threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was
defined as pubic hair developing in girls younger than 8 years old and boys younger than 9
years However the results of a large cross-sectional study (Herman-Giddens Slora amp
Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous
studies have documented with pubic hair development appearing in white girls as young as 7
years (between 711 years) and in African American girls as young as 6 years (between 611
years) The timing of puberty is significant from a clinical standpoint given the observation
that early-maturing girls and late-maturing boys show more evidence of adjustment
problems than other adolescents (Graber et al 1997) However the definition of early
puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys
(Saenger 2003)
Early
The majority of children who show signs of puberty at a young age have no discernable
underlying pathology particularly if they meet other criteria (see Table 1) Some physicians
order an x-ray to check that the skeletal age of the child is no more than 25 standard
deviations (typically about 2 years) above the chronological age For boys younger than 9
years of age who have penile enlargement scrotal thinning and accelerated growth a formal
evaluation is warranted
TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY
Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly
Source Nakamoto 2000
Page 9 of 17
When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is
designated central or true precocious puberty (CPP) In a minority of patients CPP
arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-
cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS
lesions seem to predispose males and females equally to early central puberty that is the sex
ratio among patients with neurogenic CPP approximates unity However among children
with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex
difference with the female to male ratio approaching 101 in most series (Palmert amp
Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with
behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)
reported more withdrawal social problems aggression somatic complaints and depression
in children with premature adrenarche as compared to children with on-time adrenarche
Precocious puberty also places a child at risk for not achieving hisher genetic height
potential The rapid maturation of the growth plate (due to sex steroid exposure) will often
result in temporary acceleration of linear growth but the accompanying early closure of
growth plates results in early cessation of growth and ultimately shorter than would be
expected adult height (Lee 1999)
Delayed
Delayed puberty describes the clinical condition in which the physical manifestations of
puberty start late (usually gt +25 SD later than the mean) In the United States puberty is
considered to be delayed if sexual maturation has not become apparent by age 14 years in
boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche
by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these
criteria approximately 25 of healthy adolescents will be identified as having pubertal delay
(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying
pathology but instead represents an extreme end of normal puberty referred to as
constitutional delay of growth and maturation When puberty does begin it is entirely
normal However delayed puberty generally warrants referral to a pediatric endocrinologist
to rule out possible genetic hypothalamic pituitary gonodal or system conditions that
could be present
Page 10 of 17
PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is
the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969
1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and
breast (female)genitalia (males) development
In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is
characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast
buds become larger and pubic hair growth continues but it is mostly in the center and does
not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of
pubic hair underarm hair growth and the breasts take on a mound form The first
menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached
Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and
type forming the classical upside-down triangle shape common to women Rough estimates
based upon the size and shape of the breasts (see Figure 1) along with the amount and type
of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp
Tanner 1969)
In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)
In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the
same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in
the pubic area testicular enlargement and scrotum growth thinning and reddening During
stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is
characterized by more pubic hair darkening of the scrotum and increased growth of the
penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his
pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the
testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-
hood) The Prader orchidometer which consists of a series of increasingly larger oval beads
is the standard by which the practitioner makes a determination of the patients testicular
size (Styne 2002)
Page 11 of 17
When a child presents with abnormal puberty the goal of the initial assessment is to
distinguish benign constitutional causes from pathologic causes The history should focus on
the childs previous growth and development including the timing and sequence of the
physical milestones of puberty A history of medical or surgical treatment may provide clues
to an underlying pathologic condition The family history may reveal information about a
familial pattern of delayed or early puberty as well as information about genetic disease A
physical examination should focus on evaluation of the genitalia and determination of the
stage of pubertal development A detailed growth chart is used to estimate annual growth
rate (centimeters per year) and to determine if a growth spurt has occurred When the history
andor evaluation of the child with early or delayed pubertal development suggest a
pathological cause referral to a pediatric endocrinologist is warranted
CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for
pediatric practitioners Parents and adolescents often experience anxiety when puberty is not
occurring as expected even when it occurs within the range of normal The pediatric
practitioner can allay much of that anxiety with counseling regarding the natural and normal
variation of this process A clear understanding of pubertal milestones also promotes
appropriate interventions for delayed or advanced puberty when the practitioner and parents
are in agreement that intervention is in the best interest of the child Recently changes in the
timing of puberty as compared to previously published standards now make the
understanding of this complex process even more important The observation that more
children are showing signs of puberty earlier places pressure upon the practitioner to
differentiate the child with early but otherwise normal puberty from the child with early
onset puberty as a consequence of a pathologic process Even with normal but early-onset
puberty close observation of the temporal process is needed to adequately predict if the
abnormal timing will impact final adult height Referral to a specialist in pediatric
endocrinology is indicated for patients who present with signs of early or delayed puberty
Health care for adolescents should include systematic monitoring of pubertal development
and concerns in order to aggressively educate preadolescents to negotiate this period
smoothly and to avoid high-risk behaviors that could have negative health and social
Page 12 of 17
sequelae during adolescence and adulthood Interventions with parents of children who
present with abnormal puberty include providing anticipatory guidance supporting parent
communication strategies and providing support and information resources (Doswell amp
Vandestienne 1996 Williams 1995) Finally with the observation that precocious
adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity
insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated
with the metabolic syndrome are particularly relevant when the child presents with signs of
early puberty
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 2 of 17
ABSTRACT
Puberty is a dynamic period of physical growth sexual maturation and psychosocial
achievement that generally begins between age 8 and 14 years The age of onset varies as a
function of gender ethnicity health status genetics nutrition and activity level Puberty is
initiated by hormonal changes triggered by the hypothalamus Children with variants of
normal pubertal developmentboth early and late pubertyare common in pediatric
practice Recognizing when variations are normal and when referral for further evaluation is
indicated is an important skill
INTRODUCTION
Puberty derived from the Latin pubertas meaning adulthood is not a de novo event but a
process leading to physical sexual and psychosocial maturation (Blondell Foster amp Dave
1999) Puberty differs from adolescence in that it is just one change (maturation of the
reproductive system) that occurs during adolescence From a biological perspective puberty
is the stage of development during which an individual first attains fertility and is capable of
reproduction Physical changes that occur during puberty include somatic growth primary
sexual organ development (gonads and genitals) and the appearance of secondary sexual
characteristics (breasts and pubic hair) This paper reviews the hormonal processes
responsible for inducing puberty clinical indicators and staging of normal puberty and
psychosocial changes that accompany the physical maturation Abnormal puberty patterns
and guidelines for assessment are also reviewed
OVERVIEW REGULATION OF PUBERTY In normal puberty hormone secretion changes dramatically Central to the process is a
section of the brain called the hypothalamus which produces a substance called gonadotropin
releasing hormone (GnRH) During childhood GnRH secretion is minimal but with the onset
of puberty secretion of GnRH is enhanced The primary function of GnRH is to regulate
the growth development and function of the testes in the male and the ovaries in the
female GnRH signals the pituitary gland to secrete luteinizing hormone (LH) and follicle-
When its time to change you have to rearrange - Peter Brady
Page 3 of 17
stimulating hormone (FSH) (also known as gonadotropins) In boys LH stimulates
testosterone production and FSH promotes sperm production In girls both LH and FSH
are necessary for ovulation (rupture of follicle and release of egg from the ovary) while FSH
stimulates development and maturation of a follicle in one the ovaries
HORMONAL CHANGES Two processes contribute to the physical manifestations of puberty gonadarche the ovary or
testes component of puberty and adrenarche the adrenal gland component of puberty These
two components may seem to occur simultaneous and be a consequence of the same
phenomena but they are separate and distinct events
Gonadarche is initiated by cells of the hypothalamus that secrete GnRH During childhood
prior to the onset of puberty the hypothalamus gonadostat is exquisitely sensitive to very
low concentrations of sex steroids (androgens and estrogens) As a result GnRH secretion is
suppressed preventing LH and follicle-stimulating hormone FSH release from the pituitary
At the end of childhood the hypothalamus is released from the suppressive effects of the
sex steroids resulting in increased GnRH release and increased release of LH and FSH In
boys LH stimulates testosterone production and FSH supports sperm maturation In girls
FSH and LH stimulate ovary production of estrogen progesterone and testosterone all
necessary for normal menstruation (Lee 2003)
Adrenarche can occur separate from and without other signs of sexual development The
physical signs of adrenarche include the development of adult body odor increase in
testicular size and early changes in body growth axillary hair growth and development of
pubic hair (pubarche) Biochemically adrenarche actually begins earlier then these signs
Studies have shown that in both boys and girls at approximately six years there is an increase
production of adrenal hormones by the adrenal gland The stimulus of adrenarche has not
yet been determined but it is separate from the onset of pituitary secretion of LH and FSH
(Lalwani Reindollar amp Davis 2003)
While adrenarche begins biochemically in boys and girls at the same time pubarche (onset of
sexual hair development) occurs 6 to 12 months later in boys than girls In females the signs
Page 4 of 17
of adrenarche occur approximately six to 12 months after the onset of gonadarche
Physically it is observed that shortly after the onset of the first signs of breast development
(a sign of ovarian estrogen secretion) a young girl will then show signs of adrenal androgen
secretion For some girls this sequence is reversed Recently there is greater attention being
given to this component of puberty because abnormalities in the timing of adrenarche have
been shown to be associated with irregular menstrual cycles obesity insulin resistance and
increased risks for diabetes (Ibanez et al 1998) In boys the physical signs of adrenarche
cannot be distinguished from the signs of gonadarche However the presence of pubarche
without a change in testicular size is usually a sign that gonadarche has not yet begun
STAGING AND TIMING The pubertal sequence of events follows a certain pattern (accelerated growth breast
development adrenarche menarche) on average requiring a period of 45 years (range 156
years) with girls beginning puberty earlier than boys In fact most information available
about the timing of puberty is for girls as breast development and onset of menstruation
(menarche) are more overt and recordable than changes in penis and testicle size in boys
Several factors in addition to gender and ethnicity impact the timing of puberty including
genetics dietary intake and energy expenditure Genetic factors play an important role as
illustrated by the similar age of menarche in members of an ethnic population and in
mother-daughter and sibling pairs (Meyer et al 1991) Type of protein consumption (animal
versus vegetable) amount of dietary fat and total calories has also been related to onset of
puberty (Grumbach amp Styne 2003) Puberty often begins earlier in heavier children of both
sexes (Qing amp Karlberg 2001) whereas excessive exercise and psychiatric illnesses (eg
anorexia nervosa) are associated with hypogonadotropic states that can delay or arrest the
onset of puberty (Warren amp Vu 2003)
What specifically triggers the onset is still debated The attainment of a particular proportion
of fat mass has long been argued to be requisite for the onset of puberty in girls (Plant
2002) Interest in this theory has intensified recently as a result of delayed puberty noted in
athletic girls and girls with eating disorders (Georgopoulos et al 1999 Warren amp Fried
2001)
Page 5 of 17
Females
The first visible sign of sexual maturation is the appearance of breast buds generally
around age 10 or 11 years of age Full breast development takes 3 to 4 years and is generally
complete by 14 years of age In approximately 20 percent of girls pubic hair may be the first
sign of puberty (Lalwani Reindollar amp Davis 2003) As mentioned pubic and axillary hair
growth is primarily due to a pubertal increase in adrenal androgen (adrenarche) Over the
next three years the pubic hair becomes darker curlier and coarser and spread to cover a
larger area Hair also develops under the arms on the arms and legs and to a slight degree
on the face
The most dramatic sign of sexual maturity in girls is the onset of menstruation which usually
occurs at an average age of 128 years (range 1113) Initial menstrual cycles are usually
anovulatory which is associated with irregular and often painful periods After
approximately one to two years the menstrual cycles become ovulatory and more regular
(Zacharias Rand amp Wurtman 1976
Males
For boys an increase in testicular size occurs at 95135 yr (average 12 yr) of age which is
followed by the growth of pubic hair (Marshall amp Tanner 1970) The testes and scrotum
begin to grow and the scrotum thins darkens and becomes pendulous The penis lengthens
and widens taking several years to reach full size Sperm production coincides with testicular
and penile growth generally occurring at age 13514 years Facial hair appears about three
years after the onset of pubic hair growth first in the mustache area above the upper lip and
later at the sides of the face and on the chin The density and distribution of hair growth
varies considerably among adult men and is correlated more with genetic factors than with
hormone levels (Lee 2003) Gynecomastia (visible breast tissue) occurs in approximately
two-thirds of males some time during puberty Onset may coincide with the onset of puberty
but primarily begins at ages 1314 before testosterone levels have reached adult levels Most
commonly it persists for 1824 months then regresses by age 16 years (Zosi et al 2002)
Page 6 of 17
OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES Growth Spurt
During puberty females and males experience a growth velocity greater than at any postnatal
age since infancy The pubertal growth spurt in girls is usually observed along with the first
signs of puberty (breast development and pubic hair) Peak growth occurs when breast
development is between Tanner stages 2 and 3 Because girls reach peak height velocity
about 13 years before menarche there is limited growth potential after menarche most girls
grow only about 25 cm in height after menarche although there is a variation from 1 to as
much as 7 cm (Grumbach amp Styne 2003) In contrast to females the peak growth spurt in
males occurs during midpuberty (Tanner stages 34) when testosterone levels are rapidly
rising Peak growth velocity in boys is generally at 1415 years of age Boys attain 28 to 31
cm of growth during the pubertal growth spurt whereas girls attain 275 to 29 cm of growth
(Abbassi 1998)
In both males and females the ages at menarche and peak height velocity are not good
predictors of adult height because the duration of pubertal growth is the more important
determinant of final height Nonetheless extremely early onset of puberty can diminish
ultimate adult stature (Bourguignon 1988) and prolonged delay of puberty (Haumlgg amp
Juranger 1991) can increase stature
Acne
Comedones acne and seborrhea of the scalp appear as a result of the increased secretion of
gonadal and adrenal sex steroids Early-onset acne correlates with the development of severe
acne later in puberty Acne vulgaris the most prevalent skin disorder in adolescence occurs
at a mean age of 122 years plusmn 14 years (SD range 915 years) in boys and progresses with
advancement through puberty However acne vulgaris can be the first notable sign of
puberty in a girl preceding public hair and breast development
Mood and depression
During puberty young girls frequently exhibit a negative self-image Prepubertal boys and
girls demonstrate an equal frequency of depression although there is a more frequent
occurrence in girls at stage 3 This change in the prevalence of depression appears more
Page 7 of 17
related to serum sex steroid concentrations than to LH or FSH values or the physical
changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide
increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-
to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually
committed suicide during puberty had the onset of their depression in childhood or early
puberty even though the act of suicide occurred later in puberty (Rao et al 1993)
Body image
An important aspect of puberty is the development of body image Body image is a persons
inner conception of hisher physical appearance As obvious from the previous discussion
adolescence is a time of great physical and social change Adolescents are critical and
embarrassed about their bodies during puberty either because they are maturing too early
too late or they are not developing according to societals standards of attractiveness
Adolescent girls appear to be particularly vulnerable to developing a negative body image
especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis
1999) Adolescents with severe body image distortions are vulnerable to developing
psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
Psychosocial changes
Puberty includes a profound social change from the sheltered single-classroom environment
of elementary school to the multiple classrooms and teachers of middle school (Mayer amp
Carter 2003) There is exposure to new peers often with different life experiences and
behavior patterns Risk-taking behaviors often increase including sexual precocity and
alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child
entering puberty develops maturing abstract thought and decision-making processes Other
psychological and psychosocial changes that occur during this time include the ability to
absorb the perspectives or viewpoints of others the development of personal and sexual
identity the establishment of a system of values and increasing autonomy from family
(Remschmidt 1994)
Page 8 of 17
ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years
recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the
threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was
defined as pubic hair developing in girls younger than 8 years old and boys younger than 9
years However the results of a large cross-sectional study (Herman-Giddens Slora amp
Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous
studies have documented with pubic hair development appearing in white girls as young as 7
years (between 711 years) and in African American girls as young as 6 years (between 611
years) The timing of puberty is significant from a clinical standpoint given the observation
that early-maturing girls and late-maturing boys show more evidence of adjustment
problems than other adolescents (Graber et al 1997) However the definition of early
puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys
(Saenger 2003)
Early
The majority of children who show signs of puberty at a young age have no discernable
underlying pathology particularly if they meet other criteria (see Table 1) Some physicians
order an x-ray to check that the skeletal age of the child is no more than 25 standard
deviations (typically about 2 years) above the chronological age For boys younger than 9
years of age who have penile enlargement scrotal thinning and accelerated growth a formal
evaluation is warranted
TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY
Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly
Source Nakamoto 2000
Page 9 of 17
When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is
designated central or true precocious puberty (CPP) In a minority of patients CPP
arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-
cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS
lesions seem to predispose males and females equally to early central puberty that is the sex
ratio among patients with neurogenic CPP approximates unity However among children
with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex
difference with the female to male ratio approaching 101 in most series (Palmert amp
Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with
behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)
reported more withdrawal social problems aggression somatic complaints and depression
in children with premature adrenarche as compared to children with on-time adrenarche
Precocious puberty also places a child at risk for not achieving hisher genetic height
potential The rapid maturation of the growth plate (due to sex steroid exposure) will often
result in temporary acceleration of linear growth but the accompanying early closure of
growth plates results in early cessation of growth and ultimately shorter than would be
expected adult height (Lee 1999)
Delayed
Delayed puberty describes the clinical condition in which the physical manifestations of
puberty start late (usually gt +25 SD later than the mean) In the United States puberty is
considered to be delayed if sexual maturation has not become apparent by age 14 years in
boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche
by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these
criteria approximately 25 of healthy adolescents will be identified as having pubertal delay
(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying
pathology but instead represents an extreme end of normal puberty referred to as
constitutional delay of growth and maturation When puberty does begin it is entirely
normal However delayed puberty generally warrants referral to a pediatric endocrinologist
to rule out possible genetic hypothalamic pituitary gonodal or system conditions that
could be present
Page 10 of 17
PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is
the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969
1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and
breast (female)genitalia (males) development
In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is
characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast
buds become larger and pubic hair growth continues but it is mostly in the center and does
not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of
pubic hair underarm hair growth and the breasts take on a mound form The first
menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached
Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and
type forming the classical upside-down triangle shape common to women Rough estimates
based upon the size and shape of the breasts (see Figure 1) along with the amount and type
of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp
Tanner 1969)
In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)
In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the
same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in
the pubic area testicular enlargement and scrotum growth thinning and reddening During
stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is
characterized by more pubic hair darkening of the scrotum and increased growth of the
penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his
pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the
testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-
hood) The Prader orchidometer which consists of a series of increasingly larger oval beads
is the standard by which the practitioner makes a determination of the patients testicular
size (Styne 2002)
Page 11 of 17
When a child presents with abnormal puberty the goal of the initial assessment is to
distinguish benign constitutional causes from pathologic causes The history should focus on
the childs previous growth and development including the timing and sequence of the
physical milestones of puberty A history of medical or surgical treatment may provide clues
to an underlying pathologic condition The family history may reveal information about a
familial pattern of delayed or early puberty as well as information about genetic disease A
physical examination should focus on evaluation of the genitalia and determination of the
stage of pubertal development A detailed growth chart is used to estimate annual growth
rate (centimeters per year) and to determine if a growth spurt has occurred When the history
andor evaluation of the child with early or delayed pubertal development suggest a
pathological cause referral to a pediatric endocrinologist is warranted
CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for
pediatric practitioners Parents and adolescents often experience anxiety when puberty is not
occurring as expected even when it occurs within the range of normal The pediatric
practitioner can allay much of that anxiety with counseling regarding the natural and normal
variation of this process A clear understanding of pubertal milestones also promotes
appropriate interventions for delayed or advanced puberty when the practitioner and parents
are in agreement that intervention is in the best interest of the child Recently changes in the
timing of puberty as compared to previously published standards now make the
understanding of this complex process even more important The observation that more
children are showing signs of puberty earlier places pressure upon the practitioner to
differentiate the child with early but otherwise normal puberty from the child with early
onset puberty as a consequence of a pathologic process Even with normal but early-onset
puberty close observation of the temporal process is needed to adequately predict if the
abnormal timing will impact final adult height Referral to a specialist in pediatric
endocrinology is indicated for patients who present with signs of early or delayed puberty
Health care for adolescents should include systematic monitoring of pubertal development
and concerns in order to aggressively educate preadolescents to negotiate this period
smoothly and to avoid high-risk behaviors that could have negative health and social
Page 12 of 17
sequelae during adolescence and adulthood Interventions with parents of children who
present with abnormal puberty include providing anticipatory guidance supporting parent
communication strategies and providing support and information resources (Doswell amp
Vandestienne 1996 Williams 1995) Finally with the observation that precocious
adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity
insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated
with the metabolic syndrome are particularly relevant when the child presents with signs of
early puberty
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 3 of 17
stimulating hormone (FSH) (also known as gonadotropins) In boys LH stimulates
testosterone production and FSH promotes sperm production In girls both LH and FSH
are necessary for ovulation (rupture of follicle and release of egg from the ovary) while FSH
stimulates development and maturation of a follicle in one the ovaries
HORMONAL CHANGES Two processes contribute to the physical manifestations of puberty gonadarche the ovary or
testes component of puberty and adrenarche the adrenal gland component of puberty These
two components may seem to occur simultaneous and be a consequence of the same
phenomena but they are separate and distinct events
Gonadarche is initiated by cells of the hypothalamus that secrete GnRH During childhood
prior to the onset of puberty the hypothalamus gonadostat is exquisitely sensitive to very
low concentrations of sex steroids (androgens and estrogens) As a result GnRH secretion is
suppressed preventing LH and follicle-stimulating hormone FSH release from the pituitary
At the end of childhood the hypothalamus is released from the suppressive effects of the
sex steroids resulting in increased GnRH release and increased release of LH and FSH In
boys LH stimulates testosterone production and FSH supports sperm maturation In girls
FSH and LH stimulate ovary production of estrogen progesterone and testosterone all
necessary for normal menstruation (Lee 2003)
Adrenarche can occur separate from and without other signs of sexual development The
physical signs of adrenarche include the development of adult body odor increase in
testicular size and early changes in body growth axillary hair growth and development of
pubic hair (pubarche) Biochemically adrenarche actually begins earlier then these signs
Studies have shown that in both boys and girls at approximately six years there is an increase
production of adrenal hormones by the adrenal gland The stimulus of adrenarche has not
yet been determined but it is separate from the onset of pituitary secretion of LH and FSH
(Lalwani Reindollar amp Davis 2003)
While adrenarche begins biochemically in boys and girls at the same time pubarche (onset of
sexual hair development) occurs 6 to 12 months later in boys than girls In females the signs
Page 4 of 17
of adrenarche occur approximately six to 12 months after the onset of gonadarche
Physically it is observed that shortly after the onset of the first signs of breast development
(a sign of ovarian estrogen secretion) a young girl will then show signs of adrenal androgen
secretion For some girls this sequence is reversed Recently there is greater attention being
given to this component of puberty because abnormalities in the timing of adrenarche have
been shown to be associated with irregular menstrual cycles obesity insulin resistance and
increased risks for diabetes (Ibanez et al 1998) In boys the physical signs of adrenarche
cannot be distinguished from the signs of gonadarche However the presence of pubarche
without a change in testicular size is usually a sign that gonadarche has not yet begun
STAGING AND TIMING The pubertal sequence of events follows a certain pattern (accelerated growth breast
development adrenarche menarche) on average requiring a period of 45 years (range 156
years) with girls beginning puberty earlier than boys In fact most information available
about the timing of puberty is for girls as breast development and onset of menstruation
(menarche) are more overt and recordable than changes in penis and testicle size in boys
Several factors in addition to gender and ethnicity impact the timing of puberty including
genetics dietary intake and energy expenditure Genetic factors play an important role as
illustrated by the similar age of menarche in members of an ethnic population and in
mother-daughter and sibling pairs (Meyer et al 1991) Type of protein consumption (animal
versus vegetable) amount of dietary fat and total calories has also been related to onset of
puberty (Grumbach amp Styne 2003) Puberty often begins earlier in heavier children of both
sexes (Qing amp Karlberg 2001) whereas excessive exercise and psychiatric illnesses (eg
anorexia nervosa) are associated with hypogonadotropic states that can delay or arrest the
onset of puberty (Warren amp Vu 2003)
What specifically triggers the onset is still debated The attainment of a particular proportion
of fat mass has long been argued to be requisite for the onset of puberty in girls (Plant
2002) Interest in this theory has intensified recently as a result of delayed puberty noted in
athletic girls and girls with eating disorders (Georgopoulos et al 1999 Warren amp Fried
2001)
Page 5 of 17
Females
The first visible sign of sexual maturation is the appearance of breast buds generally
around age 10 or 11 years of age Full breast development takes 3 to 4 years and is generally
complete by 14 years of age In approximately 20 percent of girls pubic hair may be the first
sign of puberty (Lalwani Reindollar amp Davis 2003) As mentioned pubic and axillary hair
growth is primarily due to a pubertal increase in adrenal androgen (adrenarche) Over the
next three years the pubic hair becomes darker curlier and coarser and spread to cover a
larger area Hair also develops under the arms on the arms and legs and to a slight degree
on the face
The most dramatic sign of sexual maturity in girls is the onset of menstruation which usually
occurs at an average age of 128 years (range 1113) Initial menstrual cycles are usually
anovulatory which is associated with irregular and often painful periods After
approximately one to two years the menstrual cycles become ovulatory and more regular
(Zacharias Rand amp Wurtman 1976
Males
For boys an increase in testicular size occurs at 95135 yr (average 12 yr) of age which is
followed by the growth of pubic hair (Marshall amp Tanner 1970) The testes and scrotum
begin to grow and the scrotum thins darkens and becomes pendulous The penis lengthens
and widens taking several years to reach full size Sperm production coincides with testicular
and penile growth generally occurring at age 13514 years Facial hair appears about three
years after the onset of pubic hair growth first in the mustache area above the upper lip and
later at the sides of the face and on the chin The density and distribution of hair growth
varies considerably among adult men and is correlated more with genetic factors than with
hormone levels (Lee 2003) Gynecomastia (visible breast tissue) occurs in approximately
two-thirds of males some time during puberty Onset may coincide with the onset of puberty
but primarily begins at ages 1314 before testosterone levels have reached adult levels Most
commonly it persists for 1824 months then regresses by age 16 years (Zosi et al 2002)
Page 6 of 17
OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES Growth Spurt
During puberty females and males experience a growth velocity greater than at any postnatal
age since infancy The pubertal growth spurt in girls is usually observed along with the first
signs of puberty (breast development and pubic hair) Peak growth occurs when breast
development is between Tanner stages 2 and 3 Because girls reach peak height velocity
about 13 years before menarche there is limited growth potential after menarche most girls
grow only about 25 cm in height after menarche although there is a variation from 1 to as
much as 7 cm (Grumbach amp Styne 2003) In contrast to females the peak growth spurt in
males occurs during midpuberty (Tanner stages 34) when testosterone levels are rapidly
rising Peak growth velocity in boys is generally at 1415 years of age Boys attain 28 to 31
cm of growth during the pubertal growth spurt whereas girls attain 275 to 29 cm of growth
(Abbassi 1998)
In both males and females the ages at menarche and peak height velocity are not good
predictors of adult height because the duration of pubertal growth is the more important
determinant of final height Nonetheless extremely early onset of puberty can diminish
ultimate adult stature (Bourguignon 1988) and prolonged delay of puberty (Haumlgg amp
Juranger 1991) can increase stature
Acne
Comedones acne and seborrhea of the scalp appear as a result of the increased secretion of
gonadal and adrenal sex steroids Early-onset acne correlates with the development of severe
acne later in puberty Acne vulgaris the most prevalent skin disorder in adolescence occurs
at a mean age of 122 years plusmn 14 years (SD range 915 years) in boys and progresses with
advancement through puberty However acne vulgaris can be the first notable sign of
puberty in a girl preceding public hair and breast development
Mood and depression
During puberty young girls frequently exhibit a negative self-image Prepubertal boys and
girls demonstrate an equal frequency of depression although there is a more frequent
occurrence in girls at stage 3 This change in the prevalence of depression appears more
Page 7 of 17
related to serum sex steroid concentrations than to LH or FSH values or the physical
changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide
increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-
to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually
committed suicide during puberty had the onset of their depression in childhood or early
puberty even though the act of suicide occurred later in puberty (Rao et al 1993)
Body image
An important aspect of puberty is the development of body image Body image is a persons
inner conception of hisher physical appearance As obvious from the previous discussion
adolescence is a time of great physical and social change Adolescents are critical and
embarrassed about their bodies during puberty either because they are maturing too early
too late or they are not developing according to societals standards of attractiveness
Adolescent girls appear to be particularly vulnerable to developing a negative body image
especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis
1999) Adolescents with severe body image distortions are vulnerable to developing
psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
Psychosocial changes
Puberty includes a profound social change from the sheltered single-classroom environment
of elementary school to the multiple classrooms and teachers of middle school (Mayer amp
Carter 2003) There is exposure to new peers often with different life experiences and
behavior patterns Risk-taking behaviors often increase including sexual precocity and
alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child
entering puberty develops maturing abstract thought and decision-making processes Other
psychological and psychosocial changes that occur during this time include the ability to
absorb the perspectives or viewpoints of others the development of personal and sexual
identity the establishment of a system of values and increasing autonomy from family
(Remschmidt 1994)
Page 8 of 17
ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years
recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the
threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was
defined as pubic hair developing in girls younger than 8 years old and boys younger than 9
years However the results of a large cross-sectional study (Herman-Giddens Slora amp
Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous
studies have documented with pubic hair development appearing in white girls as young as 7
years (between 711 years) and in African American girls as young as 6 years (between 611
years) The timing of puberty is significant from a clinical standpoint given the observation
that early-maturing girls and late-maturing boys show more evidence of adjustment
problems than other adolescents (Graber et al 1997) However the definition of early
puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys
(Saenger 2003)
Early
The majority of children who show signs of puberty at a young age have no discernable
underlying pathology particularly if they meet other criteria (see Table 1) Some physicians
order an x-ray to check that the skeletal age of the child is no more than 25 standard
deviations (typically about 2 years) above the chronological age For boys younger than 9
years of age who have penile enlargement scrotal thinning and accelerated growth a formal
evaluation is warranted
TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY
Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly
Source Nakamoto 2000
Page 9 of 17
When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is
designated central or true precocious puberty (CPP) In a minority of patients CPP
arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-
cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS
lesions seem to predispose males and females equally to early central puberty that is the sex
ratio among patients with neurogenic CPP approximates unity However among children
with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex
difference with the female to male ratio approaching 101 in most series (Palmert amp
Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with
behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)
reported more withdrawal social problems aggression somatic complaints and depression
in children with premature adrenarche as compared to children with on-time adrenarche
Precocious puberty also places a child at risk for not achieving hisher genetic height
potential The rapid maturation of the growth plate (due to sex steroid exposure) will often
result in temporary acceleration of linear growth but the accompanying early closure of
growth plates results in early cessation of growth and ultimately shorter than would be
expected adult height (Lee 1999)
Delayed
Delayed puberty describes the clinical condition in which the physical manifestations of
puberty start late (usually gt +25 SD later than the mean) In the United States puberty is
considered to be delayed if sexual maturation has not become apparent by age 14 years in
boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche
by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these
criteria approximately 25 of healthy adolescents will be identified as having pubertal delay
(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying
pathology but instead represents an extreme end of normal puberty referred to as
constitutional delay of growth and maturation When puberty does begin it is entirely
normal However delayed puberty generally warrants referral to a pediatric endocrinologist
to rule out possible genetic hypothalamic pituitary gonodal or system conditions that
could be present
Page 10 of 17
PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is
the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969
1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and
breast (female)genitalia (males) development
In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is
characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast
buds become larger and pubic hair growth continues but it is mostly in the center and does
not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of
pubic hair underarm hair growth and the breasts take on a mound form The first
menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached
Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and
type forming the classical upside-down triangle shape common to women Rough estimates
based upon the size and shape of the breasts (see Figure 1) along with the amount and type
of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp
Tanner 1969)
In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)
In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the
same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in
the pubic area testicular enlargement and scrotum growth thinning and reddening During
stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is
characterized by more pubic hair darkening of the scrotum and increased growth of the
penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his
pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the
testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-
hood) The Prader orchidometer which consists of a series of increasingly larger oval beads
is the standard by which the practitioner makes a determination of the patients testicular
size (Styne 2002)
Page 11 of 17
When a child presents with abnormal puberty the goal of the initial assessment is to
distinguish benign constitutional causes from pathologic causes The history should focus on
the childs previous growth and development including the timing and sequence of the
physical milestones of puberty A history of medical or surgical treatment may provide clues
to an underlying pathologic condition The family history may reveal information about a
familial pattern of delayed or early puberty as well as information about genetic disease A
physical examination should focus on evaluation of the genitalia and determination of the
stage of pubertal development A detailed growth chart is used to estimate annual growth
rate (centimeters per year) and to determine if a growth spurt has occurred When the history
andor evaluation of the child with early or delayed pubertal development suggest a
pathological cause referral to a pediatric endocrinologist is warranted
CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for
pediatric practitioners Parents and adolescents often experience anxiety when puberty is not
occurring as expected even when it occurs within the range of normal The pediatric
practitioner can allay much of that anxiety with counseling regarding the natural and normal
variation of this process A clear understanding of pubertal milestones also promotes
appropriate interventions for delayed or advanced puberty when the practitioner and parents
are in agreement that intervention is in the best interest of the child Recently changes in the
timing of puberty as compared to previously published standards now make the
understanding of this complex process even more important The observation that more
children are showing signs of puberty earlier places pressure upon the practitioner to
differentiate the child with early but otherwise normal puberty from the child with early
onset puberty as a consequence of a pathologic process Even with normal but early-onset
puberty close observation of the temporal process is needed to adequately predict if the
abnormal timing will impact final adult height Referral to a specialist in pediatric
endocrinology is indicated for patients who present with signs of early or delayed puberty
Health care for adolescents should include systematic monitoring of pubertal development
and concerns in order to aggressively educate preadolescents to negotiate this period
smoothly and to avoid high-risk behaviors that could have negative health and social
Page 12 of 17
sequelae during adolescence and adulthood Interventions with parents of children who
present with abnormal puberty include providing anticipatory guidance supporting parent
communication strategies and providing support and information resources (Doswell amp
Vandestienne 1996 Williams 1995) Finally with the observation that precocious
adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity
insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated
with the metabolic syndrome are particularly relevant when the child presents with signs of
early puberty
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 4 of 17
of adrenarche occur approximately six to 12 months after the onset of gonadarche
Physically it is observed that shortly after the onset of the first signs of breast development
(a sign of ovarian estrogen secretion) a young girl will then show signs of adrenal androgen
secretion For some girls this sequence is reversed Recently there is greater attention being
given to this component of puberty because abnormalities in the timing of adrenarche have
been shown to be associated with irregular menstrual cycles obesity insulin resistance and
increased risks for diabetes (Ibanez et al 1998) In boys the physical signs of adrenarche
cannot be distinguished from the signs of gonadarche However the presence of pubarche
without a change in testicular size is usually a sign that gonadarche has not yet begun
STAGING AND TIMING The pubertal sequence of events follows a certain pattern (accelerated growth breast
development adrenarche menarche) on average requiring a period of 45 years (range 156
years) with girls beginning puberty earlier than boys In fact most information available
about the timing of puberty is for girls as breast development and onset of menstruation
(menarche) are more overt and recordable than changes in penis and testicle size in boys
Several factors in addition to gender and ethnicity impact the timing of puberty including
genetics dietary intake and energy expenditure Genetic factors play an important role as
illustrated by the similar age of menarche in members of an ethnic population and in
mother-daughter and sibling pairs (Meyer et al 1991) Type of protein consumption (animal
versus vegetable) amount of dietary fat and total calories has also been related to onset of
puberty (Grumbach amp Styne 2003) Puberty often begins earlier in heavier children of both
sexes (Qing amp Karlberg 2001) whereas excessive exercise and psychiatric illnesses (eg
anorexia nervosa) are associated with hypogonadotropic states that can delay or arrest the
onset of puberty (Warren amp Vu 2003)
What specifically triggers the onset is still debated The attainment of a particular proportion
of fat mass has long been argued to be requisite for the onset of puberty in girls (Plant
2002) Interest in this theory has intensified recently as a result of delayed puberty noted in
athletic girls and girls with eating disorders (Georgopoulos et al 1999 Warren amp Fried
2001)
Page 5 of 17
Females
The first visible sign of sexual maturation is the appearance of breast buds generally
around age 10 or 11 years of age Full breast development takes 3 to 4 years and is generally
complete by 14 years of age In approximately 20 percent of girls pubic hair may be the first
sign of puberty (Lalwani Reindollar amp Davis 2003) As mentioned pubic and axillary hair
growth is primarily due to a pubertal increase in adrenal androgen (adrenarche) Over the
next three years the pubic hair becomes darker curlier and coarser and spread to cover a
larger area Hair also develops under the arms on the arms and legs and to a slight degree
on the face
The most dramatic sign of sexual maturity in girls is the onset of menstruation which usually
occurs at an average age of 128 years (range 1113) Initial menstrual cycles are usually
anovulatory which is associated with irregular and often painful periods After
approximately one to two years the menstrual cycles become ovulatory and more regular
(Zacharias Rand amp Wurtman 1976
Males
For boys an increase in testicular size occurs at 95135 yr (average 12 yr) of age which is
followed by the growth of pubic hair (Marshall amp Tanner 1970) The testes and scrotum
begin to grow and the scrotum thins darkens and becomes pendulous The penis lengthens
and widens taking several years to reach full size Sperm production coincides with testicular
and penile growth generally occurring at age 13514 years Facial hair appears about three
years after the onset of pubic hair growth first in the mustache area above the upper lip and
later at the sides of the face and on the chin The density and distribution of hair growth
varies considerably among adult men and is correlated more with genetic factors than with
hormone levels (Lee 2003) Gynecomastia (visible breast tissue) occurs in approximately
two-thirds of males some time during puberty Onset may coincide with the onset of puberty
but primarily begins at ages 1314 before testosterone levels have reached adult levels Most
commonly it persists for 1824 months then regresses by age 16 years (Zosi et al 2002)
Page 6 of 17
OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES Growth Spurt
During puberty females and males experience a growth velocity greater than at any postnatal
age since infancy The pubertal growth spurt in girls is usually observed along with the first
signs of puberty (breast development and pubic hair) Peak growth occurs when breast
development is between Tanner stages 2 and 3 Because girls reach peak height velocity
about 13 years before menarche there is limited growth potential after menarche most girls
grow only about 25 cm in height after menarche although there is a variation from 1 to as
much as 7 cm (Grumbach amp Styne 2003) In contrast to females the peak growth spurt in
males occurs during midpuberty (Tanner stages 34) when testosterone levels are rapidly
rising Peak growth velocity in boys is generally at 1415 years of age Boys attain 28 to 31
cm of growth during the pubertal growth spurt whereas girls attain 275 to 29 cm of growth
(Abbassi 1998)
In both males and females the ages at menarche and peak height velocity are not good
predictors of adult height because the duration of pubertal growth is the more important
determinant of final height Nonetheless extremely early onset of puberty can diminish
ultimate adult stature (Bourguignon 1988) and prolonged delay of puberty (Haumlgg amp
Juranger 1991) can increase stature
Acne
Comedones acne and seborrhea of the scalp appear as a result of the increased secretion of
gonadal and adrenal sex steroids Early-onset acne correlates with the development of severe
acne later in puberty Acne vulgaris the most prevalent skin disorder in adolescence occurs
at a mean age of 122 years plusmn 14 years (SD range 915 years) in boys and progresses with
advancement through puberty However acne vulgaris can be the first notable sign of
puberty in a girl preceding public hair and breast development
Mood and depression
During puberty young girls frequently exhibit a negative self-image Prepubertal boys and
girls demonstrate an equal frequency of depression although there is a more frequent
occurrence in girls at stage 3 This change in the prevalence of depression appears more
Page 7 of 17
related to serum sex steroid concentrations than to LH or FSH values or the physical
changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide
increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-
to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually
committed suicide during puberty had the onset of their depression in childhood or early
puberty even though the act of suicide occurred later in puberty (Rao et al 1993)
Body image
An important aspect of puberty is the development of body image Body image is a persons
inner conception of hisher physical appearance As obvious from the previous discussion
adolescence is a time of great physical and social change Adolescents are critical and
embarrassed about their bodies during puberty either because they are maturing too early
too late or they are not developing according to societals standards of attractiveness
Adolescent girls appear to be particularly vulnerable to developing a negative body image
especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis
1999) Adolescents with severe body image distortions are vulnerable to developing
psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
Psychosocial changes
Puberty includes a profound social change from the sheltered single-classroom environment
of elementary school to the multiple classrooms and teachers of middle school (Mayer amp
Carter 2003) There is exposure to new peers often with different life experiences and
behavior patterns Risk-taking behaviors often increase including sexual precocity and
alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child
entering puberty develops maturing abstract thought and decision-making processes Other
psychological and psychosocial changes that occur during this time include the ability to
absorb the perspectives or viewpoints of others the development of personal and sexual
identity the establishment of a system of values and increasing autonomy from family
(Remschmidt 1994)
Page 8 of 17
ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years
recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the
threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was
defined as pubic hair developing in girls younger than 8 years old and boys younger than 9
years However the results of a large cross-sectional study (Herman-Giddens Slora amp
Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous
studies have documented with pubic hair development appearing in white girls as young as 7
years (between 711 years) and in African American girls as young as 6 years (between 611
years) The timing of puberty is significant from a clinical standpoint given the observation
that early-maturing girls and late-maturing boys show more evidence of adjustment
problems than other adolescents (Graber et al 1997) However the definition of early
puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys
(Saenger 2003)
Early
The majority of children who show signs of puberty at a young age have no discernable
underlying pathology particularly if they meet other criteria (see Table 1) Some physicians
order an x-ray to check that the skeletal age of the child is no more than 25 standard
deviations (typically about 2 years) above the chronological age For boys younger than 9
years of age who have penile enlargement scrotal thinning and accelerated growth a formal
evaluation is warranted
TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY
Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly
Source Nakamoto 2000
Page 9 of 17
When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is
designated central or true precocious puberty (CPP) In a minority of patients CPP
arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-
cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS
lesions seem to predispose males and females equally to early central puberty that is the sex
ratio among patients with neurogenic CPP approximates unity However among children
with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex
difference with the female to male ratio approaching 101 in most series (Palmert amp
Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with
behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)
reported more withdrawal social problems aggression somatic complaints and depression
in children with premature adrenarche as compared to children with on-time adrenarche
Precocious puberty also places a child at risk for not achieving hisher genetic height
potential The rapid maturation of the growth plate (due to sex steroid exposure) will often
result in temporary acceleration of linear growth but the accompanying early closure of
growth plates results in early cessation of growth and ultimately shorter than would be
expected adult height (Lee 1999)
Delayed
Delayed puberty describes the clinical condition in which the physical manifestations of
puberty start late (usually gt +25 SD later than the mean) In the United States puberty is
considered to be delayed if sexual maturation has not become apparent by age 14 years in
boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche
by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these
criteria approximately 25 of healthy adolescents will be identified as having pubertal delay
(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying
pathology but instead represents an extreme end of normal puberty referred to as
constitutional delay of growth and maturation When puberty does begin it is entirely
normal However delayed puberty generally warrants referral to a pediatric endocrinologist
to rule out possible genetic hypothalamic pituitary gonodal or system conditions that
could be present
Page 10 of 17
PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is
the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969
1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and
breast (female)genitalia (males) development
In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is
characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast
buds become larger and pubic hair growth continues but it is mostly in the center and does
not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of
pubic hair underarm hair growth and the breasts take on a mound form The first
menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached
Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and
type forming the classical upside-down triangle shape common to women Rough estimates
based upon the size and shape of the breasts (see Figure 1) along with the amount and type
of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp
Tanner 1969)
In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)
In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the
same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in
the pubic area testicular enlargement and scrotum growth thinning and reddening During
stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is
characterized by more pubic hair darkening of the scrotum and increased growth of the
penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his
pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the
testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-
hood) The Prader orchidometer which consists of a series of increasingly larger oval beads
is the standard by which the practitioner makes a determination of the patients testicular
size (Styne 2002)
Page 11 of 17
When a child presents with abnormal puberty the goal of the initial assessment is to
distinguish benign constitutional causes from pathologic causes The history should focus on
the childs previous growth and development including the timing and sequence of the
physical milestones of puberty A history of medical or surgical treatment may provide clues
to an underlying pathologic condition The family history may reveal information about a
familial pattern of delayed or early puberty as well as information about genetic disease A
physical examination should focus on evaluation of the genitalia and determination of the
stage of pubertal development A detailed growth chart is used to estimate annual growth
rate (centimeters per year) and to determine if a growth spurt has occurred When the history
andor evaluation of the child with early or delayed pubertal development suggest a
pathological cause referral to a pediatric endocrinologist is warranted
CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for
pediatric practitioners Parents and adolescents often experience anxiety when puberty is not
occurring as expected even when it occurs within the range of normal The pediatric
practitioner can allay much of that anxiety with counseling regarding the natural and normal
variation of this process A clear understanding of pubertal milestones also promotes
appropriate interventions for delayed or advanced puberty when the practitioner and parents
are in agreement that intervention is in the best interest of the child Recently changes in the
timing of puberty as compared to previously published standards now make the
understanding of this complex process even more important The observation that more
children are showing signs of puberty earlier places pressure upon the practitioner to
differentiate the child with early but otherwise normal puberty from the child with early
onset puberty as a consequence of a pathologic process Even with normal but early-onset
puberty close observation of the temporal process is needed to adequately predict if the
abnormal timing will impact final adult height Referral to a specialist in pediatric
endocrinology is indicated for patients who present with signs of early or delayed puberty
Health care for adolescents should include systematic monitoring of pubertal development
and concerns in order to aggressively educate preadolescents to negotiate this period
smoothly and to avoid high-risk behaviors that could have negative health and social
Page 12 of 17
sequelae during adolescence and adulthood Interventions with parents of children who
present with abnormal puberty include providing anticipatory guidance supporting parent
communication strategies and providing support and information resources (Doswell amp
Vandestienne 1996 Williams 1995) Finally with the observation that precocious
adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity
insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated
with the metabolic syndrome are particularly relevant when the child presents with signs of
early puberty
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 5 of 17
Females
The first visible sign of sexual maturation is the appearance of breast buds generally
around age 10 or 11 years of age Full breast development takes 3 to 4 years and is generally
complete by 14 years of age In approximately 20 percent of girls pubic hair may be the first
sign of puberty (Lalwani Reindollar amp Davis 2003) As mentioned pubic and axillary hair
growth is primarily due to a pubertal increase in adrenal androgen (adrenarche) Over the
next three years the pubic hair becomes darker curlier and coarser and spread to cover a
larger area Hair also develops under the arms on the arms and legs and to a slight degree
on the face
The most dramatic sign of sexual maturity in girls is the onset of menstruation which usually
occurs at an average age of 128 years (range 1113) Initial menstrual cycles are usually
anovulatory which is associated with irregular and often painful periods After
approximately one to two years the menstrual cycles become ovulatory and more regular
(Zacharias Rand amp Wurtman 1976
Males
For boys an increase in testicular size occurs at 95135 yr (average 12 yr) of age which is
followed by the growth of pubic hair (Marshall amp Tanner 1970) The testes and scrotum
begin to grow and the scrotum thins darkens and becomes pendulous The penis lengthens
and widens taking several years to reach full size Sperm production coincides with testicular
and penile growth generally occurring at age 13514 years Facial hair appears about three
years after the onset of pubic hair growth first in the mustache area above the upper lip and
later at the sides of the face and on the chin The density and distribution of hair growth
varies considerably among adult men and is correlated more with genetic factors than with
hormone levels (Lee 2003) Gynecomastia (visible breast tissue) occurs in approximately
two-thirds of males some time during puberty Onset may coincide with the onset of puberty
but primarily begins at ages 1314 before testosterone levels have reached adult levels Most
commonly it persists for 1824 months then regresses by age 16 years (Zosi et al 2002)
Page 6 of 17
OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES Growth Spurt
During puberty females and males experience a growth velocity greater than at any postnatal
age since infancy The pubertal growth spurt in girls is usually observed along with the first
signs of puberty (breast development and pubic hair) Peak growth occurs when breast
development is between Tanner stages 2 and 3 Because girls reach peak height velocity
about 13 years before menarche there is limited growth potential after menarche most girls
grow only about 25 cm in height after menarche although there is a variation from 1 to as
much as 7 cm (Grumbach amp Styne 2003) In contrast to females the peak growth spurt in
males occurs during midpuberty (Tanner stages 34) when testosterone levels are rapidly
rising Peak growth velocity in boys is generally at 1415 years of age Boys attain 28 to 31
cm of growth during the pubertal growth spurt whereas girls attain 275 to 29 cm of growth
(Abbassi 1998)
In both males and females the ages at menarche and peak height velocity are not good
predictors of adult height because the duration of pubertal growth is the more important
determinant of final height Nonetheless extremely early onset of puberty can diminish
ultimate adult stature (Bourguignon 1988) and prolonged delay of puberty (Haumlgg amp
Juranger 1991) can increase stature
Acne
Comedones acne and seborrhea of the scalp appear as a result of the increased secretion of
gonadal and adrenal sex steroids Early-onset acne correlates with the development of severe
acne later in puberty Acne vulgaris the most prevalent skin disorder in adolescence occurs
at a mean age of 122 years plusmn 14 years (SD range 915 years) in boys and progresses with
advancement through puberty However acne vulgaris can be the first notable sign of
puberty in a girl preceding public hair and breast development
Mood and depression
During puberty young girls frequently exhibit a negative self-image Prepubertal boys and
girls demonstrate an equal frequency of depression although there is a more frequent
occurrence in girls at stage 3 This change in the prevalence of depression appears more
Page 7 of 17
related to serum sex steroid concentrations than to LH or FSH values or the physical
changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide
increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-
to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually
committed suicide during puberty had the onset of their depression in childhood or early
puberty even though the act of suicide occurred later in puberty (Rao et al 1993)
Body image
An important aspect of puberty is the development of body image Body image is a persons
inner conception of hisher physical appearance As obvious from the previous discussion
adolescence is a time of great physical and social change Adolescents are critical and
embarrassed about their bodies during puberty either because they are maturing too early
too late or they are not developing according to societals standards of attractiveness
Adolescent girls appear to be particularly vulnerable to developing a negative body image
especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis
1999) Adolescents with severe body image distortions are vulnerable to developing
psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
Psychosocial changes
Puberty includes a profound social change from the sheltered single-classroom environment
of elementary school to the multiple classrooms and teachers of middle school (Mayer amp
Carter 2003) There is exposure to new peers often with different life experiences and
behavior patterns Risk-taking behaviors often increase including sexual precocity and
alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child
entering puberty develops maturing abstract thought and decision-making processes Other
psychological and psychosocial changes that occur during this time include the ability to
absorb the perspectives or viewpoints of others the development of personal and sexual
identity the establishment of a system of values and increasing autonomy from family
(Remschmidt 1994)
Page 8 of 17
ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years
recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the
threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was
defined as pubic hair developing in girls younger than 8 years old and boys younger than 9
years However the results of a large cross-sectional study (Herman-Giddens Slora amp
Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous
studies have documented with pubic hair development appearing in white girls as young as 7
years (between 711 years) and in African American girls as young as 6 years (between 611
years) The timing of puberty is significant from a clinical standpoint given the observation
that early-maturing girls and late-maturing boys show more evidence of adjustment
problems than other adolescents (Graber et al 1997) However the definition of early
puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys
(Saenger 2003)
Early
The majority of children who show signs of puberty at a young age have no discernable
underlying pathology particularly if they meet other criteria (see Table 1) Some physicians
order an x-ray to check that the skeletal age of the child is no more than 25 standard
deviations (typically about 2 years) above the chronological age For boys younger than 9
years of age who have penile enlargement scrotal thinning and accelerated growth a formal
evaluation is warranted
TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY
Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly
Source Nakamoto 2000
Page 9 of 17
When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is
designated central or true precocious puberty (CPP) In a minority of patients CPP
arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-
cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS
lesions seem to predispose males and females equally to early central puberty that is the sex
ratio among patients with neurogenic CPP approximates unity However among children
with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex
difference with the female to male ratio approaching 101 in most series (Palmert amp
Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with
behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)
reported more withdrawal social problems aggression somatic complaints and depression
in children with premature adrenarche as compared to children with on-time adrenarche
Precocious puberty also places a child at risk for not achieving hisher genetic height
potential The rapid maturation of the growth plate (due to sex steroid exposure) will often
result in temporary acceleration of linear growth but the accompanying early closure of
growth plates results in early cessation of growth and ultimately shorter than would be
expected adult height (Lee 1999)
Delayed
Delayed puberty describes the clinical condition in which the physical manifestations of
puberty start late (usually gt +25 SD later than the mean) In the United States puberty is
considered to be delayed if sexual maturation has not become apparent by age 14 years in
boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche
by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these
criteria approximately 25 of healthy adolescents will be identified as having pubertal delay
(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying
pathology but instead represents an extreme end of normal puberty referred to as
constitutional delay of growth and maturation When puberty does begin it is entirely
normal However delayed puberty generally warrants referral to a pediatric endocrinologist
to rule out possible genetic hypothalamic pituitary gonodal or system conditions that
could be present
Page 10 of 17
PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is
the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969
1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and
breast (female)genitalia (males) development
In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is
characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast
buds become larger and pubic hair growth continues but it is mostly in the center and does
not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of
pubic hair underarm hair growth and the breasts take on a mound form The first
menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached
Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and
type forming the classical upside-down triangle shape common to women Rough estimates
based upon the size and shape of the breasts (see Figure 1) along with the amount and type
of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp
Tanner 1969)
In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)
In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the
same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in
the pubic area testicular enlargement and scrotum growth thinning and reddening During
stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is
characterized by more pubic hair darkening of the scrotum and increased growth of the
penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his
pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the
testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-
hood) The Prader orchidometer which consists of a series of increasingly larger oval beads
is the standard by which the practitioner makes a determination of the patients testicular
size (Styne 2002)
Page 11 of 17
When a child presents with abnormal puberty the goal of the initial assessment is to
distinguish benign constitutional causes from pathologic causes The history should focus on
the childs previous growth and development including the timing and sequence of the
physical milestones of puberty A history of medical or surgical treatment may provide clues
to an underlying pathologic condition The family history may reveal information about a
familial pattern of delayed or early puberty as well as information about genetic disease A
physical examination should focus on evaluation of the genitalia and determination of the
stage of pubertal development A detailed growth chart is used to estimate annual growth
rate (centimeters per year) and to determine if a growth spurt has occurred When the history
andor evaluation of the child with early or delayed pubertal development suggest a
pathological cause referral to a pediatric endocrinologist is warranted
CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for
pediatric practitioners Parents and adolescents often experience anxiety when puberty is not
occurring as expected even when it occurs within the range of normal The pediatric
practitioner can allay much of that anxiety with counseling regarding the natural and normal
variation of this process A clear understanding of pubertal milestones also promotes
appropriate interventions for delayed or advanced puberty when the practitioner and parents
are in agreement that intervention is in the best interest of the child Recently changes in the
timing of puberty as compared to previously published standards now make the
understanding of this complex process even more important The observation that more
children are showing signs of puberty earlier places pressure upon the practitioner to
differentiate the child with early but otherwise normal puberty from the child with early
onset puberty as a consequence of a pathologic process Even with normal but early-onset
puberty close observation of the temporal process is needed to adequately predict if the
abnormal timing will impact final adult height Referral to a specialist in pediatric
endocrinology is indicated for patients who present with signs of early or delayed puberty
Health care for adolescents should include systematic monitoring of pubertal development
and concerns in order to aggressively educate preadolescents to negotiate this period
smoothly and to avoid high-risk behaviors that could have negative health and social
Page 12 of 17
sequelae during adolescence and adulthood Interventions with parents of children who
present with abnormal puberty include providing anticipatory guidance supporting parent
communication strategies and providing support and information resources (Doswell amp
Vandestienne 1996 Williams 1995) Finally with the observation that precocious
adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity
insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated
with the metabolic syndrome are particularly relevant when the child presents with signs of
early puberty
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 6 of 17
OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES Growth Spurt
During puberty females and males experience a growth velocity greater than at any postnatal
age since infancy The pubertal growth spurt in girls is usually observed along with the first
signs of puberty (breast development and pubic hair) Peak growth occurs when breast
development is between Tanner stages 2 and 3 Because girls reach peak height velocity
about 13 years before menarche there is limited growth potential after menarche most girls
grow only about 25 cm in height after menarche although there is a variation from 1 to as
much as 7 cm (Grumbach amp Styne 2003) In contrast to females the peak growth spurt in
males occurs during midpuberty (Tanner stages 34) when testosterone levels are rapidly
rising Peak growth velocity in boys is generally at 1415 years of age Boys attain 28 to 31
cm of growth during the pubertal growth spurt whereas girls attain 275 to 29 cm of growth
(Abbassi 1998)
In both males and females the ages at menarche and peak height velocity are not good
predictors of adult height because the duration of pubertal growth is the more important
determinant of final height Nonetheless extremely early onset of puberty can diminish
ultimate adult stature (Bourguignon 1988) and prolonged delay of puberty (Haumlgg amp
Juranger 1991) can increase stature
Acne
Comedones acne and seborrhea of the scalp appear as a result of the increased secretion of
gonadal and adrenal sex steroids Early-onset acne correlates with the development of severe
acne later in puberty Acne vulgaris the most prevalent skin disorder in adolescence occurs
at a mean age of 122 years plusmn 14 years (SD range 915 years) in boys and progresses with
advancement through puberty However acne vulgaris can be the first notable sign of
puberty in a girl preceding public hair and breast development
Mood and depression
During puberty young girls frequently exhibit a negative self-image Prepubertal boys and
girls demonstrate an equal frequency of depression although there is a more frequent
occurrence in girls at stage 3 This change in the prevalence of depression appears more
Page 7 of 17
related to serum sex steroid concentrations than to LH or FSH values or the physical
changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide
increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-
to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually
committed suicide during puberty had the onset of their depression in childhood or early
puberty even though the act of suicide occurred later in puberty (Rao et al 1993)
Body image
An important aspect of puberty is the development of body image Body image is a persons
inner conception of hisher physical appearance As obvious from the previous discussion
adolescence is a time of great physical and social change Adolescents are critical and
embarrassed about their bodies during puberty either because they are maturing too early
too late or they are not developing according to societals standards of attractiveness
Adolescent girls appear to be particularly vulnerable to developing a negative body image
especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis
1999) Adolescents with severe body image distortions are vulnerable to developing
psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
Psychosocial changes
Puberty includes a profound social change from the sheltered single-classroom environment
of elementary school to the multiple classrooms and teachers of middle school (Mayer amp
Carter 2003) There is exposure to new peers often with different life experiences and
behavior patterns Risk-taking behaviors often increase including sexual precocity and
alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child
entering puberty develops maturing abstract thought and decision-making processes Other
psychological and psychosocial changes that occur during this time include the ability to
absorb the perspectives or viewpoints of others the development of personal and sexual
identity the establishment of a system of values and increasing autonomy from family
(Remschmidt 1994)
Page 8 of 17
ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years
recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the
threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was
defined as pubic hair developing in girls younger than 8 years old and boys younger than 9
years However the results of a large cross-sectional study (Herman-Giddens Slora amp
Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous
studies have documented with pubic hair development appearing in white girls as young as 7
years (between 711 years) and in African American girls as young as 6 years (between 611
years) The timing of puberty is significant from a clinical standpoint given the observation
that early-maturing girls and late-maturing boys show more evidence of adjustment
problems than other adolescents (Graber et al 1997) However the definition of early
puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys
(Saenger 2003)
Early
The majority of children who show signs of puberty at a young age have no discernable
underlying pathology particularly if they meet other criteria (see Table 1) Some physicians
order an x-ray to check that the skeletal age of the child is no more than 25 standard
deviations (typically about 2 years) above the chronological age For boys younger than 9
years of age who have penile enlargement scrotal thinning and accelerated growth a formal
evaluation is warranted
TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY
Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly
Source Nakamoto 2000
Page 9 of 17
When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is
designated central or true precocious puberty (CPP) In a minority of patients CPP
arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-
cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS
lesions seem to predispose males and females equally to early central puberty that is the sex
ratio among patients with neurogenic CPP approximates unity However among children
with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex
difference with the female to male ratio approaching 101 in most series (Palmert amp
Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with
behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)
reported more withdrawal social problems aggression somatic complaints and depression
in children with premature adrenarche as compared to children with on-time adrenarche
Precocious puberty also places a child at risk for not achieving hisher genetic height
potential The rapid maturation of the growth plate (due to sex steroid exposure) will often
result in temporary acceleration of linear growth but the accompanying early closure of
growth plates results in early cessation of growth and ultimately shorter than would be
expected adult height (Lee 1999)
Delayed
Delayed puberty describes the clinical condition in which the physical manifestations of
puberty start late (usually gt +25 SD later than the mean) In the United States puberty is
considered to be delayed if sexual maturation has not become apparent by age 14 years in
boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche
by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these
criteria approximately 25 of healthy adolescents will be identified as having pubertal delay
(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying
pathology but instead represents an extreme end of normal puberty referred to as
constitutional delay of growth and maturation When puberty does begin it is entirely
normal However delayed puberty generally warrants referral to a pediatric endocrinologist
to rule out possible genetic hypothalamic pituitary gonodal or system conditions that
could be present
Page 10 of 17
PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is
the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969
1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and
breast (female)genitalia (males) development
In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is
characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast
buds become larger and pubic hair growth continues but it is mostly in the center and does
not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of
pubic hair underarm hair growth and the breasts take on a mound form The first
menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached
Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and
type forming the classical upside-down triangle shape common to women Rough estimates
based upon the size and shape of the breasts (see Figure 1) along with the amount and type
of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp
Tanner 1969)
In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)
In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the
same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in
the pubic area testicular enlargement and scrotum growth thinning and reddening During
stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is
characterized by more pubic hair darkening of the scrotum and increased growth of the
penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his
pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the
testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-
hood) The Prader orchidometer which consists of a series of increasingly larger oval beads
is the standard by which the practitioner makes a determination of the patients testicular
size (Styne 2002)
Page 11 of 17
When a child presents with abnormal puberty the goal of the initial assessment is to
distinguish benign constitutional causes from pathologic causes The history should focus on
the childs previous growth and development including the timing and sequence of the
physical milestones of puberty A history of medical or surgical treatment may provide clues
to an underlying pathologic condition The family history may reveal information about a
familial pattern of delayed or early puberty as well as information about genetic disease A
physical examination should focus on evaluation of the genitalia and determination of the
stage of pubertal development A detailed growth chart is used to estimate annual growth
rate (centimeters per year) and to determine if a growth spurt has occurred When the history
andor evaluation of the child with early or delayed pubertal development suggest a
pathological cause referral to a pediatric endocrinologist is warranted
CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for
pediatric practitioners Parents and adolescents often experience anxiety when puberty is not
occurring as expected even when it occurs within the range of normal The pediatric
practitioner can allay much of that anxiety with counseling regarding the natural and normal
variation of this process A clear understanding of pubertal milestones also promotes
appropriate interventions for delayed or advanced puberty when the practitioner and parents
are in agreement that intervention is in the best interest of the child Recently changes in the
timing of puberty as compared to previously published standards now make the
understanding of this complex process even more important The observation that more
children are showing signs of puberty earlier places pressure upon the practitioner to
differentiate the child with early but otherwise normal puberty from the child with early
onset puberty as a consequence of a pathologic process Even with normal but early-onset
puberty close observation of the temporal process is needed to adequately predict if the
abnormal timing will impact final adult height Referral to a specialist in pediatric
endocrinology is indicated for patients who present with signs of early or delayed puberty
Health care for adolescents should include systematic monitoring of pubertal development
and concerns in order to aggressively educate preadolescents to negotiate this period
smoothly and to avoid high-risk behaviors that could have negative health and social
Page 12 of 17
sequelae during adolescence and adulthood Interventions with parents of children who
present with abnormal puberty include providing anticipatory guidance supporting parent
communication strategies and providing support and information resources (Doswell amp
Vandestienne 1996 Williams 1995) Finally with the observation that precocious
adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity
insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated
with the metabolic syndrome are particularly relevant when the child presents with signs of
early puberty
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 7 of 17
related to serum sex steroid concentrations than to LH or FSH values or the physical
changes of puberty (Angold Costello amp Worthman 1998) Reports of attempted suicide
increase sharply during puberty and suicide now ranks fourth as a cause of death among 15-
to 19-year-olds (Larsen 2003) A retrospective analysis showed that adolescents who actually
committed suicide during puberty had the onset of their depression in childhood or early
puberty even though the act of suicide occurred later in puberty (Rao et al 1993)
Body image
An important aspect of puberty is the development of body image Body image is a persons
inner conception of hisher physical appearance As obvious from the previous discussion
adolescence is a time of great physical and social change Adolescents are critical and
embarrassed about their bodies during puberty either because they are maturing too early
too late or they are not developing according to societals standards of attractiveness
Adolescent girls appear to be particularly vulnerable to developing a negative body image
especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis
1999) Adolescents with severe body image distortions are vulnerable to developing
psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
Psychosocial changes
Puberty includes a profound social change from the sheltered single-classroom environment
of elementary school to the multiple classrooms and teachers of middle school (Mayer amp
Carter 2003) There is exposure to new peers often with different life experiences and
behavior patterns Risk-taking behaviors often increase including sexual precocity and
alcohol and cigarette abuse In contrast to the concrete reasoning of childhood the child
entering puberty develops maturing abstract thought and decision-making processes Other
psychological and psychosocial changes that occur during this time include the ability to
absorb the perspectives or viewpoints of others the development of personal and sexual
identity the establishment of a system of values and increasing autonomy from family
(Remschmidt 1994)
Page 8 of 17
ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years
recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the
threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was
defined as pubic hair developing in girls younger than 8 years old and boys younger than 9
years However the results of a large cross-sectional study (Herman-Giddens Slora amp
Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous
studies have documented with pubic hair development appearing in white girls as young as 7
years (between 711 years) and in African American girls as young as 6 years (between 611
years) The timing of puberty is significant from a clinical standpoint given the observation
that early-maturing girls and late-maturing boys show more evidence of adjustment
problems than other adolescents (Graber et al 1997) However the definition of early
puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys
(Saenger 2003)
Early
The majority of children who show signs of puberty at a young age have no discernable
underlying pathology particularly if they meet other criteria (see Table 1) Some physicians
order an x-ray to check that the skeletal age of the child is no more than 25 standard
deviations (typically about 2 years) above the chronological age For boys younger than 9
years of age who have penile enlargement scrotal thinning and accelerated growth a formal
evaluation is warranted
TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY
Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly
Source Nakamoto 2000
Page 9 of 17
When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is
designated central or true precocious puberty (CPP) In a minority of patients CPP
arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-
cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS
lesions seem to predispose males and females equally to early central puberty that is the sex
ratio among patients with neurogenic CPP approximates unity However among children
with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex
difference with the female to male ratio approaching 101 in most series (Palmert amp
Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with
behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)
reported more withdrawal social problems aggression somatic complaints and depression
in children with premature adrenarche as compared to children with on-time adrenarche
Precocious puberty also places a child at risk for not achieving hisher genetic height
potential The rapid maturation of the growth plate (due to sex steroid exposure) will often
result in temporary acceleration of linear growth but the accompanying early closure of
growth plates results in early cessation of growth and ultimately shorter than would be
expected adult height (Lee 1999)
Delayed
Delayed puberty describes the clinical condition in which the physical manifestations of
puberty start late (usually gt +25 SD later than the mean) In the United States puberty is
considered to be delayed if sexual maturation has not become apparent by age 14 years in
boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche
by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these
criteria approximately 25 of healthy adolescents will be identified as having pubertal delay
(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying
pathology but instead represents an extreme end of normal puberty referred to as
constitutional delay of growth and maturation When puberty does begin it is entirely
normal However delayed puberty generally warrants referral to a pediatric endocrinologist
to rule out possible genetic hypothalamic pituitary gonodal or system conditions that
could be present
Page 10 of 17
PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is
the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969
1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and
breast (female)genitalia (males) development
In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is
characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast
buds become larger and pubic hair growth continues but it is mostly in the center and does
not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of
pubic hair underarm hair growth and the breasts take on a mound form The first
menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached
Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and
type forming the classical upside-down triangle shape common to women Rough estimates
based upon the size and shape of the breasts (see Figure 1) along with the amount and type
of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp
Tanner 1969)
In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)
In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the
same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in
the pubic area testicular enlargement and scrotum growth thinning and reddening During
stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is
characterized by more pubic hair darkening of the scrotum and increased growth of the
penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his
pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the
testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-
hood) The Prader orchidometer which consists of a series of increasingly larger oval beads
is the standard by which the practitioner makes a determination of the patients testicular
size (Styne 2002)
Page 11 of 17
When a child presents with abnormal puberty the goal of the initial assessment is to
distinguish benign constitutional causes from pathologic causes The history should focus on
the childs previous growth and development including the timing and sequence of the
physical milestones of puberty A history of medical or surgical treatment may provide clues
to an underlying pathologic condition The family history may reveal information about a
familial pattern of delayed or early puberty as well as information about genetic disease A
physical examination should focus on evaluation of the genitalia and determination of the
stage of pubertal development A detailed growth chart is used to estimate annual growth
rate (centimeters per year) and to determine if a growth spurt has occurred When the history
andor evaluation of the child with early or delayed pubertal development suggest a
pathological cause referral to a pediatric endocrinologist is warranted
CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for
pediatric practitioners Parents and adolescents often experience anxiety when puberty is not
occurring as expected even when it occurs within the range of normal The pediatric
practitioner can allay much of that anxiety with counseling regarding the natural and normal
variation of this process A clear understanding of pubertal milestones also promotes
appropriate interventions for delayed or advanced puberty when the practitioner and parents
are in agreement that intervention is in the best interest of the child Recently changes in the
timing of puberty as compared to previously published standards now make the
understanding of this complex process even more important The observation that more
children are showing signs of puberty earlier places pressure upon the practitioner to
differentiate the child with early but otherwise normal puberty from the child with early
onset puberty as a consequence of a pathologic process Even with normal but early-onset
puberty close observation of the temporal process is needed to adequately predict if the
abnormal timing will impact final adult height Referral to a specialist in pediatric
endocrinology is indicated for patients who present with signs of early or delayed puberty
Health care for adolescents should include systematic monitoring of pubertal development
and concerns in order to aggressively educate preadolescents to negotiate this period
smoothly and to avoid high-risk behaviors that could have negative health and social
Page 12 of 17
sequelae during adolescence and adulthood Interventions with parents of children who
present with abnormal puberty include providing anticipatory guidance supporting parent
communication strategies and providing support and information resources (Doswell amp
Vandestienne 1996 Williams 1995) Finally with the observation that precocious
adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity
insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated
with the metabolic syndrome are particularly relevant when the child presents with signs of
early puberty
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 8 of 17
ABNORMAL PUBERTY Although the average age at menarche (128 years) has not fallen much in the past 60 years
recent data suggest that the lower age limit for normal pubertal (thelarche) onset is below the
threshold of 8 years that is cited in many texts Before 1997 premature adrenarche was
defined as pubic hair developing in girls younger than 8 years old and boys younger than 9
years However the results of a large cross-sectional study (Herman-Giddens Slora amp
Wasserman 1997) suggest that the onset of puberty in girls is occurring earlier than previous
studies have documented with pubic hair development appearing in white girls as young as 7
years (between 711 years) and in African American girls as young as 6 years (between 611
years) The timing of puberty is significant from a clinical standpoint given the observation
that early-maturing girls and late-maturing boys show more evidence of adjustment
problems than other adolescents (Graber et al 1997) However the definition of early
puberty remains puberty that occurs prior to age 8 years in girls and nine years in boys
(Saenger 2003)
Early
The majority of children who show signs of puberty at a young age have no discernable
underlying pathology particularly if they meet other criteria (see Table 1) Some physicians
order an x-ray to check that the skeletal age of the child is no more than 25 standard
deviations (typically about 2 years) above the chronological age For boys younger than 9
years of age who have penile enlargement scrotal thinning and accelerated growth a formal
evaluation is warranted
TABLE 1 CRITERIA OF BENIGN PREMATURE PUBERTY
Sparse to moderate development of pubic hair Sparse or no growth of axillary hair Mild or no acne Minimal or no acceleration in growth rate Mild apocrine body order No lowering of voice No breast or testicular enlargement No clitoromegaly
Source Nakamoto 2000
Page 9 of 17
When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is
designated central or true precocious puberty (CPP) In a minority of patients CPP
arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-
cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS
lesions seem to predispose males and females equally to early central puberty that is the sex
ratio among patients with neurogenic CPP approximates unity However among children
with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex
difference with the female to male ratio approaching 101 in most series (Palmert amp
Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with
behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)
reported more withdrawal social problems aggression somatic complaints and depression
in children with premature adrenarche as compared to children with on-time adrenarche
Precocious puberty also places a child at risk for not achieving hisher genetic height
potential The rapid maturation of the growth plate (due to sex steroid exposure) will often
result in temporary acceleration of linear growth but the accompanying early closure of
growth plates results in early cessation of growth and ultimately shorter than would be
expected adult height (Lee 1999)
Delayed
Delayed puberty describes the clinical condition in which the physical manifestations of
puberty start late (usually gt +25 SD later than the mean) In the United States puberty is
considered to be delayed if sexual maturation has not become apparent by age 14 years in
boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche
by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these
criteria approximately 25 of healthy adolescents will be identified as having pubertal delay
(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying
pathology but instead represents an extreme end of normal puberty referred to as
constitutional delay of growth and maturation When puberty does begin it is entirely
normal However delayed puberty generally warrants referral to a pediatric endocrinologist
to rule out possible genetic hypothalamic pituitary gonodal or system conditions that
could be present
Page 10 of 17
PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is
the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969
1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and
breast (female)genitalia (males) development
In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is
characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast
buds become larger and pubic hair growth continues but it is mostly in the center and does
not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of
pubic hair underarm hair growth and the breasts take on a mound form The first
menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached
Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and
type forming the classical upside-down triangle shape common to women Rough estimates
based upon the size and shape of the breasts (see Figure 1) along with the amount and type
of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp
Tanner 1969)
In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)
In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the
same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in
the pubic area testicular enlargement and scrotum growth thinning and reddening During
stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is
characterized by more pubic hair darkening of the scrotum and increased growth of the
penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his
pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the
testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-
hood) The Prader orchidometer which consists of a series of increasingly larger oval beads
is the standard by which the practitioner makes a determination of the patients testicular
size (Styne 2002)
Page 11 of 17
When a child presents with abnormal puberty the goal of the initial assessment is to
distinguish benign constitutional causes from pathologic causes The history should focus on
the childs previous growth and development including the timing and sequence of the
physical milestones of puberty A history of medical or surgical treatment may provide clues
to an underlying pathologic condition The family history may reveal information about a
familial pattern of delayed or early puberty as well as information about genetic disease A
physical examination should focus on evaluation of the genitalia and determination of the
stage of pubertal development A detailed growth chart is used to estimate annual growth
rate (centimeters per year) and to determine if a growth spurt has occurred When the history
andor evaluation of the child with early or delayed pubertal development suggest a
pathological cause referral to a pediatric endocrinologist is warranted
CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for
pediatric practitioners Parents and adolescents often experience anxiety when puberty is not
occurring as expected even when it occurs within the range of normal The pediatric
practitioner can allay much of that anxiety with counseling regarding the natural and normal
variation of this process A clear understanding of pubertal milestones also promotes
appropriate interventions for delayed or advanced puberty when the practitioner and parents
are in agreement that intervention is in the best interest of the child Recently changes in the
timing of puberty as compared to previously published standards now make the
understanding of this complex process even more important The observation that more
children are showing signs of puberty earlier places pressure upon the practitioner to
differentiate the child with early but otherwise normal puberty from the child with early
onset puberty as a consequence of a pathologic process Even with normal but early-onset
puberty close observation of the temporal process is needed to adequately predict if the
abnormal timing will impact final adult height Referral to a specialist in pediatric
endocrinology is indicated for patients who present with signs of early or delayed puberty
Health care for adolescents should include systematic monitoring of pubertal development
and concerns in order to aggressively educate preadolescents to negotiate this period
smoothly and to avoid high-risk behaviors that could have negative health and social
Page 12 of 17
sequelae during adolescence and adulthood Interventions with parents of children who
present with abnormal puberty include providing anticipatory guidance supporting parent
communication strategies and providing support and information resources (Doswell amp
Vandestienne 1996 Williams 1995) Finally with the observation that precocious
adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity
insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated
with the metabolic syndrome are particularly relevant when the child presents with signs of
early puberty
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 9 of 17
When puberty in a young child is driven by activation of hypothalamic GnRH secretion it is
designated central or true precocious puberty (CPP) In a minority of patients CPP
arises in the setting of a central nervous system (CNS) lesion (eg neurofibromatosis hydro-
cephalus CNS infection and intracranial neoplasm with or without radiation therapy) CNS
lesions seem to predispose males and females equally to early central puberty that is the sex
ratio among patients with neurogenic CPP approximates unity However among children
with CPP in whom there is no underlying pathology (idiopathic CPP) there is a striking sex
difference with the female to male ratio approaching 101 in most series (Palmert amp
Boepple 2001) From a psychosocial perspective CPP is sometimes accompanied with
behavioral disturbances and symptoms of depression andor anxiety Dorn et al (1999)
reported more withdrawal social problems aggression somatic complaints and depression
in children with premature adrenarche as compared to children with on-time adrenarche
Precocious puberty also places a child at risk for not achieving hisher genetic height
potential The rapid maturation of the growth plate (due to sex steroid exposure) will often
result in temporary acceleration of linear growth but the accompanying early closure of
growth plates results in early cessation of growth and ultimately shorter than would be
expected adult height (Lee 1999)
Delayed
Delayed puberty describes the clinical condition in which the physical manifestations of
puberty start late (usually gt +25 SD later than the mean) In the United States puberty is
considered to be delayed if sexual maturation has not become apparent by age 14 years in
boys or age 13 years in girls This clinical diagnosis also is made in the absence of menarche
by age 16 years or in the absence of menarche within 5 years of pubertal onset Using these
criteria approximately 25 of healthy adolescents will be identified as having pubertal delay
(Rosen amp Foster 2001) In most cases delayed puberty is not due to any underlying
pathology but instead represents an extreme end of normal puberty referred to as
constitutional delay of growth and maturation When puberty does begin it is entirely
normal However delayed puberty generally warrants referral to a pediatric endocrinologist
to rule out possible genetic hypothalamic pituitary gonodal or system conditions that
could be present
Page 10 of 17
PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is
the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969
1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and
breast (female)genitalia (males) development
In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is
characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast
buds become larger and pubic hair growth continues but it is mostly in the center and does
not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of
pubic hair underarm hair growth and the breasts take on a mound form The first
menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached
Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and
type forming the classical upside-down triangle shape common to women Rough estimates
based upon the size and shape of the breasts (see Figure 1) along with the amount and type
of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp
Tanner 1969)
In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)
In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the
same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in
the pubic area testicular enlargement and scrotum growth thinning and reddening During
stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is
characterized by more pubic hair darkening of the scrotum and increased growth of the
penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his
pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the
testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-
hood) The Prader orchidometer which consists of a series of increasingly larger oval beads
is the standard by which the practitioner makes a determination of the patients testicular
size (Styne 2002)
Page 11 of 17
When a child presents with abnormal puberty the goal of the initial assessment is to
distinguish benign constitutional causes from pathologic causes The history should focus on
the childs previous growth and development including the timing and sequence of the
physical milestones of puberty A history of medical or surgical treatment may provide clues
to an underlying pathologic condition The family history may reveal information about a
familial pattern of delayed or early puberty as well as information about genetic disease A
physical examination should focus on evaluation of the genitalia and determination of the
stage of pubertal development A detailed growth chart is used to estimate annual growth
rate (centimeters per year) and to determine if a growth spurt has occurred When the history
andor evaluation of the child with early or delayed pubertal development suggest a
pathological cause referral to a pediatric endocrinologist is warranted
CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for
pediatric practitioners Parents and adolescents often experience anxiety when puberty is not
occurring as expected even when it occurs within the range of normal The pediatric
practitioner can allay much of that anxiety with counseling regarding the natural and normal
variation of this process A clear understanding of pubertal milestones also promotes
appropriate interventions for delayed or advanced puberty when the practitioner and parents
are in agreement that intervention is in the best interest of the child Recently changes in the
timing of puberty as compared to previously published standards now make the
understanding of this complex process even more important The observation that more
children are showing signs of puberty earlier places pressure upon the practitioner to
differentiate the child with early but otherwise normal puberty from the child with early
onset puberty as a consequence of a pathologic process Even with normal but early-onset
puberty close observation of the temporal process is needed to adequately predict if the
abnormal timing will impact final adult height Referral to a specialist in pediatric
endocrinology is indicated for patients who present with signs of early or delayed puberty
Health care for adolescents should include systematic monitoring of pubertal development
and concerns in order to aggressively educate preadolescents to negotiate this period
smoothly and to avoid high-risk behaviors that could have negative health and social
Page 12 of 17
sequelae during adolescence and adulthood Interventions with parents of children who
present with abnormal puberty include providing anticipatory guidance supporting parent
communication strategies and providing support and information resources (Doswell amp
Vandestienne 1996 Williams 1995) Finally with the observation that precocious
adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity
insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated
with the metabolic syndrome are particularly relevant when the child presents with signs of
early puberty
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 10 of 17
PUBERTAL ASSESSMENT The standard clinical system for describing normal pubertal development and its variations is
the five-stage system (called Tanner Staging) developed by Marshall amp Tanner (1969
1970) (refer to Tables 2 amp 3) Each stage represents the extent of pubic hair growth and
breast (female)genitalia (males) development
In girls breasts and pubic hair must be staged separately (see Table 2) Tanner stage 2 is
characterized by small breast buds and peach-fuzz in the pubic area During stage 3 breast
buds become larger and pubic hair growth continues but it is mostly in the center and does
not extend out to the thighs or upward Stage 4 is characterized by noticeable growth of
pubic hair underarm hair growth and the breasts take on a mound form The first
menstrual period usually occurs sometime during the fourth or fifth stage A girl has reached
Tanner stage 5 when her breasts are fully formed and her pubic hair is adult in quantity and
type forming the classical upside-down triangle shape common to women Rough estimates
based upon the size and shape of the breasts (see Figure 1) along with the amount and type
of hair present in the pubic area are the indexes used to track pubertal changes (Marshall amp
Tanner 1969)
In boys pubertal hair distribution and testicular size must be staged separately (see Table 3)
In stage 1 there is no pubic hair growth and the penis testes and scrotum are about the
same size and proportion as in early childhood Stage 2 is characterized by peach-fuzz in
the pubic area testicular enlargement and scrotum growth thinning and reddening During
stage 3 the penis grows in length and pubic hair growth is darker and coarser Stage 4 is
characterized by more pubic hair darkening of the scrotum and increased growth of the
penis A boy has reached Tanner stage 5 when the genitalia are adult size and shape and his
pubic hair has spread to the medial thighs (Marshall amp Tanner 1970) During this time the
testes increase in volume from approximately 3 mL (prepubertal) to up to 20 mL (adult-
hood) The Prader orchidometer which consists of a series of increasingly larger oval beads
is the standard by which the practitioner makes a determination of the patients testicular
size (Styne 2002)
Page 11 of 17
When a child presents with abnormal puberty the goal of the initial assessment is to
distinguish benign constitutional causes from pathologic causes The history should focus on
the childs previous growth and development including the timing and sequence of the
physical milestones of puberty A history of medical or surgical treatment may provide clues
to an underlying pathologic condition The family history may reveal information about a
familial pattern of delayed or early puberty as well as information about genetic disease A
physical examination should focus on evaluation of the genitalia and determination of the
stage of pubertal development A detailed growth chart is used to estimate annual growth
rate (centimeters per year) and to determine if a growth spurt has occurred When the history
andor evaluation of the child with early or delayed pubertal development suggest a
pathological cause referral to a pediatric endocrinologist is warranted
CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for
pediatric practitioners Parents and adolescents often experience anxiety when puberty is not
occurring as expected even when it occurs within the range of normal The pediatric
practitioner can allay much of that anxiety with counseling regarding the natural and normal
variation of this process A clear understanding of pubertal milestones also promotes
appropriate interventions for delayed or advanced puberty when the practitioner and parents
are in agreement that intervention is in the best interest of the child Recently changes in the
timing of puberty as compared to previously published standards now make the
understanding of this complex process even more important The observation that more
children are showing signs of puberty earlier places pressure upon the practitioner to
differentiate the child with early but otherwise normal puberty from the child with early
onset puberty as a consequence of a pathologic process Even with normal but early-onset
puberty close observation of the temporal process is needed to adequately predict if the
abnormal timing will impact final adult height Referral to a specialist in pediatric
endocrinology is indicated for patients who present with signs of early or delayed puberty
Health care for adolescents should include systematic monitoring of pubertal development
and concerns in order to aggressively educate preadolescents to negotiate this period
smoothly and to avoid high-risk behaviors that could have negative health and social
Page 12 of 17
sequelae during adolescence and adulthood Interventions with parents of children who
present with abnormal puberty include providing anticipatory guidance supporting parent
communication strategies and providing support and information resources (Doswell amp
Vandestienne 1996 Williams 1995) Finally with the observation that precocious
adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity
insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated
with the metabolic syndrome are particularly relevant when the child presents with signs of
early puberty
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 11 of 17
When a child presents with abnormal puberty the goal of the initial assessment is to
distinguish benign constitutional causes from pathologic causes The history should focus on
the childs previous growth and development including the timing and sequence of the
physical milestones of puberty A history of medical or surgical treatment may provide clues
to an underlying pathologic condition The family history may reveal information about a
familial pattern of delayed or early puberty as well as information about genetic disease A
physical examination should focus on evaluation of the genitalia and determination of the
stage of pubertal development A detailed growth chart is used to estimate annual growth
rate (centimeters per year) and to determine if a growth spurt has occurred When the history
andor evaluation of the child with early or delayed pubertal development suggest a
pathological cause referral to a pediatric endocrinologist is warranted
CLINICAL IMPLICATIONS Knowledge of the timing and the physical changes associated with puberty is important for
pediatric practitioners Parents and adolescents often experience anxiety when puberty is not
occurring as expected even when it occurs within the range of normal The pediatric
practitioner can allay much of that anxiety with counseling regarding the natural and normal
variation of this process A clear understanding of pubertal milestones also promotes
appropriate interventions for delayed or advanced puberty when the practitioner and parents
are in agreement that intervention is in the best interest of the child Recently changes in the
timing of puberty as compared to previously published standards now make the
understanding of this complex process even more important The observation that more
children are showing signs of puberty earlier places pressure upon the practitioner to
differentiate the child with early but otherwise normal puberty from the child with early
onset puberty as a consequence of a pathologic process Even with normal but early-onset
puberty close observation of the temporal process is needed to adequately predict if the
abnormal timing will impact final adult height Referral to a specialist in pediatric
endocrinology is indicated for patients who present with signs of early or delayed puberty
Health care for adolescents should include systematic monitoring of pubertal development
and concerns in order to aggressively educate preadolescents to negotiate this period
smoothly and to avoid high-risk behaviors that could have negative health and social
Page 12 of 17
sequelae during adolescence and adulthood Interventions with parents of children who
present with abnormal puberty include providing anticipatory guidance supporting parent
communication strategies and providing support and information resources (Doswell amp
Vandestienne 1996 Williams 1995) Finally with the observation that precocious
adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity
insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated
with the metabolic syndrome are particularly relevant when the child presents with signs of
early puberty
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 12 of 17
sequelae during adolescence and adulthood Interventions with parents of children who
present with abnormal puberty include providing anticipatory guidance supporting parent
communication strategies and providing support and information resources (Doswell amp
Vandestienne 1996 Williams 1995) Finally with the observation that precocious
adrenarche can be an early sign of the metabolic syndrome close monitoring for obesity
insulin resistance acanthosis nigracans hypertriglyceridemia and other problems associated
with the metabolic syndrome are particularly relevant when the child presents with signs of
early puberty
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 13 of 17
TABLE 2 TANNER STAGES OF FEMALE PUBERTY
FIGURE 1 DIAGRAMMATIC REPRESENTATION OF TANNER STAGES I TO V OF HUMAN BREAST MATURATION
From Marshall WA Tanner JM Variations in patterns of pubertal changes in girls Archives of Disease in Childhood 44291-303 1969 USED WITH PERMISSION
STAGE BREAST PUBIC HAIR
1
Preadolescent
Only papillae are elevated Vellus hair only and hair is similar to development over anterior abdominal wall (ie no pubic hair)
2 Breast bud and papilla are elevated and a small mount is present areola diameter is enlarged
There is sparse growth of long slightly pigmented downy hair or only slightly curled hair appearing along labia
3 Further enlargement of breast mound increased palpable glandular tissue
Hair is darker coarser more curled and spreads to the pubic junction
4 Areola and papilla are elevated to form a second mound above the level of the rest of the breast
Adult-type hair area covered is less than that in most adults there is no spread to the medial surface of thighs
5
Adult
Adult mature breast recession of areola to the mound of breast tissue rounding of the breast mound and projection of only the papilla are evident
Adult-type hair with increased spread to medial surface of thighs distribution is as an inverse triangle
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 14 of 17
TABLE 3 TANNER STAGES OF MALE PUBERTY
STAGE GENITAL STAGE PUBIC HAIR STAGE
1
Preadolescent
Testes scrotum and penis are about the same size and proportion as those in early childhood
Vellus over the pubes is no further developed than that over the abdominal wall ie no pubic hair
2 Scrotum and testes have enlarged and there is a change in the texture of scrotal skin and some reddening of scrotal skin
There is sparse growth of long slightly pigmented downy hair straight or only slightly curled appearing chiefly at base of penis
3 Growth of the penis has occurred at first mainly in length but with some increase in breadth There has been further growth of the testes and the scrotum
Hair is considerably darker coarser and more curled and spreads sparsely over junction of pubes
4 The penis is further enlarged in length and breadth with development of glans The testes and the scrotum are further enlarged There is also further darkening of scrotal skin
Hair is now adult in type but the area covered by it is smaller than that in most adults There is no spread to the medial surface of the thighs
5
Adult
Genitalia are adult in size and shape No further enlargement takes place after stage 5 is reached
Hair is adult in quantity and type distributed as an inverse triangle There is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 15 of 17
REFERENCES Abbassi V (1998) Growth and normal puberty Pediatrics 102 507-511 Angold A Costello EJ amp Worthman CM (1998) Puberty and depression the roles of age pubertal status and pubertal timing Psycholological Medicine 28 51-61 Blondell RD Foster MB amp Dave KC (1999) Disorders of puberty American Family Physician 60 209-224 Bourguignon JP (1988) Linear growth as a function of age at onset of puberty and sex steroid dosage therapeutic implications Endocrine Reviews 9 467-488 Dorn LD Mitt SF amp Rotenstein D (1999) Biopsychological and cognitive differences in children with premature vs on-time adrenarche Archives Pediatric Adolescent Medicine 153 137-146 Doswell WM amp Vandestienne G (1996) The use of focus groups to examine pubertal concerns in preteen girls initial findings and implications for practice and research Issues in Comprehensive Pediatric Nursing 19(2) 103-120 Georgopoulos N Markou K Theodoropoulou A Paraskevopoulou P Varaki L Kazantzi Z Leglise M amp Vagenakis AG (1999) Growth and pubertal development in elite female rhythmic gymnasts Journal of Clinical Endocrinology and Metabolism 84(12) 4525-4530 Graber JA Lewinsohn PM Seeley JR ampBrooks-Gunn J (1997) Is psychopathology associated with the timing of pubertal development Journal of the American Academy of Child and Adolescent Psychiatry 36(12) 1768-1776 Grumbach MM amp Styne DM (2003) Puberty Ontogeny neuroendocrinology physiology and disorders In Larsen PR (Ed) Williams textbook of endocrinology 10th ed (pp 1115-1200) St Louis Saunders Haumlgg U amp Juranger J (1991) Height and height velocity in early average and late maturers followed to the age of 25 a prospective longitudinal study of Swedish urban children from birth to adulthood Annals of Human Biology 18 47-56 Hamann A amp Matthaei S (1996) Regulation of energy balance by leptin Experimental and Clinical Endocrinology and Diabetes 104 293-300 Herman-Giddens ME Slora EJ Wasserman RC et al (1997) Secondary sexual characteristics and menses in young girls seen in office practice a study from the Pediatric Research in Office Settings Network Pediatrics 99 505-512 Ibanez L Potau N Francois I amp de Zegher F (1998) Precocious pubarche hyper-insulinism and ovarian hyperandrogenism in girls relation to reduced fetal growth Journal of Clinical Endocrinology and Metabolism 83 3558-3562
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 16 of 17
Lalwani S Reindollar RH amp Davis AJ (2003) Normal onset of puberty have definitions of onset changed Obstetrics and Gynecology Clinics of North America 30(2) 279-286 Lee PA (1999) Central precocious puberty An overview of diagnosis treatment and outcome Endocrinology and Metabolism Clinics 28(4) 901-908 Lee PA (2003) Puberty and its disorders In F Lifshitz F (Ed) Pediatric endocrinology 4th ed (pp 221-237) New York Marcel Dekker
Marshall WA amp Tanner JM (1969) Variations in pattern of pubertal changes in girls Archives of Disease in Childhood 44(235) 291-303
Marshall WA amp Tanner JM (1970) Variations in the pattern of pubertal changes in boys Archives of Disease in Childhood 45(239) 13-23
Mayer C amp Carter J (2003) Puberty advice for year 6 and 7 boys and girls The Journal of Family Health Care 13(3) 70-72 Meyer JM Eaves LJ Heath AC amp Martin NG (1991) Estimating genetic influences on the age-at-menarche a survival analysis approach American Journal of Medical Genetics 39 148-154 Nakamoto JM (2000) Myths and variations in normal pubertal development Western Journal of Medicine 172(3) 182-185 Palmert MR amp Boepple PA (2001)Variation in the timing of puberty clinical spectrum and genetic investigation Journal of Clinical Endocrinology and Metabolism 86 2364-2368 Plant TM (2002) Neurophysiology of puberty Journal of Adolescent Health 31(6 Suppl) 185-191 Qing H amp Karlberg J (2001) BMI in childhood and its association with height gain timing of puberty and final height Pediatric Research 49 244-251 Rao U Weissman MM Martin JA amp Hammond RW (1993) Childhood depression and risk of suicide a preliminary report of a longitudinal study Journal of the American Academy of Child and Adolescent Psychiatry 32 21-27 Remschmidt H (1994) Psychosocial milestones in normal puberty and adolescence Hormone Research 41(suppl 2) 19-29 Rosen DS amp Foster C (2001) Delayed puberty Pediatrics in Review 22(9) 309-315 Rosenblum GD amp Lewis M (1999) The relations among body image physical attractiveness and body mass in adolescence Child Development 70 50-64
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-
Page 17 of 17
Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10 Styne DM (2002) The testes disorders of sexual differentiation and puberty in the male In MA Sperling (Ed) Pediatric endocrinology (pp 565-628) Philadelphia Saunders Warren MP amp Fried JL (2001) Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system a central effect of the central nervous system Endocrinology and Metabolism Clinics of North America 30(3) 611-629 Warren MP amp Vu C (2003) Central causes of hypogonadismfunctional and organic Endocrinology and Metabolism Clinics of North America 32(3) 593-612 Weinshenker N (2002)Adolescence and body image School Nurse News 19(3) 12-16 Williams JK (1995) Parenting a daughter with precocious puberty or Turner syndrome Journal of Pediatric Health Care 9(3) 751-752 Zacharias L Rand WM amp Wurtman RJ (1976)A prospective study of sexual development and growth in American girls the statistics of menarche Obstetrical and Gynecological Survey 31(4) 325-337 Zosi P Karakaidos D Triantafyllidis G Milioni N Franglinos P amp Karis C (2002) Natural course of pubertal gynecomastia Endocrine Abstracts 4 P18
- STAGING AND TIMING
-
- Females
- Males
-
- OTHER PHYSICAL AND PSYCHOLOGICAL CHANGES
-
- Body image
- An important aspect of puberty is the development of body image Body image is a personrsquos inner conception of hisher physical appearance As obvious from the previous discussion adolescence is a time of great physical and social change Adolescents are critical and embarrassed about their bodies during puberty either because they are maturing too early too late or they are not developing according to societalrsquos standards of ldquoattractivenessrdquo Adolescent girls appear to be particularly vulnerable to developing a negative body image especially if their bodies develop at a pace that differs from average (Rosenblum amp Lewis 1999) Adolescents with severe body image distortions are vulnerable to developing psychiatric disorders that can have life-threatening consequences (Weinshenker 2002)
- Psychosocial changes
-
- ABNORMAL PUBERTY
-
- Early
- Delayed
-
- CLINICAL IMPLICATIONS
-
- Saenger P (2003) Precocious puberty McCune-Albright syndrome and beyond Journal of Pediatrics 143(1) 9-10
-