Several reports indicate a recent increase in the number of cases of precocious puberty at worldwide. Focus on diagnostic assessment and management strategies.
Increase in cases precocious puberty
At the end of March, a report published jointly by the washington post and the FullerProject highlighted a global spike in precocious puberty, especially among girls (see infographic).
A recent study in Italy showed that more than 300 girls were referred to five pediatric endocrinology centers between March and September 2020, compared to 140 patients during the same period in 2019.
In another study, in Turkey, a pediatric endocrinology clinic reported 58 cases in the first year of the pandemic, compared to a total of 66 cases in the previous three years.
The current upsurge could be due to stress associated with the pandemic and lockdowns. In most cases, these changes decreased the level of physical activity and increased the consumption of junk food, two factors linked to a higher risk of precocious puberty.
Dr. Mark P Trolice (Professor of Obstetrics and Gynecology, University of Florida, Orlando, FL, USA) recently recalled that the first step in evaluating affected patients is to determine the origin of puberty precocious: is it central precocious puberty (CPP) or peripheral precocious puberty (PPP)?
PCP is indeed dependent on gonadotropins. This means that the hypothalamic-pituitary-ovarian (HPO) axis is activated prematurely, resulting in the normal progression of puberty. Idiopathic causes account for 80-90% of presentations in girls and 25-80% in boys.
On the other hand, PPP, which is independent of gonadotropins, is the result of secretion of sex steroids by the ovaries, adrenal gland, or exogenous or ectopic production (eg, germ cell tumor). The stages of puberty then take place in a disorderly fashion.
When to treat?
Treatment of PPP consists primarily of maximizing adult height, most commonly by suppression of PH0 from pituitary downregulation with a gonadotropin-releasing hormone (GnRH) agonist.
In girls with PPP, the primary treatment is dictated by the underlying causative pathology. For example, in patients with ovarian or adrenal tumors, treatment would be surgical excision.
Even before the current upsurge, the treatment of precocious puberty was debated. Specifically, when it comes to 6-8 year old girls with breast development, many experts advocate observation before deciding whether to start treatment with a GnRH analogue to suppress puberty. Evidence suggests that stopping puberty before age 6 is beneficial for achieving adult height. However, interventions in children aged 6 to 8 years are less well documented. The key to treatment would therefore be to put in place a personalized therapeutic approach.
Precocious puberty and obesity
A recent study also examined the optimal way to approach the assessment and management of precocious puberty in children with obesity. Among the suggestions are :
Age thresholds should not differ substantially between children with a healthy weight and those with obesity. Girls with obesity who have been confirmed to have their first menstrual period should be evaluated for gonadotropin-dependent CPAP to determine if further investigation or treatment is indicated.
Basal luteinizing hormone (LH) testing is recommended as the first-line test in children with obesity and precocious puberty. However, false negatives could be a point to consider.
The diagnostic utility of bone age assessment is limited because girls with obesity often have advanced bone age.
In girls with established PCP, obesity does not eliminate the need for an MRI. Neuroimaging is determined by age and clinical characteristics.
Bone age can be used to predict adult height in girls with CPAP and obesity to guide management.
The use of GnRH analogues leads to an increase in adult height in girls with precocious puberty and obesity.
Obesity should not limit the use of GnRH analogues, as these drugs do not deteriorate weight status in this population.
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