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Growing Pains
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  • 1. Rebecca Green, MD, PhD Pediatric Endocrinologywww.SpringfieldClinic.com
  • 2. Growing Pains – When puberty is too early or too late – What does puberty it look like? – When should it happen? – What else could it be? – What might it mean if its too early? – What might it mean if it comes late? – What to expect when your child comes for a visit
  • 3. What is puberty? • Body changes that occur as a child becomes sexually mature • What I tell the young kids: – Puberty means all the changes that happen to your body that make it look and act more grown up. – Puberty is normal. It happens to every one, but sometimes it starts too soon. Your doctor thinks your body might be trying to grow up too soon. – We need to figure out if that is true, so we can make sure you have plenty of time to be a kid.
  • 4. What are signs of puberty: Girls • Breast development • Pubic hair/underarm hair • Body odor • Acne • Growth spurt; growing tall faster • Vaginal secretions • Menstrual periods (at the end)
  • 5. What are signs of puberty: Boys • Pubic hair/underarm hair/body odor • Acne • Scrotum thins out and testes get bigger • Penis gets bigger • Growth spurt • Facial hair/body hair • Voice changes/Adams apple • Increased prominence of jaw and brow
  • 6. When should it happen • Girls – Starts between 6-7 years and 13 years • Between 6 and 8 isn’t always ok, talk with your PCP – Periods (“end”) between 10 and 15 years – From beginning to end average 2-2 ½ year • Early starting girls 2 ½ to 3 ½+ years • Late starting girls 1 ½ to 2 years • Boys – Starts between 9 and 15 years – “End” 2-3 year after start
  • 7. What things predict your childmight have a early normal puberty • Tall for the family • Overweight (girls) • Family history of earlier puberty • Teeth coming out early (first tooth lost before age 5 years)
  • 8. What things predict your childmight have a late normal puberty • Short for family • Family history of “late bloomers” – Girls with later onset of menstrual periods – Men who have grown late in high school or college • Teeth coming out late/new ones coming in late (first tooth out after age 6 years, orthodontist waiting on teeth to catch up for braces)
  • 9. It isn’t always puberty! • Breasts in little girls: Benign premature thelarche – Breast development in little girls between the ages of 6 months and 2 years – No growth spurt – No other signs of puberty • No pubic hair • No acne • No vaginal discharge/bleeding
  • 10. It isn’t always puberty! • Premature adrenarche – Early pubic hair, under arm hair, body odor or acne without breast development (girls) or testes getting bigger (boys) – The majority of the time it is benign – Most likely to be benign premature adrenarche if: • No change in growth rate (not growing faster OR slower) • Penis is not getting larger
  • 11. Benign premature adrenarche • Normal adrenal glands in both boys and girls make testosterone like hormones (androgens) • Adrenal hormones are what make girls develop pubic hair and underarm hair • They have the same effect in boys, but testosterone does it better • Usually the adrenal glands turn on and start making hormones at puberty, but sometime they start early, and it doesn’t have to mean there is a problem.
  • 12. Is early adrenarche alwaysbenign? • Some premature adrenarche isn’t benign • If it isn’t benign, we are usually looking at one of two problems – Congenital adrenal hyperplasia (CAH) – genetic problem where the adrenal gland makes too many androgens – Adrenal tumor
  • 13. Sometimes it is puberty! • Where do the hormones come from in puberty? • What hormones are we talking about? • What physical signs are we looking for?
  • 14. Girls• Hormone: estrogen, estradiol• Made in the ovary• Signs: – Breast development – Vaginal secretions – Menstrual period – Growth spurt http://www.odec.ca/projects/2010/maymxm2/mikhea.htm
  • 15. Boys• Hormone: Testosterone• Made in the testes• Signs: – Pubic hair/underarm hair/BO – Acne – Scrotum thins out and testes get bigger – Penis gets bigger – Growth spurt – Facial hair/body hair – Voice changes/Adams apple – Increased prominence of jam and brow http://malecontraceptives.org/methods/heat_biology.php
  • 16. Are there different kinds of puberty? • Central puberty – Controlled by the pituitary (master gland) – Pituitary makes hormones called gonadotropins that turn on the ovaries or testes – This is what happens in normal puberty, but it can also start to soon (precocious) http://www.cushings-help.com/the_body.htm
  • 17. Central precocious puberty • More common in girls then in boys • In girls, it is most often idiopathic, meaning we never know what made it happen, but also, it doesn’t cause any other problems • In boys it is much more likely to be caused by some underlying problem – Example brain injury or brain tumor
  • 18. Are there different kinds of puberty? • Gonadotropin independent puberty – When ovaries or testes make hormones without being turned on by the hormones from the pituitary – This is abnormal no matter when it happens – Can be due to: • Cysts (ovaries) • Tumors • Genetic problem
  • 19. What about when puberty is late? • Most common diagnosis is constitutional delay of growth and puberty (late bloomer) • But could also be: – Primary gonadal failure –ovaries or testes don’t work • Turner syndrome (girls) /Klinefelter syndrome (boys) • Other nongenetic reasons – none are common – Hypogonadotropic hypogonadism – pituitary can’t send the hormone signal • Lots of things can cause this, including many diseases that don’t directly hurt the pituitary gland or brain
  • 20. What to expect when you comefor a visit • Lots of questions! – What signs of puberty are you seeing, when did they start and how rapidly are they changing? – How is your child growing? Review of growth chart – Family history • When did mom, dad and siblings develop, how tall are they, anything unusual, any testing done? – Exposures • Hormones or supplements in use in the home, lavender or tea tree oil personal products being used, food and water sources, chemical exposures – Other symptoms
  • 21. What to expect when you comefor a visit • Exam – in addition to the usual.. – Look at growth, carefully measure height and weight and compare to prior measurements from your doctors office – Look at skin for hair patterns, birth marks, and acne – Feel thyroid, look in eyes, look at and count teeth – Look at pubertal changes: • Girls: Examine and feel breasts, look at the opening to the vagina (nothing inside the vaginal) • Boys: Examine genitals, feel testes, measure penis
  • 22. https://www.mja.com.au/journal/2004/180/10/11-androgen-deficiency-and-replacement-therapy-men
  • 23. What to expect when you comefor a visit – initial tests • Blood tests – Puberty too early or too late • Hormones from the pituitary (LH/FSH) • Hormones from the ovaries or testes • Possibly thyroid testing – Adrenarche without puberty • Hormones from the adrenal glands (17- hydroxyprogesterone/DHEA-S) • X-rays – bone age (film of left hand)
  • 24. Bone age film
  • 25. What to expect when you comefor a visit – follow up testing • Stimulation testing (early puberty) – St. Johns pediatric day hospital – IV placed to get repeated blood tests – Baseline levels, and more levels after “stimulation” • Imaging studies – Head MRI – Uterus and ovary, testicular or adrenal ultrasound
  • 26. Treatment depends on what we find • Early puberty – Not puberty, likely no treatment needed – Tumors – surgery – CAH – oral medications – Central puberty treatment until appropriate age for puberty • shots (monthly or three monthly) • implant (yearly) • Late puberty – Late bloomer – no treatment/ reassurance – Ovary/testes/pituitary problem – estrogen/testosterone – Other diseases – treat the disease
  • 27. Questions?