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Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
Growing Pains
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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?

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