Worldwide Secular Trends in Age at Pubertal Onset Assessed by Breast Development Among Girls: A Systematic Review and Meta-analysis

Girls with idiopathic central precocious puberty did not display substatial changes in body mass index after treatment with gonadotropin-releasing hormone analogues

AIM

To evaluate changes in body mass index (BMI) in girls during and after treatment for idiopathic central precocious puberty (iCPP).

METHODS

We studied 123 girls receiving gonadotropin-releasing hormone analogue (GnRHa)treatment for iCPP from 2009 to 2019. Pubertal and anthropometric measurements were monitored at routine clinical visits. BMI standard deviation scores (SDS) were estimated at baseline and followed in two stages from baseline to end of treatment (median 18.9 months) and from end of treatment to end of follow-up (median 18.2 months). The influence of baseline BMI SDS and the frequency and dose of treatment was evaluated using BMI trajectories and latent class mixed models.

RESULTS

The median age at treatment initiation was 8.5 years. The median BMI SDS at baseline was 0.7, corresponding to a median BMI of 17.4 kg/m2. Overall, no changes in BMI SDS were observed during treatment. According to baseline BMI subgroups, an increasing trend in BMI trajectories during treatment was observed for girls in the lowest BMI group. After treatment, most girls maintained stable BMI levels.

CONCLUSION

Our retrospective study did not provide evidence that GnRHa treatment for iCPP had a significant impact on BMI trajectories in girls.

Ovarian Insufficiency and Fertility Preservation During and After Childhood Cancer Treatment

Premature ovarian insufficiency (POI) is one of many potential long-term consequences of childhood cancer treatment in females. Causes of POI in this patient population can include chemotherapy, especially alkylating agents, and radiation therapy. Rarely, ovarian tumors lead to ovarian dysfunction. POI can manifest as delayed pubertal development, irregular menses or amenorrhea, and infertility. This diagnosis often negatively impacts emotional health due to the implications of impaired ovarian function after already enduring treatment for a primary malignancy. The emerging adult may be challenged by the impact on energy level, quality of life, and fertility potential. POI can also lead to low bone density and compromised skeletal strength. This review discusses the health consequences of POI in childhood cancer survivors (CCS). We also explore the role of fertility preservation for CCS, including ovarian tissue cryopreservation and other available options. Lastly, knowledge gaps are identified that will drive a future research agenda.

Internalizing Symptoms among Kosovar Adolescents: Pubertal Correlates in Boys and Girls

Pubertal status/stage of maturation and pubertal timing have been linked with emotional symptoms of problems among youth, particularly in vulnerable developmental contexts at risk for stress exposure. The present study tested the extent to which pubertal status/stage of maturation and pubertal timing were associated with anxious/depressed, withdrawn/depressed, and somatic complaint symptoms in Kosovar adolescents. It also tested whether sex moderated these relationships. Data were collected from N = 1,342 Kosovar adolescents (665 girls; M age = 13.26 years, SD = 1.27; 677 boys M age = 13.19 years, SD = 1.31). Regression analyses provided evidence that pubertal status/stage was positively associated with rates of anxious/depressed, withdrawn/depressed, and somatic complaint symptoms in girls, but only with withdrawn/depressed symptoms in boys. Additionally, pubertal timing was positively associated with anxious/depressed, and somatic complaint symptoms in girls; no significant links were found for boys. The present study provided evidence that advanced pubertal status/stage as well as timing is positively associated with internalizing symptoms in girls; however, only pubertal status/stage was positively associated with withdrawn/depressed symptoms in boys. The study highlights the importance of pubertal development for internalizing symptoms in a developmental context known for high stress exposure, particularly for girls.

Normal Puberty

Puberty is characterized by gonadarche and adrenarche. Gonadarche represents the reactivation of the hypothalamic-pituitary-gonadal axis with increased gonadotropin-releasing hormone, luteinizing hormone, and follicle-stimulating hormone secretion following the quiescence during childhood. Pubarche is the development of pubic hair, axillary hair, apocrine odor reflecting the onset of pubertal adrenal maturation known as adrenarche. A detailed understanding of these pubertal processes will help clarify relationships between the timing of the onset of puberty and cardiovascular, metabolic, and reproductive outcomes in adulthood. The onset of gonadarche is influenced by neuroendocrine signals, genetic variants, metabolic factors, and environmental elements.

Navigating Pubertal Goldilocks: The Optimal Pace for Hierarchical Brain Organization

Adolescence is a timed process with an onset, tempo, and duration. Nevertheless, the temporal dimension, especially the pace of maturation, remains an insufficiently studied aspect of developmental progression. The primary objective is to estimate the precise influence of pubertal maturational tempo on the configuration of associative brain regions. To this end, the connection between maturational stages and the level of hierarchical organization of large-scale brain networks in 12-13-year-old females is analyzed. Skeletal maturity is used as a proxy for pubertal progress. The degree of maturity is defined by the difference between bone age and chronological age. To assess the level of hierarchical organization in the brain, the temporal dynamic of closed eye resting state high-density electroencephalography (EEG) in the alpha frequency range is analyzed. Different levels of hierarchical order are captured by the measured asymmetry in the directionality of information flow between different regions. The calculated EEG-based entropy production of participant groups is then compared with accelerated, average, and decelerated maturity. Results indicate that an average maturational trajectory optimally aligns with cerebral hierarchical order, and both accelerated and decelerated timelines result in diminished cortical organization. This suggests that a "Goldilocks rule" of brain development is favoring a particular maturational tempo.

Diagnosis of Central Precocious Puberty

A thorough history and physical examination including Tanner staging and growth assessments can guide differential diagnosis and aid in the evaluation of precocious puberty. Basal luteinizing hormone levels measured using a highly sensitive assay can be helpful in diagnosing central precocious puberty (CPP). Brain MRI is indicated with males diagnosed with CPP and females under the age of 6 with CPP. As more information becomes available regarding the genetic etiologies of CPP, genetic testing may preclude the need for imaging studies and other hormonal testing, especially in familial cases.

The Spider; A Multisystemic Symptom Impact Tool for People with Hypermobility-Related Disorders. Initial Validation in Adolescents

Objectives

The multisystemic comorbid symptoms/conditions of hypermobility spectrum disorders (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS) often significantly affect daily life. Many of these symptoms are under-recognized during diagnosis and treatment; therefore, a comprehensive questionnaire was developed to evaluate their presence and impact. The Spider's 8 domains assess neuromusculoskeletal, pain, fatigue, cardiac dysautonomia, urogenital, gastrointestinal, anxiety, and depression symptoms. This study aims to evaluate the construct validity of the Spider in adolescents.

Study design

This cross-sectional study recruited international participants through 3 patient charities and a hypermobility unit. Adolescents aged 13-18 years, with and without HSD/hEDS, were included. Validated and frequently used comparator questionnaires were used to establish convergent validity. Participants answered each Spider domain and the respective comparator via 4 online surveys. Convergent validity was assessed by comparing Spider domain and comparator scores through correlational analysis. Known-group validity was assessed by comparing Spider domain scores of hypermobile and control groups using Mann-Whitney U analysis.

Results

In total, 1154 adolescents participated, 1036 with HSD/hEDS and 118 controls. Six domains (pain, fatigue, depression, cardiac dysautonomia, gastrointestinal, and neuromusculoskeletal) demonstrated strong correlations (r = -0.7 to 0.8) with the respective comparator. The urogenital and anxiety domains showed moderate correlations (r = 0.6). All correlations reached statistical significance (P < .001). Known-group validity was demonstrated in 7 domains (P < .001). The urogenital domain did not show a significant difference between the groups (P = .094).

Conclusions

The Spider domains demonstrate acceptable convergent validity. The Spider questionnaire can accurately, rapidly, and concisely measure the effect of common multisystemic comorbid symptoms/conditions associated with HSD/hEDS to help direct care in adolescents.

Disentangling associations between pubertal development, healthy activity behaviors, and sex in adolescent social networks

With the onset of puberty, youth begin to choose their social environments and develop health-promoting habits, making it a vital period to study social and biological factors contextually. An important question is how pubertal development and behaviors such as physical activity and sleep may be differentially linked with youths' friendships. Cross-sectional statistical network models that account for interpersonal dependence were used to estimate associations between three measures of pubertal development and youth friendships at two large US schools drawn from the National Longitudinal Study of Adolescent to Adult Health. Whole-network models suggest that friendships are more likely between youth with similar levels of pubertal development, physical activity, and sleep. Sex-stratified models suggest that girls' friendships are more likely given a similar age at menarche. Attention to similar pubertal timing within friendship groups may offer inclusive opportunities for tailored developmental puberty education in ways that reduce stigma and improve health behaviors.

Diagnostic Value of Single LH and LH/FSH Ratio at 60-minute after GnRHa Stimulation Test for Central Precocious Puberty

OBJECTIVES

To evaluate the diagnostic value of luteinizing hormone (LH) and LH/follicle stimulating hormone (FSH) ratio at 60 min after gonadotropin-releasing hormone analogs (GnRHa) stimulation test for central precocious puberty (CPP) in girls.

METHODS

Two hundred and fifty-seven girls, aged 3 to 7.5 y, suspected of precocious puberty at authors' hospital from April 2020 through November 2023 were enrolled in the study. The blood was taken at 0, 30, 60 min after GnRHa stimulation test, and LH and LH/FSH were detected by chemiluminescence assay. The diagnostic efficacy was analysed by Mann-Whitney U test, spearman's correlation analysis and receiver operating characteristic (ROC) analysis. The proportion of obesity was analysed by Chi-square test.

RESULTS

LH and LH/FSH at different times were statistically significantly different (P <0.05) between the CPP and non-CPP groups. Spearman's correlation analysis showed that the level of LH and LH/FSH at 60 min had the strongest consistency with the peak of LH (r = 0.9988, P <0.001) and LH/FSH (r = 0.9981, P <0.001). ROC curve analysis showed that the area under the ROC curves at 60 min of LH and LH/FSH were 0.975 and 0.997 with a cut-off value of 5.70 IU/L and 0.609, respectively.

CONCLUSIONS

The peak of LH and LH/FSH in the diagnosis of CPP can be determined by LH and LH/FSH at 60 min after the triptorelin acetate is injected. This will reduce the number of blood draws required compared with the traditional stimulation test, which is more effective and acceptable for children.

Association between BMI and age at menarche or spermarche among both sexes: Findings from six successive national surveys in China

Background

To explore trends of the association between body mass index (BMI) and age at menarche or spermarche and its urban-rural disparities from 1995 to 2019.

Methods

A total of 912 753 children and adolescents - including 519 940 9-18 years old girls and 392 813 11-18 years old boys - were involved in six successive cross-sectional surveys conducted across 30 provinces in China from 1995 to 2019. Data on menarche and spermarche was collected using the status quo method, where same-gender physicians conducted face-to-face interviews to determine if children and adolescents had experienced their first menstrual cycle or ejaculation (yes/no). The median age at menarche or spermarche was estimated by probit analysis. Anthropometric measurements measured the height and weight of the study subjects. Children and adolescents were classified into thinness, normal range of weight, overweight, and obesity. t test was used to compare the differences in BMI between premenarchal and postmenarchal girls or prespermarcheal and postspermarcheal boys. Logistic regression was used to explore the associations between BMI/nutritional status and menarche or spermarche stratified by urban or rural residency status.

Results

From 1995 to 2019, BMI in all age groups growth over time, and the values of BMI among children and adolescents under 15 who had menarche or spermarche were more significant than those without menarche or spermarche. In 2019, for girls, thinness was associated with delayed menarche (odds ratio (OR) = 0.26; 95% confidence interval (CI) = 0.24-0.28), while overweight (OR = 1.99; 95% CI = 1.85-2.14) and obesity (OR = 2.20; 95% CI = 1.92-2.53) was associated with advanced menarche. For boys, thinness was associated with delayed spermarche (OR = 0.71; 95% CI = 0.65-0.78), overweight was associated with advanced spermarche (OR = 1.08; 95% CI = 1.01-1.15) while obesity had no association with spermarche. The OR between BMI and menarche in 1995 was 1.35 (95% CI = 1.33-1.37), which decreased to 1.19 (95% CI = 1.18-1.20) by 2019. The OR between BMI and spermarche in 1995 was 1.10 (95% CI = 1.09-1.11), which decreased to 1.02 (95% CI = 1.02-1.03) by 2019. The trends by urban-rural stratification were consistent with the total sample.

Conclusions

We have established a dose-response relationship between BMI and menarche in girls, whereas the association appears to be nonlinear in boys, and the associations were diminishing. Similar findings were observed in both urban and rural areas. Considering the dual adverse effects of obesity and early puberty on health, the results of this study suggest that sexual health education should be strengthened, especially among obese girls. Further research on the influencing factors and biological mechanisms of early puberty will be beneficial.

Urinary gonadotropin assay on 24-h collections as a tool to detect early central puberty onset in girls: determination of predictive thresholds

STUDY QUESTION

Is the 24-h urinary gonadotropin assay an effective diagnostic tool in central precocious puberty (CPP) in girls?

SUMMARY ANSWER

This study is the first to provide 24-h urinary gonadotropin assay data, using an electrochemiluminescent immunoassay (CMIA), and to report its usefulness as a tool for the diagnosis of CPP.

WHAT IS KNOWN ALREADY

Data about the GnRH test in the diagnosis of CPP are variable and there is no consensus regarding its interpretation. The measurement of FSH and LH in urines was previously reported to be an alternative biological tool.

STUDY DESIGN, SIZE, DURATION

This is a retrospective two-cohort study, involving a setting and a validation cohort. A total of 516 girls, included between October 2012 and July 2015, and 632 urinary collections were analyzed in the setting cohort. In the validation cohort, 39 girls were included between January 2021 and May 2023, and 49 urinary collections were analyzed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study included girls who consulted for an investigation of disturbed growth rate or a clinical suspicion of puberty onset in different medical centres across France (setting cohort). Girls with a suspicion of precocious puberty onset were addressed at the expert centre of paediatric endocrinology of the Groupement Hospitalier Lyon Est (validation cohort). Pelvic ultrasonography was performed and enabled their classification according to clinical and morphologic changes criteria (prepubertal or pubertal groups). The parents collected 24-h urine samples (u24) according to standardized instructions. FSH and LH (urinary or plasmatic) were measured using a current and automated CMIA.

MAIN RESULTS AND THE ROLE OF CHANCE

The area under the ROC curves for CPP prediction was 0.709 for u24FSH (P < 0.001), 0.767 for u24LH (P < 0.001), and 0.753 for the u24LH/u24FSH ratio (P < 0.001). We retained all possible combinations of the four thresholds in the validation cohort (u24FSH = 1.1 or 2.0 IU/24 h; u24LH = 0.035 or 0.08 IU/24 h). The combination of u24FSH > 1.1 IU/24 h and u24LH > 0.08 IU/24 h had a positive PV of 85.7% and a negative PV of 94.3%, a sensitivity of 85.7% and a specificity of 94.3%, for classifying prepubertal and pubertal girls in this cohort.

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study, in which a margin of error remains due to the inherent uncertainty regarding the clinical assessment of pubertal onset. It must be considered that the thresholds can only apply to the used reagents; measurements without extractions using other reagents are likely to show important heterogeneity.

WIDER IMPLICATIONS OF THE FINDINGS

The assay performed herein is a simple, non-invasive, and analytically robust technique meeting the criteria for an alternative to the GnRH test which could be used to supplement its lack of sensitivity.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was used. All authors declared no conflict of interest.

TRIAL REGISTRATION NUMBER

In-house #23-5214 registered study.

Trajectory of depressive symptoms over adolescence in autistic and neurotypical youth

BACKGROUND

Adolescence coincides with a dramatic rise in the onset of psychiatric conditions including depression. Depression symptoms may be particularly prevalent and impairing for youth with autism spectrum disorder (ASD). While prior research suggests adolescence is associated with worsening depression symptoms for typically developing (TD) and autistic youth, it is unclear if they follow a similar course.

METHOD

The study examined the trajectory of depressive symptoms in autistic and neurotypical youth over a 4-year longitudinal study using linear and logistic mixed effects models. In youth with clinically relevant depressive scores (t-score > 65), moderating factors (i.e., diagnosis, age, puberty, sex) were explored. During Year 1, the sample included 244 youth 10-to-13 years: 140 in the ASD group (36 females) and 104 in the TD group (46 females).

RESULTS

Autistic youth had elevated depression scores compared to TD peers (p < 0.001) and females were higher than males in both groups (p = 0.001). There was significant diagnosis by age (p < 0.001) and diagnosis by pubertal stage (p < 0.05) interactions. In the ASD group, elevated depressive scores presented in early adolescence and decreased during middle adolescence and puberty, whereas the TD group showed the opposite trend with an increase in depression symptoms with advancing development.

LIMITATIONS

Limitations include an unequal sex distribution (fewer females), non-representative autistic sample (e.g., cognition and race/ethnicity), and potential confound of the COVID-19 pandemic.

CONCLUSIONS

Autistic youth present with higher rates of depressive symptoms early in development; yet, approaching middle adolescence and puberty, the symptom trajectory in the autistic youth declines coinciding with an increase in the TD youth. While group trajectories are divergent, they lead to similar levels of depression in late adolescence with higher symptoms in females. Findings suggest a period of quiescence in depressive symptomology influenced by biopsychosocial factors impacting affective profiles.

Pubertal Timing Across Asian American, Native Hawaiian, and Pacific Islander Subgroups

Importance

Earlier puberty is associated with adverse health outcomes, such as mental health issues in adolescence and cardiometabolic diseases in adulthood. Despite rapid growth of the Asian American, Native Hawaiian, and Pacific Islander populations in the US, limited research exists on their pubertal timing, potentially masking health disparities.

Objective

To examine pubertal timing among Asian American, Native Hawaiian, and Pacific Islander children and adolescents by disaggregating ethnic subgroups.

Design, Setting, and Participants

This retrospective cohort study included Asian American, Native Hawaiian, and Pacific Islander youths aged 5 to 18 years assessed for pubertal development at Kaiser Permanente Northern California, a large, integrated health care delivery system. Follow-up occurred from March 2005, through December 31, 2019. Data were analyzed in October 2023.

Exposure

Race and ethnicity, categorized into 11 ethnic subgroups: Asian Indian, Chinese, Filipino, Japanese, Korean, Native Hawaiian and Pacific Islander, Other South Asian, Other Southeast Asian, Vietnamese, multiethnic, and multiracial.

Main Outcomes and Measures

Pubertal timing was determined using physician-assessed sexual maturity ratings (SMRs). Outcomes included the median age at transition from SMR 1 (prepubertal) to SMR 2 or higher (pubertal) for onset of genital development (gonadarche) in boys, breast development (thelarche) in girls, and pubic hair development (pubarche) in both boys and girls.

Results

In this cohort of 107 325 Asian American, Native Hawaiian, and Pacific Islander children and adolescents (54.61% boys; 12.96% Asian Indian, 22.24% Chinese, 26.46% Filipino, 1.80% Japanese, 1.66% Korean, 1.96% Native Hawaiian and Pacific Islander, 0.86% Other South Asian, 3.26% Other Southeast Asian, 5.99% Vietnamese, 0.74% multiethnic, and 22.05% multiracial), the overall median ages for girls' pubarche and thelarche were 10.98 years (95% CI, 10.96-11.01 years) and 10.13 years (95% CI, 10.11-10.15 years), respectively. For boys' pubarche and gonadarche, median ages were 12.08 years (95% CI, 12.06-12.10 years) and 11.54 years (95% CI, 11.52-11.56 years), respectively. Differences between subgroups with earliest and latest median age at onset were 14 months for girls' pubarche, 8 months for thelarche, 8 months for boys' pubarche, and 4 months for gonadarche. In general, Asian Indian, Native Hawaiian and Pacific Islander, and Other South Asian subgroups had the earliest ages at onset across pubertal markers, while East Asian youths exhibited the latest onset. Restricting to those with healthy body mass index did not substantially change the findings.

Conclusions and Relevance

In this cohort study of Asian American, Native Hawaiian, and Pacific Islander children and adolescents, pubertal timing varied considerably across ethnic subgroups. Further investigation is warranted to assess whether these differences contribute to observed health disparities in adulthood, such as type 2 diabetes and cardiovascular diseases.

Irisin combined index to diagnose central precocious puberty in girls: a cross-sectional study

BACKGROUND

To investigate serum irisin levels in girls at different developmental status and explore the significance of irisin for the diagnosis of central precocious puberty (CPP) in girls.

METHODS

In this cross-sectional study 111 girls were enrolled, including 43 cases of CPP, 44 cases of peripheral precocious puberty (PPP) and 24 cases of girls with normal sexual development as controls. The data on age, weight and height, measured blood levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol, and irisin were collected. Pelvic Doppler ultrasound was performed to evaluate uterine length, transverse diameter, anteroposterior diameter. The girls were divided into non-CPP group and CPP group according to gonadotropin-releasing hormone (GnRH) stimulation test.

RESULTS

Serum irisin levels were significantly higher in CPP group than in PPP group and normal control group. Serum irisin level was positively correlated with basal LH level, basal FSH level, peak LH level, peak LH /FSH ratio, uterine volume, bone age, and bone age index. The area under the curve, cut-off value, sensitivity and specificity of serum irisin were 0.958, 219.255 pg/ml, 100% and 80.6%. The combined diagnosis of CPP in girls by serum irisin and serum basal LH combined with uterine volume had an AUC, sensitivity, and specificity of 0.994, 97.6%, and 100%, superior to that of the single index.

CONCLUSIONS

Serum irisin level in girls with CPP is significantly increased. An irisin combined index could help the diagnosis of CPP in girls.

The effect of GnRH analog treatment on BMI in children treated for precocious puberty: a systematic review and meta-analysis

INTRODUCTION

The purpose of the present meta-analysis was to systematically evaluate the effect of GnRHa treatment on the BMI of children with precocious puberty after GnRHa treatment as compared to before, and to analyze the effect of GnRHa treatment on the body composition of children with precocious puberty at different BMIs by classifying into normal body mass, overweight, and obese groups according to BMI at the time of initial diagnosis.

CONTENT

A meta-analysis was performed using Stata 12.0 software by searching PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP database), and Wan fang database for relevant literature on standard deviation score of body mass index (BMI-SDS) after GnRHa treatment as compared to before in children with precocious puberty.

SUMMARY

A total of eight studies were included with a total sample size of 715 cases, and the results of meta-analysis showed that BMI-SDS increased in children with precocious puberty after GnRHa treatment as compared to before starting [(weighted mean difference (WMD)=0.23, 95 % CI: 0.14-0.33, p=0.000)] and also increased in children with normal body mass [(WMD=0.37, 95 % CI: 0.28-0.46, p=0.000)], and there was no significant change in BMI-SDS in children in the overweight or obese group [(WMD=0.01, 95 % CI: -0.08-0.10, p=0.775)].

OUTLOOK

Overall, there was an observed increase in BMI-SDS at the conclusion of GnRHa treatment in children with precocious puberty. Additionally, it was found that the effect of GnRHa treatment on body composition varied among children with different BMI status. Clinicians should emphasize the promotion of a healthy lifestyle and personalized dietary management for children.

Influence of vitamin D supplementation on growth, body composition, pubertal development and spirometry in South African schoolchildren: a randomised controlled trial (ViDiKids)

OBJECTIVE

To determine whether weekly oral vitamin D supplementation influences growth, body composition, pubertal development or spirometric outcomes in South African schoolchildren.

DESIGN

Phase 3 double-blind randomised placebo-controlled trial.

SETTING

Socioeconomically disadvantaged peri-urban district of Cape Town, South Africa.

PARTICIPANTS

1682 children of black African ancestry attending government primary schools and aged 6-11 years at baseline.

INTERVENTIONS

Oral vitamin D3 (10 000 IU/week) versus placebo for 3 years.

MAIN OUTCOME MEASURES

Height-for-age and body mass index-for-age, measured in all participants; Tanner scores for pubertal development, spirometric lung volumes and body composition, measured in a subset of 450 children who additionally took part in a nested substudy.

RESULTS

Mean serum 25-hydroxyvitamin D3 concentration at 3-year follow-up was higher among children randomised to receive vitamin D versus placebo (104.3 vs 64.7 nmol/L, respectively; mean difference (MD) 39.7 nmol/L, 95% CI 37.6 to 41.9 nmol/L). No statistically significant differences in height-for-age z-score (adjusted MD (aMD) -0.08, 95% CI -0.19 to 0.03) or body mass index-for-age z-score (aMD -0.04, 95% CI -0.16 to 0.07) were seen between vitamin D versus placebo groups at follow-up. Among substudy participants, allocation to vitamin D versus placebo did not influence pubertal development scores, % predicted forced expiratory volume in 1 s (FEV1), % predicted forced vital capacity (FVC), % predicted FEV1/FVC, fat mass or fat-free mass.

CONCLUSIONS

Weekly oral administration of 10 000 IU vitamin D3 boosted vitamin D status but did not influence growth, body composition, pubertal development or spirometric outcomes in South African schoolchildren.

TRIAL REGISTRATION NUMBERS

ClinicalTrials.gov NCT02880982, South African National Clinical Trials Register DOH-27-0916-5527.

Characterization of Puberty in an Australian Population-Based Cohort Study

PURPOSE

Current knowledge of the characteristics of puberty beyond age at menarche and thelarche is limited, particularly within population-based cohorts. Secular trends and concerns of the health effects of early puberty reinforce the value of contemporary studies characterizing the timing, tempo, duration, and synchronicity of puberty.

METHODS

The Childhood to Adolescence Transition Study is a unique Australian cohort of individuals followed annually from late childhood to late adolescence, with up to eight assessments of pubertal stage from 9 to 19 years of age (N = 1,183; 636 females). At each assessment, females reported their Tanner Stage of breast and pubic hair development, while males reported on genital/pubic hair development. Nonlinear mixed-effects models characterized pubertal trajectories and were used to derive each individual's estimates of timing, tempo, and synchronicity. Parametric survival models were used to estimate the overall duration of puberty.

RESULTS

Timing of mid-puberty (Tanner Stage 3) ranged from 12.5 to 13.5 years, with females developing approximately 6 months before males. Pubertal tempo (at mid-puberty) was similar across sex (between half and one Tanner Stage per year), but the overall duration of puberty was slightly shorter in males. Most females exhibited asynchronous changes of breast and pubic hair development.

DISCUSSION

Estimates of pubertal timing and tempo are consistent with reports of cohorts from two or more decades ago, suggesting stabilization of certain pubertal characteristics in predominantly White populations. However, our understanding of the duration of puberty and individual differences in pubertal characteristics (e.g., synchronicity of physical changes) remains limited.

Sex and Age Characteristics in Acute or Chronic Myocarditis A Descriptive, Multicenter Cohort Study

BACKGROUND

Understanding the clinical features of myocarditis in various age groups is required to identify age-specific disease patterns.

OBJECTIVES

The objective of this study was to examine differences in sex distribution and clinical outcomes in patients with myocarditis of various ages.

METHODS

Patients with acute or chronic myocarditis in 3 centers in Berlin, Germany from 2005 to 2021 and in the United States (National Inpatient Sample) from 2010 to 2019 were included. Age groups examined included "prepubescent" (below 11 years for females and below 13 years for males), adolescents (11 [female] or 13 [male] to 18 years), young adults (18-35 years), "middle-aged adults" (35-54 years), and older adults (age >54 years). In patients admitted to the hospital, hospital mortality, length of stay, and medical complication rates were examined.

RESULTS

Overall, 6,023 cases in Berlin and 9,079 cases in the U.S. cohort were included. In both cohorts, there were differences in sex distribution among the 5 age categories, and differences in the distribution were most notable in adolescents (69.3% males vs 30.7% females) and in young adults (73.8% males vs 26.3% females). Prepubescent and older adults had the highest rates of in-hospital mortality, hospital length of stay, and medical complications. In the Berlin cohort, prepubescent patients had higher levels of leukocytes (P < 0.001), antistreptolysin antibody (P < 0.001), and NT-proBNP (P < 0.001) when compared to young adults.

CONCLUSIONS

In this study, we found that sex differences in myocarditis and clinical features of myocarditis were age-dependent.

Annual Research Review: Sex, gender, and internalizing conditions among adolescents in the 21st century - trends, causes, consequences

Internalizing conditions of psychopathology include depressive and anxiety disorders; they most often onset in adolescence, are relatively common, and contribute to significant population morbidity and mortality. In this research review, we present the evidence that internalizing conditions, including depression and anxiety, as well as psychological distress, suicidal thoughts and self-harm, and fatal suicide, are considerably increasing in adolescent populations across many countries. Evidence indicates that increases are currently greatest in female adolescents. We present an epidemiological framework for evaluating the causes of these increases, and synthesize research on whether several established risk factors (e.g., age of pubertal transition and stressful life events) and novel risk factors (e.g., digital technology and social media) meet conditions necessary to be plausible causes of increases in adolescent internalizing conditions. We conclude that there are a multitude of potential causes of increases in adolescent internalizing conditions, outline evidence gaps including the lack of research on nonbinary and gender nonconforming populations, and recommend necessary prevention and intervention foci from a clinical and public health perspective.

Association between sex hormones and bone age in boys aged 9-18 years from China

This study aimed to analyse the association between sex hormones and bone age (BA) in boys aged 9-18 years, both individually and interactively, and further to explore whether nutritional status may influence this association. A retrospective analysis was performed among 1382 Chinese boys with physical measurements, sexual characteristics, BA radiographs and sex hormone indicators from February 2015 to February 2022. A total of 470 (34.0%) boys had advanced BA. BA was positively associated with estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and testosterone in both advanced and normal BA groups after adjusting for age, genetic height and body mass index. Multiple logistic regression showed that after adjusting for covariates, estradiol (odds ratio [OR] = 1.66, 95% confidence interval [CI]: 1.14-2.12), LH (OR = 1.43, 95% CI: 1.04-1.96), and testosterone (OR = 1.58, 95% CI: 1.17-2.13) were significantly associated with the increased risk of advanced BA in boys, and the association was reinforced when these hormones were interactively explored. Stratified by nutritional status, the interaction between estradiol, LH, and testosterone showed a strong association with advanced BA in boys with normal weight.

Endocrine Disruptors and Metabolic Changes: Impact on Puberty Control

OBJECTIVE

This study aims to explore the significant impact of environmental chemicals on disease development, focusing on their role in developing metabolic and endocrine diseases. The objective is to understand how these chemicals contribute to the increasing prevalence of precocious puberty, considering various factors, including epigenetic changes, lifestyle, and emotional disturbances.

METHODS

The study employs a comprehensive review of descriptive observational studies in both human and animal models to identify a degree of causality between exposure to environmental chemicals and disease development, specifically focusing on endocrine disruption. Due to ethical constraints, direct causation studies in human subjects are not feasible; therefore, the research relies on accumulated observational data.

RESULTS

Puberty is a crucial life period with marked physiological and psychological changes. The age at which sexual characteristics develop is changing in many regions. The findings indicate a correlation between exposure to endocrine-disrupting chemicals and the early onset of puberty. These chemicals have been shown to interfere with normal hormonal processes, particularly during critical developmental stages such as adolescence. The research also highlights the interaction of these chemical exposures with other factors, including nutritional history, social and lifestyle changes, and emotional stress, which together contribute to the prevalence of precocious puberty.

CONCLUSION

Environmental chemicals significantly contribute to the development of certain metabolic and endocrine diseases, particularly in the rising incidence of precocious puberty. Although the evidence is mainly observational, it adequately justifies regulatory actions to reduce exposure risks. Furthermore, these findings highlight the urgent need for more research on the epigenetic effects of these chemicals and their wider impact on human health, especially during vital developmental periods.

Childhood adversity and accelerated reproductive events: a systematic review and meta-analysis

OBJECTIVE

Accelerated female reproductive events represent the early onset of reproductive events involving puberty, menarche, pregnancy loss, first sexual intercourse, first birth, parity, and menopause. This study aimed to explore the association between childhood adversity and accelerated female reproductive events.

DATA SOURCES

PubMed, Web of Science, and Embase were systematically searched from September 22, 2022 to September 23, 2022.

STUDY ELIGIBILITY CRITERIA

Observational cohort, cross-sectional, and case-control studies in human populations were included if they reported the time of reproductive events for female individuals with experience of childhood adversity and were published in English.

METHODS

Two reviewers independently screened studies, obtained data, and assessed study quality, and conflicts were resolved by a third reviewer. Dichotomous outcomes were evaluated using meta-analysis, and pooled odds ratios and 95% confidence intervals were generated using random-effects models. Moderation analysis and meta-regression were used to investigate heterogeneity.

RESULTS

In total, 21 cohort studies, 9 cross-sectional studies, and 3 case-control studies were identified. Overall, female individuals with childhood adversity were nearly 2 times more likely to report accelerated reproductive events than those with no adversity exposure (odds ratio, 1.91; 95% confidence interval, 1.33-2.76; I2=99.6%; P<.001). Moderation analysis indicated that effect sizes for the types of childhood adversity ranged from an odds ratio of 1.61 (95% confidence interval, 1.23-2.09) for low socioeconomic status to 2.13 (95% confidence interval, 1.14-3.99) for dysfunctional family dynamics. Among the 7 groups based on different reproductive events, including early onset of puberty, early menarche, early sexual initiation, teenage childbirth, preterm birth, pregnancy loss, and early menopause, early sexual initiation had a nonsignificant correlation with childhood adversity (odds ratio, 2.70; 95% confidence interval, 0.88-8.30; I2=99.9%; P<.001). Considerable heterogeneity (I2>75%) between estimates was observed for over half of the outcomes. Age, study type, and method of data collection could explain 35.9% of the variance.

CONCLUSION

The literature tentatively corroborates that female individuals who reported adverse events in childhood are more likely to experience accelerated reproductive events. This association is especially strong for exposure to abuse and dysfunctional family dynamics. However, the heterogeneity among studies was high, requiring caution in interpreting the findings and highlighting the need for further evaluation of the types and timing of childhood events that influence accelerated female reproductive events.

Standardization of Weightage Assigned to Different Segments of the Hand X-ray for Assessment of Bone Age by the Greulich-Pyle Method

Introduction

Bone age (BA) assessment is important in evaluating disorders of growth and puberty; the Greulich and Pyle atlas method (GP) is most used. We aimed to determine the weightage to be attributed by raters to various segments of the hand x-ray, namely, distal end of radius-ulna (RU), carpals, and short bones for rating bone age using the GP atlas method.

Methods

692 deidentified x-rays from a previous study (PUNE-dataset) and 400 from the Radiological Society of North America (RSNA-dataset) were included in the study. Mean of BA assessed by experienced raters was termed reference rating. Linear regression was used to model reference age as function of age ratings of the three segments. The root-mean-square-error (RMSE) of segmental arithmetic mean and weighted mean with respect to reference rating were computed for both datasets.

Results

Short bones were assigned the highest weightage. Carpals were assigned higher weightage in pre-pubertal PUNE participants as compared to RSNA, vice-versa in RU segment of post-pubertal participants. The RMSE of weighted mean ratings was significantly lower than for the arithmetic mean in the PUNE dataset.

Conclusion

We thus determined weightage to be attributed by raters to segments of the hand x-ray for assessment of bone age by the GP method.

A developmental framework for understanding the influence of sex and gender on health: Pediatric pain as an exemplar

Sex differences are a robust finding in many areas of adult health, including cardiovascular disease, psychiatric disorders, and chronic pain. However, many sex differences are not consistently observed until after the onset of puberty. This has led to the hypothesis that hormones are primary contributors to sex differences in health outcomes, largely ignoring the relative contributions of early developmental influences, emerging psychosocial factors, gender, and the interaction between these variables. In this paper, we argue that a comprehensive understanding of sex and gender contributions to health outcomes should start as early as conception and take an iterative biopsychosocial-developmental perspective that considers intersecting social positions. We present a conceptual framework, informed by a review of the literature in basic, clinical, and social science that captures how critical developmental stages for both sex and gender can affect children's health and longer-term outcomes. The literature on pediatric chronic pain is used as a worked example of how the framework can be applied to understanding different chronic conditions.

Early life adversity accelerates hypothalamic drive of pubertal timing in female rats with associated enhanced acoustic startle

Early life adversity in the form of childhood maltreatment in humans or as modeled by maternal separation (MS) in rodents is often associated with an earlier emergence of puberty in females. Earlier pubertal initiation is an example of accelerated biological aging and predicts later risk for anxiety in women, especially in populations exposed to early life trauma. Here we investigated external pubertal markers as well as hypothalamic gene expression of pubertal regulators kisspeptin and gonadotropin-releasing hormone, to determine a biological substrate for MS-induced accelerated puberty. We further investigated a mechanism by which developmental stress might regulate pubertal timing. As kisspeptin and gonadotropin-releasing hormone secretion are typically inhibited by corticotropin releasing hormone at its receptor CRH-R1, we hypothesized that MS induces a downregulation of Crhr1 gene transcription in a cell-specific manner. Finally, we explored the association between pubertal timing and anxiety-like behavior in an acoustic startle paradigm, to drive future preclinical research linking accelerated puberty and anxiety. We replicated previous findings that MS leads to earlier puberty in females but not males, and found expression of kisspeptin and gonadotropin-releasing hormone mRNA to be prematurely increased in MS females. RNAscope confirmed increased expression of these genes, and further revealed that kisspeptin-expressing neurons in females were less likely to express Crhr1 after MS. Early puberty was associated with higher acoustic startle magnitude in females. Taken together, these findings indicate precocial maturation of central pubertal timing mechanisms after MS, as well as a potential role of CRH-R1 in these effects and an association with a translational measure of anxiety.

Effects of the COVID-19 pandemic on the incidence of central precocious puberty; a narrative review

Central precocious puberty (CPP) is the premature activation of the hypothalamus-pituitary-gonadal axis, resulting in the early development of secondary sexual characteristics. CPP classically occurs before the age of 8 years in girls and 9 years in boys. The aetiology of this precocious onset of puberty is governed by complex mechanistic interactions between genetic and environmental factors. The rates of CPP have been documented to have been rising before the COVID-19 pandemic; despite this, the incidence of CPP has increased exponentially since the start of the pandemic. There are multiple theories potentially explaining this change in incidence of CPP over COVID-19. These include the direct effect of SARS-coV-2 infection, increasing body mass index of adolescents over sequential lockdowns, changes in sleep patterns, increased use of electronic devices and levels of stress, and additionally potential earlier detection of signs of CPP by parents and carers. Whilst there is evidence from observational cohorts, case studies and animal models for each of these factors, it is difficult to definitively prove which has had the greatest impact due to the mainly retrospective nature of the human research that has been conducted. Moreover, studies set in diverse settings with varying population make comparison complex. Additionally, each country responded differently to the COVID-19 pandemic and the lockdowns varied between locations, hence the effect of lockdown was not equal or universal. Despite this, similar trends have been identified, with various lifestyle changes that occurred over the pandemic being potentially influential factors on the development of CPP.

Metabolic control of puberty: 60 years in the footsteps of Kennedy and Mitra's seminal work

An individual's nutritional status has a powerful effect on sexual maturation. Puberty onset is delayed in response to chronic energy insufficiency and is advanced under energy abundance. The consequences of altered pubertal timing for human health are profound. Late puberty increases the chances of cardiometabolic, musculoskeletal and neurocognitive disorders, whereas early puberty is associated with increased risks of adult obesity, type 2 diabetes mellitus, cardiovascular diseases and various cancers, such as breast, endometrial and prostate cancer. Kennedy and Mitra's trailblazing studies, published in 1963 and using experimental models, were the first to demonstrate that nutrition is a key factor in puberty onset. Building on this work, the field has advanced substantially in the past decade, which is largely due to the impressive development of molecular tools for experimentation and population genetics. In this Review, we discuss the latest advances in basic and translational sciences underlying the nutritional and metabolic control of pubertal development, with a focus on perspectives and future directions.

Childhood physical activity and pubertal timing: findings from the LEGACY girls study

BACKGROUND

There is limited research on whether physical activity (PA) in early childhood is associated with the timing of pubertal events in girls.

METHODS

We used data collected over 2011-16 from the LEGACY Girls Study (n = 984; primarily aged 6-13 years at study enrolment), a multicentre North American cohort enriched for girls with a breast cancer family history (BCFH), to evaluate if PA is associated with age at thelarche, pubarche and menarche. Maternal-reported questionnaire data measured puberty outcomes, PA in early childhood (ages 3-5 years) and total metabolic equivalents of organized PA in middle childhood (ages 7-9 years). We used interval-censored Weibull parametric survival regression models with age as the time scale and adjusted for sociodemographic factors, and we tested for effect modification by BCFH. We used inverse odds weighting to test for mediation by body mass index-for-age z-score (BMIZ) measured at study enrolment.

RESULTS

Being highly active vs inactive in early childhood was associated with later thelarche in girls with a BCFH [adjusted hazard ratio (aHR) = 0.39, 95% CI = 0.26-0.59), but not in girls without a BCFH. In all girls, irrespective of BCFH, being in the highest vs lowest quartile of organized PA in middle childhood was associated with later menarche (aHR = 0.70, 95% CI = 0.50-0.97). These associations remained after accounting for potential mediation by BMIZ.

CONCLUSION

This study provides new data that PA in early childhood may be associated with later thelarche in girls with a BCFH, also further supporting an overall association between PA in middle childhood and later menarche.

Post-Menarcheal Growth Patterns in a Contemporary Cohort of Latino Girls

INTRODUCTION

Menarche is the last stage of pubertal development, which coincides with the completion of longitudinal growth. As a consequence of the lack of national and up-to-date data related to post-menarcheal (PM) growth, the aim of our work was to evaluate PM growth in a group of contemporary healthy Chilean girls followed, prospectively, until 4 years PM.

METHODS

This study was nested within the GOCS cohort, in a prospective fashion. The girls were followed yearly after menarche for at least for 4 years. We modeled each girl's growth using a SuperImposition by Translation and Rotation (SITAR) model.

RESULTS

A total of 534 girls were evaluated prospectively; 399 girls had height measured 2 years after menarche, 421 after 3 years, and 364 of 534 had height measured at 4 years PM. Expected height gained PM in the complete study group was 6.6 ± 2.5 cm. We observed that the largest gain in height occurred after the first year PM (3.8 ± 1.5 cm). According to the age of menarche, the group with earlier menarche (<11 years old) had a greater height gain in cm after 4 years PM (8.2 ± 3.2 cm) and the smallest gain was among girls with menarche at an age older than 13 years (4.4 ± 1.6) (p < 0.001). Age at menarche was significantly associated with all PM growth patterns (size, timing, and intensity), indicating that girls with older age at menarche grew taller, later, and slower than girls with younger age at menarche. Adjusting the PM growth pattern by BMI maintained all these associations. Applying the SITAR model specifically, girls experiencing menarche after the age of 13 years exhibited slower growth, occurring slightly earlier and with less intensity when adjusted by BMI at menarche.

CONCLUSION

In a national and updated dataset, we observed that girls grew until 4 years PM an average of 6.6 ± 2.5 cm, with greatest gain occurring in the first year PM (3.8 ± 1.5 cm). Age at menarche was associated with menarche growth patterns.

The effect of gonadoliberin analog treatment in precocious puberty on polycystic ovarian syndrome prevalence in adulthood

Precocious puberty is diagnosed when pubertal characteristics appear before the age of 8 years in females. The most common form is gonadotropin-dependent, called axial. The primary method of treatment is administration of gonadotrophin-releasing hormone analogues (GnRHa). The aim of the study was to verify hypothesis that GnRHa therapy in the childhood may be of additive risk factor for polycystic ovary syndrome (PCOS) in adulthood.

Material and Methods

The study group consists of 24 women (median age 22 88 years, median BMI 23.5) treated with GnRHa for central precocious puberty in childhood. The control group includes 40 women (median age 23 years, median BMI 25.6) diagnosed with isolated premature thelarche and not using GnRHa in the childhood. Anthropometric measurements, ultrasound examination of minor pelvis and hormonal profile were performed. PCOS diagnosis was based on Rotterdam criteria.

Results

The study confirmed a higher prevalence of PCOS in the study group (50%) than in the control group (10%); p=0.0006. Significant, linear correlation between free testosterone levels and ovarian size was found in the study group (R=0.45 p= 0.03).

Conclusions

GnRHa therapy during childhood may have a potential influence on incidence of PCOS in the adulthood. Therefore, in this group of patients long-term follow-up focused on screening for PCOS would seem beneficial.

Puberty Today, Gone Tomorrow: Transient Refractory Central Precocious Puberty in a Toddler with End-Stage Kidney Disease

INTRODUCTION

The onset of puberty is typically delayed in children with chronic kidney disease (CKD), with only three reported cases of precocious puberty in boys with CKD.

CASE PRESENTATION

We report the case of a boy with end-stage kidney disease secondary to posterior urethral valves who, while undergoing peritoneal dialysis, presented at 17 months with central precocious puberty characterized by clinical signs of testicular and penile enlargement, pubic hair, and acne; rapid linear growth with advanced bone age; and pubertal luteinizing hormone (LH) and testosterone levels. Monthly leuprolide injections were commenced at 24 months with no pubertal or biochemical suppression thereafter, along with continued rapid bone-age advancement through 32 months. He then received a deceased-donor kidney transplant at 33 months of age, with good graft function. Within 2 months, he was noted to have prepubertal GnRH-stimulated LH and testosterone levels. Leuprolide injections were discontinued at that time with no further progression of puberty. The patient is now 48 months old with minimal further bone-age advancement and consistently prepubertal LH and testosterone levels.

CONCLUSION

Our case demonstrates the development of precocious puberty due to premature activation of the hypothalamic-pituitary-testicular axis, presumably secondary to uremia and/or disordered renal clearance of gonadotropins, which was refractory to standard management with a gonadotropin-releasing hormone agonist, perhaps due to excessively rapid removal by peritoneal dialysis and/or the uremic state itself. Kidney transplantation led to a correction of uremia and a return to the prepubertal state.

Postnatal feeding with high-fat combined with high-glucose diet induces precocious puberty in Sprague‒Dawley rat pups

With economic development and overnutrition, including high-fat diets (HFD) and high-glucose diets (HGD), the incidence of obesity in children is increasing, and thus, the incidence of precocious puberty is increasing. Therefore, it is of great importance to construct a suitable animal model of overnutrition-induced precocious puberty for further in-depth study. Here, we fed a HFD, HGD, or HFD combined with a HGD to pups after P-21 weaning, while weaned pups fed a normal diet served as the control group. The results showed that HFD combined with a HGD increased the body weight (BW) of weaned rat pups. In addition, a HFD, HGD, and HFD combined with a HGD lowered the age at which vaginal opening occurred and accelerated the vaginal cell cycle. Furthermore, a HFD combined with a HGD increased the weight of the uterus and ovaries of weaned rat pups. Additionally, a HFD combined with a HGD promoted the development of reproductive organs in weaned female rat pups. Ultimately, a HFD combined with a HGD was found to elevate the serum levels of gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH), follicle stimulating hormone (FSH), leptin, adiponectin, and oestradiol (E2) and increase hypothalamic GnRH, Kiss-1, and GPR54 expression levels in weaned female rat pups. The current study found that overnutrition, such as that through a HFD combined with HGD, could induce precocious puberty in weaned female rat pups. In addition, a rat model of overnutrition-induced precocious puberty was established.

Differentiation of Idiopathic Central Precocious Puberty From Premature Thelarche Using Principal Component Analysis

CONTEXT

Nonprogressive premature thelarche (PT) is a self-limiting variant of early puberty, while idiopathic central precocious puberty (ICPP) is a disorder that causes progressive development of secondary sexual characteristics and often requires treatment. The diagnostic differentiation between these conditions is important but can be challenging since they often both initially present clinically with isolated breast development.

OBJECTIVE

To describe relevant clinical variables in a large cohort of girls referred for early puberty, and to evaluate clinical and biochemical parameters to distinguish between girls with ICPP and PT.

METHODS

This retrospective study included 1361 girls referred with signs of early puberty to a single, tertiary center from 2009 to 2019. We evaluated clinical presentation, medical history, growth velocity, bone age, hormonal serum concentrations, and gonadotropin-releasing hormone (GnRH) test results.

RESULTS

Central precocious puberty was diagnosed in 11% (ICPP: n = 143, organic CPP: n = 11) girls, whereas 8% (n = 91 girls) presented with PT. Receiver operating characteristic (ROC) analysis showed several biochemical and anthropometric markers as potential parameters to differentiate between ICPP and PT; however, none were individually adequate. Principal component analysis (PCA)-derived clinical and hormone profiles could predict girls with ICPP from girls with PT with a specificity of 90% and sensitivity of 84%, outperforming any single marker.

CONCLUSION

Differentiation of girls with ICPP and PT can be supported by individual clinical and biochemical parameters. However, dimension reduction of clinical and hormonal profiles by PCA improved the diagnostic value, which in the future may support the diagnostic process as a supplement to the GnRH test in evaluation of pubertal disorders.

The Effect of GnRHa Treatment on Body Mass Index in Central Precocious Puberty: A Systematic Review and Meta-Analysis

BACKGROUND

Recently, numerous studies have addressed the long-term effects of treatment with gonadotropin-releasing hormone analog (GnRHa) in patients with central precocious puberty (CPP). However, the effects of GnRHa treatment on body mass index (BMI) in patients with CPP remain controversial.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the association between GnRHa treatment and BMI in patients with CPP.

METHODS

A systematic search of databases, PubMed, EMBASE, and Web of Science published before August 2021 identified relevant studies. The overall effect analysis was performed using STATA version statistical software 15.0.

RESULTS

The study included a total of 28 studies. At the end of GnRHa treatment, the BMI-standard deviation score (BMI-SDS) was greater than baseline BMI-SDS (weighted mean difference (WMD) = 0.14, 95% CI: 0.04-0.23; p = 0.004), especially in girls with CPP (WMD = 0.15, 95% CI: 0.05-0.25; p = 0.005) and in patients with normal weight (WMD = 0.34, 95% CI: 0.19-0.48, p < 0.001). After reaching adult height, BMI-SDS returned to baseline, suggesting that the effect of GnRHa treatment on BMI would disappear as the child grew (WMD = -0.03, 95% CI: -0.39 to 0.32; p = 0.815).

CONCLUSION

For patients with CPP, while treatment with GnRHa may increase the BMI in the short term after treatment, the BMI is likely to return to normal when the patients reach adult height.

The Viewing Reaction Time as a Diagnostic Tool of Pedohebephilia in the Dunkelfeld

Diagnosing pedohebephilia is fraught with obstacles given the tabooed nature of this sexual preference. The viewing reaction time effect (VRT) provides a non-intrusive indirect measure of sexual interest in minors. In forensic populations, the ability of the difference between the latencies while viewing child and adult sexual stimuli (VRT index) to discern child sexual offenders from a range of control groups has been ascertained meta-analytically. Given that the effect has been studied almost exclusively in forensic samples, its dependence or independence on prior overt (deviant) sexual behavior remains unclear. The present study sought to examine the relationship of prior sexual and non-sexual behaviors with the VRT in a sample of 282 self-referring, help-seeking men with and without pedohebephilia with and without a history of prior child sexual offenses (CSO) or a use of child sexual abuse materials (CSAM) recruited outside a forensic context. We found that (1) the clinical diagnosis of pedohebephilia but not prior CSO or CSAM showed a significant association with the VRT index; (2) the discriminatory ability of the VRT index did not differ significantly between samples with and without a history of prior overt sexual behavior with children; (3) the VRT index correlated positively with a behavioral marker of pedohebephilia in a subsample of individuals with prior judicially detected or undetected overt sexual behavior with children; and (4) in the same subsample, the VRT index correlated positively with markers of sexual interests in minors or hypersexuality but not of antisociality. Equivalence testing failed to refute a potential effect of prior sexual behavior on the VRT index. Our study showed that the VRT may provide an unintrusive diagnostic tool for pedohebephilia. The effect of prior overt sexual behavior with children needs further examination.

Time trends towards earlier puberty in boys and girls with type 1 diabetes: Insights from the German Diabetes Prospective Follow-up (DPV) registry, 2000 to 2021

AIM

To examine the time trends and factors associated with the onset of puberty in children with type 1 diabetes (T1D) using data from the German Diabetes Prospective Follow-up (Diabetes-Patienten-Verlaufsdokumentation [DPV]) registry.

METHODS

A total of 13 127 children with T1D, aged 6 to 18 years, were included in the analysis. Regression analysis was performed to investigate the relationship between diabetes duration, body mass index (BMI) standard deviation score (SDS), glycated haemoglobin (HbA1c) level, migration background, and the onset of puberty, stratified by sex.

RESULTS

Our findings revealed a significant trend towards earlier puberty in both girls and boys with T1D over the observed period (2000 to 2021). Puberty onset in girls (thelarche Tanner stage B2) decreased from 11.48 (11.35-11.65) years in 2000 to 10.93 (10.79-11.08) years in 2021 and gonadarche (Tanner stage G2/testicular volume >3 mL) decreased from 12.62 (12.42-12.82) years in 2000 to 11.98 (11.79-12.16) years in 2021 in boys (both P < 0.001). Longer diabetes duration, higher BMI SDS, and lower HbA1c level were associated with earlier puberty in both sexes (P < 0.001).

CONCLUSIONS

Our study highlights earlier puberty in children with T1D, influenced by BMI SDS, HbA1c level, and migration background. This has important implications for diabetes management and supporting healthy development. Further research is needed to understand the underlying mechanisms and develop potential interventions for this vulnerable population.

Impact of obesity on female puberty and pubertal disorders

The worldwide epidemic of obesity appears to be one of the crucial health problems. One-third of children and adolescents in the United States are classified as either overweight or obese and 6% of adolescents are severely obese. With the development of high technology, children, and adolescents, spend more time in sedentary life. Together with the availability of consuming fast caloric food, it is almost unavoidable to get an imbalance between caloric intake and caloric expenditure of energy, resulting in the accumulation of fat-energy stores. Obesity has an enormous impact on physical and psychological health and is associated with more than 29 adverse health consequences previously identified in the adult population only, such as type 2 diabetes mellitus, hypertension, metabolic syndrome, postmenopausal breast cancer, and others. In addition, excess adiposity may exert a harmful effect on the reproductive system, resulting in precocious puberty, irregular menstrual cycle, polycystic ovary syndrome, and high-risk sexual behavior. Intervention programs for healthy lifestyle modification, consisting of caloric restriction together with physical activity did not gain the expected efficacy. Other approaches as medical and surgical therapies are currently not evidence-based for the young population. The obesity crisis in children and adolescents requires a better understanding of etiology, pathophysiology, and management of obesity in this unique population. Researchers and physicians must "turn over every stone" to find a solution for deviating obesity ascent.

Increase in incidence of anorexia nervosa among 10- to 14-year-old girls: A nationwide study in the Netherlands over four decades

OBJECTIVE

This primary care study examined time trends in the incidence of anorexia nervosa (AN) and bulimia nervosa (BN) in the Netherlands across four decades.

METHODS

A nationwide network of general practitioners, serving approximately 1% of the total Dutch population, recorded newly diagnosed patients with AN and BN in their practices from 1985 to 2019 (2,890,978 person-years). DSM-IV diagnostic criteria were consistently used and the same psychiatrist was responsible for the final diagnostic decision. Incidence rates (IRs) were calculated for: the total population (all ages), females overall, and females per 5-year age category. Time trends in IRs were analyzed using JoinPoint regression analyses.

RESULTS

In four decades, the incidence of AN among 10- to 14-year-old females increased significantly from 8.6 to 38.6 per 100,000 person-years (average period percentage change [APPC] = 56.7; 95% confidence interval [CI] = 6.5-130.6. The overall incidence of AN was stable, with IRs ranging from 6.0 (95% CI = 4.3-8.1) to 8.4 (95% CI = 6.4-10.8). The IR of BN decreased significantly from 8.7 (95% CI = 6.7-11.0) to 3.2 (95% CI = 2.0-4.9) in the 2000s, before leveling off in the 2010s (IR 3.2; 95% CI = 2.0-4.8).

DISCUSSION

The incidence of AN among 10- to 14-year-old girls increased significantly over four decades. Both biological and sociocultural factors, for example, early pubertal timing and the impact of social media, might explain this. In other age groups and overall, the incidence of AN remained stable. The significant decrease of the incidence of BN in the previous decades halted in the last decade.

PUBLIC SIGNIFICANCE

An important finding of the present study is that for 10- to 14-year-old girls, the risk for developing anorexia nervosa has increased significantly over 40 years. More healthcare facilities for younger people are needed, and prevention programs could include social media use. For bulimia nervosa, the general decrease in the occurrence of new cases has halted in the 2010s.

DNA methylation sites in early adulthood characterised by pubertal timing and development: a twin study

BACKGROUND

Puberty is a highly heritable and variable trait, with environmental factors having a role in its eventual timing and development. Early and late pubertal onset are both associated with various diseases developing later in life, and epigenetic characterisation of pubertal timing and development could lead to important insights. Blood DNA methylation, reacting to both genotype and environment, has been associated with puberty; however, such studies are relatively scarce. We investigated peripheral blood DNA methylation profiles (using Illumina 450 K and EPIC platforms) of 1539 young adult Finnish twins associated with pubertal development scale (PDS) at ages 12 and 14 as well as pubertal age (PA).

RESULTS

Fixed effect meta-analysis of the two platforms on 347,521 CpGs in common identified 58 CpG sites associated (p < 1 × 10-5) with either PDS or PA. All four CpGs associated with PA and 45 CpGs associated with PDS were sex-specific. Thirteen CpGs had a high heritability (h2: 0.51-0.98), while one CpG site (mapped to GET4) had a high shared environmental component accounting for 68% of the overall variance in methylation at the site. Utilising twin discordance analysis, we found 6 CpG sites (5 associated with PDS and 1 with PA) that had an environmentally driven association with puberty. Furthermore, genes with PDS- or PA-associated CpGs were consistently linked to various developmental processes and diseases such as breast, prostate and ovarian cancer, while methylation quantitative trait loci of associated CpG sites were enriched in immune pathways developing during puberty.

CONCLUSIONS

By identifying puberty-associated DNA methylation sites and examining the effects of sex, environment and genetics, we shed light on the intricate interplay between environment and genetics in the context of puberty. Through our comprehensive analysis, we not only deepen the understanding of the significance of both genetic and environmental factors in the complex processes of puberty and its timing, but also gain insights into potential links with disease risks.

Duration of stages of the Middle Phalanx Maturation method in a contemporary population: A 6-year longitudinal analysis

OBJECTIVE

To determine the duration and age at the beginning of each stage corresponding to the circumpubertal period in the Middle Phalanx Maturation method (MPM) and to assess the differences between males and females.

MATERIALS AND METHODS

Sets of X-rays of the middle phalanx of the third finger taken at 6-month intervals were analysed for 246 skeletal Class I subjects (102 females and 144 males) between 9 and 15 years of age. After staging, the duration of each stage was derived from chronological ages, and the difference between males and females for both duration and age at the beginning of each stage was investigated.

RESULTS

The median duration for MPS2 and MPS3 was 1 year for both sexes, while MPS4 showed a median duration of 1 year in females and 9 months in males, with no significant differences between the sexes. Mean age at the beginning of MPS2 was 10y11m for females and 11y11m for males; for MPS3, it was 11y8m for females and 13y1m for males; for MPS4, it was 12y9m for females and 13y11m for males; for MPS5, it was 13y4m for females and 14y3m for males. The differences between the sexes were statistically significant for all the stages (P < .001).

CONCLUSIONS

This study confirms, with relevant sample size, the median duration of 1 year for each MPM stage from MPS2 to MPS4. Despite the distinctive interindividual variability, the interquartile range is 6 months or less for all but one interval, confirming the soundness of the results.

Association between infant breastfeeding practices and timing of peak height velocity: A nationwide longitudinal survey in Japan

BACKGROUND

Several studies have discovered an association between infant feeding practices and puberty timing; however, most have involved female cohorts. We investigated the association between infant feeding practices and the timing of peak height velocity in boys and girls.

METHODS

Data on infant feeding methods and anthropometric measurements were collected from a nationwide Japanese birth cohort study. The age at peak height velocity (APV, years) was estimated and compared. Subsequently, the effects of breastfeeding duration were analyzed.

RESULTS

Of the 13,074 eligible participants, 650, 9455, and 2969 were formula-, mixed-, and exclusively breastfed, respectively. Among girls, the mean APV was significantly later in the mixed-fed (standardized regression coefficient (β): 0.094, 95% confidence interval (CI): 0.004-0.180) and exclusively breastfed (β: 0.150, 95% CI: 0.056-0.250) groups than in the formula-fed group. Among boys, the mean APV was not significantly different among the three groups; however, a sensitivity analysis that excluded preterm birth revealed more significantly delayed APV in the breastfed-only group compared to the formula-fed group. Furthermore, a multiple linear regression model revealed that a longer breastfeeding period was associated with later APV.

CONCLUSIONS

Infant breastfeeding practices can affect the timing of peak height velocity in both boys and girls.

IMPACT

Several studies have discovered an association between infant feeding practices and puberty timing; however, most have involved female cohorts. Age at peak height velocity, derived from longitudinal height measurements, is a useful marker of secondary sexual maturity milestones in boys and girls. A Japanese birth cohort study revealed that breastfed children had a later age at peak height velocity than their formula-fed counterparts; this was more prominent among girls than boys. Furthermore, a duration-effect relationship was observed, where longer breastfeeding duration was associated with a later age at peak height velocity.

Dental Maturation in Two Groups of Children Born in 1969-1973 and 2005-2010

This study compared differences in dental maturation and dental age in Scandinavian children born in 1969-1973 and 2005-2010. The study was based on 130 ethnic Scandinavian children, who were divided in two groups corresponding to the time periods and matched on age and sex. Each group consisted of 65 children (30 girls, 35 boys, mean age 9.29 years and 9.30 years, respectively). Dental maturation was analysed by orthopantomographs, in accordance with Demirjian and Haavikko. Dental age was analysed by orthopantomographs in accordance with Demirjian. Boys and girls were analysed separately by linear regression analysis adjusted for age. For the children born in 2005-2010, teeth matured significantly earlier (Demirjian: 0.21 maturities, CI 95% 0.11-0.31, p < 0.000. Haavikko: maxilla: 0.39 maturities, CI 95% 0.21-0.56, p < 0.000. Mandible: 0.42 maturities, CI 95% 0.17-0.67, p = 0.001) and the dental age was significantly higher (Demirjian: 6.04 months, CI 95% 0.23-0.77, p < 0.000) in comparison with the children born in 1969-1973. In conclusion, the teeth of Scandinavian children born 2005-2010 matured significantly earlier than those of children born in 1969-1973. The results may prove valuable in forensic dentistry, pedodontics, and for the timing of pedodontic and orthodontic treatment.

Association Between Markers of Adiposity During Childhood and Puberty Onset in Latino Girls

CONTEXT

Prepubertal adiposity is associated with earlier puberty. It is unclear when this association starts, if all adiposity markers are similarly associated, and whether all pubertal milestones are similarly affected.

OBJECTIVE

To evaluate the association between different adiposity markers during childhood and the timing of different pubertal milestones in Latino girls.

DESIGN, SETTING, AND PARTICIPANTS

Longitudinal follow-up of 539 female participants of the Chilean Growth and Obesity Cohort recruited from childcare centers (mean age 3.5 years) from the southeast area of Santiago, Chile. Participants were singletons born between 2002 and 2003 within the normal birthweight range. Since 2006, a trained dietitian measured weight, height, waist circumference (WC) and skinfolds to estimate body mass index (BMI) Centers for Disease Control and Prevention percentiles, central obesity, percentage of fat mass (%FM), and fat mass index (FMI, fat mass/height2).

MAIN OUTCOME

Since 2009, sexual maturation was assessed every 6 months to assess age at (1) thelarche, (2) pubarche, (3) menarche, and (4) peak height velocity (PHV).

RESULTS

At thelarche, 12.5% were obese and 2% had central obesity. The median age of pubarche, menarche, and PHV were all associated with markers of adiposity at different time points during childhood whereas thelarche only with %FM and FMI. Adiposity clusters models showed that children with trajectories of high WC, %FM, and FMI during childhood were related with earlier thelarche, pubarche, menarche, and PHV but BMI trajectories only with menarche and PHV.

CONCLUSIONS

Higher WC, %FM, and FMI were associated with earlier age at thelarche, pubarche, menarche, and PHV. The effect of BMI was less consistent.

Immigrant generation status and its association with pubertal timing and tempo among Hispanic girls and boys

PURPOSE

In the United States, Hispanic-Latino children reach puberty earlier on average than non-Hispanic white children. Yet among U.S. Hispanic/Latino children, pubertal timing comparisons between immigrant generations have not been made, hence we examined whether pubertal timing differs by immigrant generational status, independent of BMI and acculturation measures.

METHODS

Cross-sectional data on 724 boys and 735 girls, aged 10-15 years, from the Hispanic Community Children's Health Study/Study of Latino (SOL) Youth, were used to predict the median ages of thelarche, pubarche, and menarche in girls, and pubarche and voice change in boys, using Weibull survival models, while adjusting for SOL center, BMI, and acculturation.

RESULTS

In girls, the first generation began thelarche earlier than second and third generations (median age [years] [95% confidence interval]: 7.4 [6.1, 8.8] vs. 8.5 [7.3, 9.7] and 9.1 [7.6, 10.7], respectively), but began menarche later (12.9 [12.0,137] vs. 11.8 [11.0, 12.5] and 11.6 [10.6, 12.6], respectively). Pubertal timing and tempo for boys did not differ by generational status.

CONCLUSIONS

First-generation U.S. Hispanic/Latino girls had the earliest thelarche, latest menarche and longest pubertal tempo, compared to second and third generations. Factors beyond BMI and acculturation may account for the differences in pubertal timing by generational status of U.S. Hispanic/Latino girls.

A Prospective Study of the Age at Menarche in North Indian Girls, Its Association With the Tanner Stage, and the Secular Trend

Background Menarche is an important event in a female's reproductive health. However, the age at menarche is variable and has implications on the future health of the girl. The purpose of this study was to estimate the mean age at menarche of North Indian adolescent girls and its association with the Tanner stage and to study the trend of menarcheal age in India in the 21st century. Materials & methods A longitudinal descriptive study was conducted on 470 healthy girls aged nine to 16 years in expectant menarche (Tanner stage II). They were followed for six months to check for the attainment of menarche. Those who achieved menarche were grouped in Group I and the rest in Group II. The data were analyzed using the independent t-test. Results Menarche was achieved by 263 girls in the six-month follow-up period. The mean (SD) age of menarche was 13.13 (1.23) years. Group I girls were mostly in Tanner stage IV and above. Group II girls had a mean (SD) age of 11.53 (1.1) years and were mostly in Tanner stage III or below. The estimated decline in the age of menarche in the 21st century was about 0.41 years per decade. Conclusion The girls who achieved menarche had a significantly higher age and Tanner stage of sexual maturity than girls who did not achieve menarche in the study period. Tanner stage is a better measure to estimate the pubertal onset than age. The studies on the age of menarche in the current century reveal that the declining trend in the menarcheal age is continuing in India.

Temporal trends in the physical fitness of Hong Kong children aged 6-12 years between 2003-04 and 2015-16

Low physical fitness in childhood is linked with poor health now and in later life. This study estimated temporal trends in physical fitness for Hong Kong children aged 6-12 years from 2003-04 to 2015-16. Objectively measured body size and physical fitness data for 27,513 children were obtained from four population-representative surveys of Hong Kong primary school students. Temporal trends in means were estimated by population-weighted linear regression. Trends in distributional characteristics were visually described. Overall, there was a small increase in mean height (effect size (ES) = 0.20 (95%CI: 0.13, 0.28)), with a negligible increase (ES < 0.2) in mean body mass. When adjusted for trends in age, gender, and body size, there was a small decline in sit-and-reach performance (ES = -0.43 (95%CI: -0.43, -0.42)), a small improvement in 9-min run/walk performance (9-to-12-year-olds, ES = 0.26 (95%CI: 0.26, 0.27)), with negligible declines in handgrip strength, 6-min run/walk (6-to 8-year-olds), and sit-ups performance. Temporal trends were not always uniform across the population distribution, with declines in run/walk, sit-ups, and sit-and-reach performance generally largest in children with low fitness. Increased national health promotion strategies that address culturally specific factors are encouraged to further improve the existing trends, especially for children with low fitness.

Temporal Trends in the Physical Fitness of Hong Kong Adolescents Between 1998 and 2015

Low physical fitness in adolescence is linked with increased cardiometabolic risk and early all-cause mortality. This study aimed to estimate temporal trends in the physical fitness of Hong Kong adolescents aged 12-17 years between 1998 and 2015. Physical fitness (9-min run/walk, sit-ups, push-ups, and sit-and-reach) and body size data in a total of 28,059 adolescents tested across five population-representative surveys of Hong Kong secondary school pupils, were reported. Temporal trends in means were estimated at the gender-age level by best-fitting sample-weighted linear regression, with national trends estimated by a post-stratified population-weighting procedure. Overall, there were small declines in 9-min run/walk (effect size (ES)=-0.29 (95%CI: -0.32, -0.26)) and sit-ups performance (ES=-0.24 (95%CI: -0.27, -0.21)), with negligible changes in push-ups and sit-and-reach performance. There were small concurrent increases in both mean height and body mass, with a negligible increase in sum of skinfolds. Trends in mean physical fitness and body size/were not always uniform across the population distribution. The small declines in mean 9-min run/walk and sit-ups performance for Hong Kong adolescents are suggestive of corresponding declines in cardiorespiratory fitness and abdominal/core endurance, respectively. Increased national health promotion strategies are required to improve existing trends.

Current Pubertal Development in Chinese Children and the Impact of Overnutrition, Lifestyle, and Perinatal Factors

CONTEXT

Age of pubertal onset has been decreasing in many countries but there have been no data on pubertal development in Chinese children over the last decade.

OBJECTIVE

The primary objective of the study was to evaluate the current status of sexual maturation in Chinese children and adolescents. Secondary objectives were to examine socioeconomic, lifestyle, and auxological associations with pubertal onset.

METHODS

In this national, cross-sectional, community-based health survey, a multistage, stratified cluster random sampling method was used to select a nationally representative sample, consisting of 231 575 children and adolescents (123 232 boys and 108 343 girls) between 2017 and 2019. Growth parameters and pubertal staging were assessed by physical examination.

RESULTS

Compared to 10 years previously, the median age of Tanner 2 breast development and menarche were similar at 9.65 years and 12.39 years respectively. However, male puberty occurred earlier with a median age of testicular volume ≥4 mL of 10.65 years. Pubertal onset did occur earlier at the extremes, with 3.3% of the girls with breast development at 6.5-6.99 years old, increasing to 5.8% by 7.5-7.99 years old. Early pubertal onset was also noted in boys, with a testicular volume ≥ 4 mL noted in 1.5% at 7.5-7.99 years, increasing to 3.5% at 8.5-8.99 years old. Obesity and overweight increased risk of developing earlier puberty relative to normal weight in both boys and girls.

CONCLUSION

Over the past decade, pubertal development is occurring earlier in Chinese children. While the cause is multifactorial, overweight and obesity are associated with earlier puberty onset. The currently used normative pubertal data of precocious puberty may not be applicable to diagnose precocious puberty.