C L I N I C A L R E P O R T O V E R V I E W
Understanding Early & Precocious
Puberty in Children
01
How would clinicians define early/precocious puberty? How is it usually diagnosed?
Early puberty refers to the onset of puberty before the usual age range.
Precocious puberty is specifically when puberty begins before age 8 years in girls and before age 9 years in boys.
Clinicians typically define puberty based on physical changes such as the development of breast tissue (thelarche) in girls and testicular enlargement in boys. Other signs include growth spurts, pubic or underarm hair, and in girls, menarche (the first menstrual period).
Diagnosis usually involves a physical examination and a bone age X-ray, which helps assess how much the child’s bones have matured compared to the usual degree expected for their chronological age. Blood tests to measure hormone levels, particularly gonadotropins (LH, FSH) and sex hormones (oestrogen, testosterone), may also be performed. In some cases, an MRI of the brain may be done to rule out underlying central causes, like a tumour.
02
Have you seen an increase in the number of children with early/precocious puberty? Could you share some relevant figures?
Yes, there has been an observed increase in the number of children experiencing early puberty; although figures vary by region, studies have shown that the average age of onset for puberty in girls has declined over the past few decades.
For example, in the U.S., a study published in Pediatrics in 2017 found that 5.5% of girls had breast development by age 7, compared to 1% in the 1990s.
In Singapore, more cases of early puberty have been reported, particularly in girls, although exact national figures are harder to come by. The increase is likely due to a mix of environmental, nutritional, and possibly genetic factors.
03
Why is early puberty a concern and how is it usually treated and/or managed?
Early puberty can cause a range of concerns:
Psychosocial impact: Children may struggle with body image issues and peer relationships, as their physical development may take place earlier than their emotional maturation. Girls may also face teasing if their breasts develop significantly before their peers.
Physical health risks: Premature closing of the growth plates in bones can result in shorter stature as adults. Early puberty may also be linked to an increased risk of certain conditions like breast cancer later in life, though this is still an area of ongoing research.
Treatment often involves medications to delay further puberty:
GnRH agonists (like leuprorelin) can suppress the production of sex hormones, effectively delaying further development until the child reaches a more typical age for puberty.
In some cases, the underlying cause, such as a brain tumour, might need to be treated.
04
Have you also noticed children showing signs of puberty earlier than before (even if they're not young enough for it to count as early puberty)? Would you say this is an observable trend in Singapore?
Yes, many parents and clinicians have noted earlier signs of puberty, such as body odour, early growth spurts, or the appearance of body hair. These signs may not be classified as true precocious puberty, but they do indicate earlier maturation than was typical in the past.
In Singapore, as in many parts of the world, there seems to be a trend of earlier onset, especially in girls. This is often attributed to factors like increased body weight and fat percentage, which may trigger earlier puberty, as well as environmental exposure to endocrine-disrupting chemicals (e.g., certain plastics, chemicals in cosmetics, and food).
05
On average, at what age do a) boys and b) girls show signs of puberty in Singapore? How does this compare with other countries?
Girls in Singapore typically begin puberty between 8-9 years of age, with the onset of breast development being the first sign.
Boys in Singapore usually begin puberty around 9-10 years of age, with an increase in testicular size and the appearance of pubic hair being early indicators.
Globally, the average onset of puberty has shifted earlier in many places. In the U.S. and Europe, girls often begin puberty around age 8, and boys around 9-10. However, in some parts of Asia, puberty may still begin later, though this is becoming less common.
06
What are the factors that may cause children to hit puberty earlier?
Several factors contribute to early puberty:
Obesity: Higher body fat can increase the production of oestrogen and other hormones, triggering puberty.
Genetics: Family history plays a significant role. Girls with a mother who had early puberty are more likely to experience it themselves.
Endocrine-disrupting chemicals (EDCs): These chemicals, found in plastics, pesticides, and some personal care products, can mimic hormones in the body.
Psychosocial stress: Stressful childhood environments (e.g., family dysfunction, abuse) can trigger early puberty in some cases.
Health conditions: Certain health conditions, such as hypothyroidism or central nervous system abnormalities, may trigger premature puberty.
07a
I've heard from some parents that they avoid feeding their children frozen chicken from certain countries because they believe that the use of growth hormones in raising the chickens might cause their kids to hit puberty earlier. What's your take on this?
The concern about growth hormones in poultry is understandable but generally misguided.
In many countries, including Singapore and the U.S., the use of hormones to promote growth in poultry is banned.
However, some antibiotics and other substances may still be used in poultry farming, but these are unlikely to directly cause early puberty. The concern is more about the potential endocrine-disrupting chemicals in food packaging or environmental pollutants, rather than hormones used in animal feed.
07b
Besides avoiding chickens with growth hormones, what can parents do if they would like to reduce the risk of their kids hitting puberty earlier?
Parents can take a few proactive steps:
Encourage a balanced, healthy diet: Focus on whole foods, reducing processed foods and those high in sugar and unhealthy fats. Maintaining a healthy weight is crucial.
Limit exposure to endocrine-disrupting chemicals: This includes avoiding plastic food containers (especially those labelled with recycling codes #3, #6, and #7) and choosing organic produce when possible.
Promote physical activity: Regular exercise can help maintain a healthy weight and reduce stress, which is also important for hormonal balance.
Mind the environment: Reducing exposure to environmental toxins, such as those found in personal care products, can be helpful.
08
What are the physical and mental health implications for children hitting puberty at an earlier age?
Physical implications:
Shorter stature: Due to earlier closure of the growth plates in bones.
Increased risk of certain cancers: Early puberty is linked to a slightly higher risk of developing breast cancer in women.
Obesity: Hormonal changes can lead to weight gain, and obesity itself can exacerbate the early onset of puberty. This in turn leads to a risk of developing other chronic diseases like type 2 diabetes mellitus, hyperlipidaemia, hypertension and obstructive sleep apnoea.
Mental health implications:
Body image issues: Children may feel uncomfortable with their early physical development, leading to low self-esteem or even depression and anxiety.
Social and emotional difficulties: Early-maturing children may struggle with peer relationships if their bodies develop faster than their emotional maturity, potentially leading to isolation or bullying.
09
What are some signs that should prompt parents to seek help for their children's puberty issues?
Parents should seek help if they notice:
Puberty signs before age 8 years in girls or 9 years in boys.
Unusually rapid growth or development.
Physical changes that seem out of sync with the child’s emotional development.
Physical changes that do not follow the normal sequence of puberty (eg menses without breast development in girls)
10
Could you provide a takeaway message for our readers regarding kids hitting puberty earlier? What would you like for them to be aware of?
The trend of children hitting puberty earlier is a growing concern for parents and clinicians alike. While there are many contributing factors, including lifestyle and environmental influences, early puberty does not always require immediate medical intervention. However, it’s important for parents to stay vigilant. Focus on a healthy diet, regular exercise, and limit exposure to harmful chemicals, and seek medical advice if you notice signs of early puberty or if your child seems emotionally or socially affected by their physical development. Lastly, keep in mind that early puberty is not only a physical change—it can also affect your child’s mental and emotional well-being. Open communication and support are essential to helping them navigate this challenging stage of life.