Continuing Education Column Observed Trends for an Earlier Onset of Puberty: When is the Need for Treatment Indicated? Jae Hyun Kim, MD Choong Ho Shin, MD Department of Pediatrics, Seoul National University College of Medicine E - mail : chshinpd@snu.ac.kr Seong Yong Lee, MD Department of Pediatrics, Boramae Medical Center J Korean Med Assoc 2009; 52(12): 1189-1200 Globally, there is a secular trend toward earlier puberty and an increased final height at adulthood. In Korea, there is a trend toward an earlier menarche in girls but insufficient data to evaluate secular trends in boys. A significant increase in height was observed in Koreans aged 0~20 years during 1965~2005. This trend has diminished, but growth maturation has accelerated in infants and young children. Genetic and environmental factors including nutritional status (e.g., obesity) contribute to these changes. Central precocious puberty results from the accelerated activation of the hypothalamic-pituitary-gonadal axis. Although the cut-off age is controversial, clinical evaluations should be conducted on girls with pubertal onset occurring younger than 8 years, and on boys younger than 9 years at least until further prospective studies define the norms for Korea. Management of precocious puberty depends on the underlying etiology, as accelerated puberty can lead to a reduced final adult height. Depot forms of GnRH agonists (GnRHas) are the standard treatment for some patients with central precocious puberty. These agents can help restore the normal adult height in both girls and boys when it might be compromised by rapidly progressive precocious puberty. However, in girls with slowly progressive precocious puberty or with the onset of puberty at 8~9.9 years of age (early normal puberty), GnRHa treatment might offer no benefit for attaining normal height. There is little evidence on whether psychosocial problems are associated with precocious puberty or are improved by GnRHa treatment. Keywords: Puberty; Secular trend; Precocity Abstract 1189
Kim JH Lee SY Shin CH Figure 1. Hormonal changes during puberty. Abbreviations: CNS, central nervous system; LH, luteinizing hormone; LHRH, LH releasing hormone; GH, growth hormone Figure 2. Distribution of timing of puberty in different condition. 1190
Observed Trends for an Earlier Onset of Puberty: When is the Need for Treatment Indicated? 1191
Kim JH Lee SY Shin CH Table 1. Korean data about menarcheal and brest development mean age (year) BII Menarche GII Pub_year Inv_year Case No. Subjects Method Hong, et al (18) 11.0 12.7 1994 1992~1994* 6,586 ES Gr 4-HS Gr 2 Dr's palpation 12.8 recall Kim, et al (19) 12.4 1997 1993~1995 4,768 MS Gr 1~3 recall Park, et al (20) 11.3 12.1 2006 2002 982 ES Gr 4-HS Gr 1 self report 12.0 recall 12.4 119 Un Gr 1~4 recall KNHNES III (21) 11.7 2006 2005 59 Age 7~12 recall 13.2 375 Age 13~19 13.9 558 Age 20~29 14.7 1,647 Age 30~49 16.2 781 Age 50~64 16.8 597 Age 65~ *Invesgation year was assumpted: supported by research fund in 1992, and published in 1994 Abbreviations: Pub_year, publication year; Inv_year, year of investigation; ES, elementary school; MS, middle school; HS, high school; Un, university; BII, breast sexual maturation rate II; GII, genital sexual maturation rate II; Dr, doctor; KNHNES III, The third Korea national health and nutrition examination survey, 2005 1192
Observed Trends for an Earlier Onset of Puberty: When is the Need for Treatment Indicated? Table 2. Secular trend of final height and puberty in Korea and Netherlands Female Male Korea (34) Year 1965 1984 1997 2005 1965 1984 1997 2005 Mean final height (cm) 155.9 157.1 160.4 161.3 168.7 170.2 173.4 174.2 Mean height (cm) 81.5 84.6 87.0 89.0 82.7 85.5 87.9 90.4 at 2 years of age Netherlands (2, 17) Year 1965 1980 1997 1965 1980 1997 Mean final height (cm) 166.3 168.3 170.6 178.0 182.0 184.0 BII or GII age (yr) 11.0 10.54 10.72 11.0 11.33 11.45 BV-BII or GV-GII (yr) 4.2 3.7 3.6 4.9 4.0 3.8 Menarcheal age (yr) 13.40 13.28 13.15 Abbreviations: BII, breast sexual maturation rate II; GII, genital sexual maturation rate II; BV, breast sexual maturation rate V; GV, genital sexual maturation rate V 1193
Kim JH Lee SY Shin CH A B Figure 3. Secular trend in mean height from 1965 to 2005 in Korean girls (A) and boys (B). A B Figure 4. Secular differences corrected by investigation interval in mean height between 2005 and 1997 (shaded bar, solid line), and between 1997 and 1984 (open bar, dotted line) in Korean girls (A) and boys (B). 1194
Observed Trends for an Earlier Onset of Puberty: When is the Need for Treatment Indicated? A B Figure 5. (A) Height velocity for American boys. Dash line, 50th centile for boys 2 SD of tempo early; chain line, 50th centile for boys 2 SD of tempo late, respectively (36). (B) Secular trend in the mean peak height velocity for boys based on the Swedish longitudinal studies (2). 1195
Kim JH Lee SY Shin CH Figure 6. Adult height of in girls treated with GnRH agonist for progressive central precocious puberty. Abbreviations: TH; target height, ipah; initial predicted adult height before treatment, FH; final adult height 1196
Observed Trends for an Earlier Onset of Puberty: When is the Need for Treatment Indicated? Figure 7. Adult height of in girls with early puberty. Abbreviations: TH, target height; ipah, initial predicted adult height before treatment; FH, final adult height; Th(+), treated with GnRH agonist; Th(-), without treatment 1197
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