Do you think your child is growing up a little late compared to other children his age? Sometimes it can be. That is, a child starts puberty later than the age that is usually expected. This is what we call delayed puberty or "delayed puberty". Some people also call it "delayed sexual development". Just like some flowers bloom a little late, some children may be a little "late bloomer". But this is not just a late start. Sometimes puberty can start right away, then stop, or go very slowly. Then the child does not complete all the stages of puberty as expected. It is normal to feel a little scared when you hear about this, but when we know exactly about it, many problems can be solved.
So, at what age is puberty considered late?
This actually varies slightly between girls and boys. Here's how doctors explain it:
Delayed puberty in girls means:
- If your breasts haven't started developing by the age of 13.
Or,
- If you have not started menstruating by the age of 15, or if you have not started menstruating three years after your breasts started developing.
Delayed puberty in boys means:
- If the testicles have not started to enlarge by the age of 14.
Or,
- Even if it has been at least five years since the testicles began to enlarge, puberty has not yet been completed.
Don't be alarmed by these age limits. These are just general guidelines. If you have any concerns about your child, it's best to talk to a pediatrician.
What are the symptoms of delayed puberty?
The main symptoms are breast development (in girls) and testicular development (in boys). However, there may be other things:
- Your child may be shorter than expected for their age. This is because they have not yet experienced the "growth spurt" that usually occurs during puberty.
- A child's bones may not have matured as expected for their age. This is called "delayed bone age." Only a doctor can tell for sure, and it requires an X-ray.
- Lack of pubic hair growth in the child's private area.
But here's the thing. Some children may have pubic hair, but they may still be considered late to puberty. They may also start to develop armpit hair or body odor. These symptoms are part of a natural process called adrenarche. This is what happens before puberty. The hormones that help trigger adrenarche are different from the hormones that control puberty. So, even if your child goes through adrenarche, they may not start puberty when expected.
What is the main reason for delayed puberty?
Often, the main reason for delayed puberty is genetic. That is, it may be something that other children in the family have had as well. Some children get the message through their genes that puberty will start a little later. There is nothing wrong with the child's organs, glands, or hormones. Everything is in working order. Simply put, your child's body is just working on a different schedule than other children.
Doctors call this `(Constitutional Delay of Growth and Puberty)` or `(CDGP)`. Some doctors also call it `(self-limited delayed puberty)`. This is because, even without any medical treatment, puberty occurs at the scheduled time and progresses normally. Imagine, if the father or uncle of the family grew up a little late, there is a small chance that the child will also do the same.
However, sometimes other conditions in a child's body can affect the onset and progression of puberty. Delays due to these causes usually require treatment.
Other causes of delayed puberty
Aside from genetics, there could be a number of other reasons. Check out this list:
- Addison's disease
- Chronic kidney disease
- Cystic fibrosis
- Genetic diseases, such as chromosomal abnormalities such as Turner syndrome and Klinefelter syndrome.
- Excessive exercise. This can lead to a significant decrease in body fat and disrupt hormonal function. (This is especially important for young children who play competitive sports.)
- Growth hormone deficiency
- Hypothyroidism (underactive thyroid)
- Inflammatory bowel disease (IBD)
- Malnutrition can occur for a variety of reasons. This can also be affected by things like eating disorders.
- Certain medications or treatments, such as corticosteroids, chemotherapy, or radiation therapy.
- Accidents or damage to the child's brain or gonads (ovaries or testicles).
- Tumors affecting the child's brain or spinal cord.
- Type I diabetes.
You might wonder how all these different things affect puberty. The answer lies in hormones.
The role of hormones in delayed puberty
Hormones are like our bodies' secret messengers. They're the ones who work behind the scenes to initiate and sustain puberty. These hormones are produced by endocrine glands. Your child may notice changes in their body, like breast development or the growth of hair under their arms. But there are some things you won't see:
1. Gonadotropin-releasing hormone (GnRH) is produced and released from a part of your baby's brain called the hypothalamus.
2. This hormone `(GnRH)` tells the pituitary gland in the child's brain to produce and release luteinizing hormone `(LH)` and follicle-stimulating hormone `(FSH)`. Together, these two are called gonadotropins `(gonadotropins).`
3. These gonadotropin hormones are what tell the baby's gonads (ovaries in girls and testes in boys) to release sex hormones (estrogen or testosterone).
4. It is the release of these sex hormones that causes the physical signs of puberty, such as breast development and testicular development.
This is like a big team working together, right? If something happens to one team member, it affects the whole team. Doctors use terms like these to explain what's going on behind the scenes:
- Hypogonadotropic hypogonadism: This means that a child's hypothalamus or pituitary gland is not working properly. They do not produce or release enough hormones. This is often caused by a medical condition. Once doctors treat the condition, puberty will begin to occur normally. Excessive exercise and malnutrition are also common causes.
- Hypergonadotropic hypogonadism: This is when a child's hypothalamus and pituitary gland are working properly. However, their gonads (testicles or ovaries) are not working properly. This happens in children with Turner syndrome and Klinefelter syndrome. This condition can occur as a side effect of cancer treatment or for other reasons.
Although these words may seem a bit complicated, in simple terms, what this means is that the problem lies in where in the hormonal control system it is.
How do doctors diagnose this condition?
Doctors do the following to diagnose delayed puberty:
- Doing a physical examination.
- We will talk to you about your child's medical history and the family's (biological parents') medical history.
- Some tests are being done.
One thing doctors will mainly look for is whether there is a family history of delayed puberty. If so, your child may also be a "late bloomer," meaning there may be no underlying medical cause for the delay.
However, even if doctors think it runs in the family, they often do tests to make sure there are no other causes. This is because doctors call ``Constitutional Delay of Growth and Puberty (CDGP)`` a ``diagnosis of exclusion.`` That is, they conclude that it is ``(CDGP)`` only after confirming that all other causes are excluded.
These tests are very important even in cases where there is no family history and when doctors are trying to find the cause.
Tests to detect delayed puberty
You can do tests like this:
- Blood tests: Check hormone levels and see if there are any signs of certain medical conditions.
- Genetic testing: Check for genetic changes that may cause delayed puberty.
- Imaging tests: Things like an MRI scan or ultrasound scan are done to confirm or rule out certain conditions.
Your family pediatrician may refer you to a pediatric endocrinologist or other specialists to help diagnose and treat this condition.
How is delayed puberty treated?
Treatment depends on the cause of the delay. Your child's medical team may recommend the following:
- A "wait and see approach": This is usually followed for young children who have no medical conditions or other known reason for the delay. Doctors will see if puberty can begin naturally. If so, your child will likely not need any treatment, and puberty will occur as expected.
- Treating medical conditions: If the delay is due to a specific condition, doctors will treat that condition. This should help puberty begin and progress as expected.
- Hormone replacement therapy: If a child's body is not producing enough hormones (testosterone or estrogen) to reach puberty, they may need medication to provide those hormones. Your medical team will explain to you how long hormone therapy is needed based on your child's specific needs.
Children who are "late bloomers" without any medical reason do not need hormone therapy. However, if the delay in puberty is very stressful for the child, it may be an option. Some young children find it difficult to wait until puberty, and this delay can cause social problems and affect their self-esteem. If you are concerned that this is happening to your child, talk to your medical team about it.
When should I seek medical advice for my child?
Take your child for regular well-checks, and share any concerns you have with your pediatrician. They will check your child's growth and development and may ask you questions about your family history. Your pediatrician will explain what tests and follow-up are needed if your child has not started puberty as expected.
Take care of your child's mental health too.
Delayed puberty can have a big impact on your young child's mental health – but it's also a time when they're already dealing with a lot of emotions and changes. It might be a good idea to arrange for your child to talk to a therapist. Counseling can help your child talk through their feelings about puberty and other things they're thinking about and work through them. They may think, "All my friends are grown up and I'm the only one who's still young." They need support at times like these.
What questions should I ask my child's doctors?
Puberty is a unique experience for every child, whether it comes "on time" or later than expected. Your pediatrician and any specialists who provide treatment can share information specific to your child. Here are some questions you can ask to start the conversation:
- How do I know if my child has started puberty?
- How do I know if puberty is not progressing as expected?
- Does my child have delayed puberty? If so, what are the signs?
- Does my child need any tests?
- Do you recommend any treatment?
- How can I best support my child?
What should I expect if my child has delayed puberty?
Your child's medical team will tell you what to expect, based on the cause of the delay in puberty and any treatment your child receives. It's hard to say exactly when puberty will start. Young children with ``Constitutional delay of growth and puberty (CDGP)'' usually start puberty by age 18. However, your child may start much earlier. Every child's experience is different.
Just remember, delayed puberty is temporary and can be treated if needed.
Does delayed puberty increase height?
It's hard to say exactly how delayed puberty will affect your child's adult height. Some young children reach a shorter adult height than would be expected based on their biological parents' height. However, for other young children, delayed puberty doesn't seem to affect their adult height.
Doctors sometimes do a "bone age" test (X-ray) to get an idea of a child's adult height. Your pediatrician can tell you more about this test and what it shows.
Does using melatonin delay puberty?
Melatonin may delay puberty, but more research is needed to know for sure. Researchers are still studying the side effects of melatonin treatment in children and young adults. Talk to your pediatrician about the pros and cons of giving your child melatonin.
Finally, things to remember (Take-Home Message)
Delayed puberty can be stressful for both you and your child. You may be worried about your child, or you may wonder why their development is delayed. Remember, every child is on their own path. Your child may reach puberty when their body is ready. Or, their body may need a little help getting there. However, your pediatrician can help you figure out what's going on and recommend the best approach.
During this time, your child may have many concerns of his own – from fitting in with peers to feeling confident about his appearance. Ask your pediatrician how you can best support your child's emotional needs. Also, keep the door open for your child to talk to you anytime they are feeling sad or upset. Even a little cuddle or a note saying "I'm proud of you" can go a long way at this time.
` Delayed Puberty, Hormones, Child Health, Adolescence, Growth, Sexual Development
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