In this lecture, we're going to discuss normal and delayed puberty in children.
So in order to understand normal puberty
we should start off with the Tanner stages.
The Tanner stages are stages of puberty development
that we use to measure so that we can also talk
about how developed a patient is in terms of their puberty.
Let’s go through the Tanner stages for boys.
Tanner 1 is no pubic hair at all.
Tanner 2 is the growth of pubic hair typically just a few hairs,
a countable number.
Tanner 3 is easiest to remember as too many to count,
if there is so many pubic hairs you couldn’t count them 50,
a hundred, that’s probably tanner 3.
Tanner 4 is when there is a full amount of pubic hair around the genitalia
but none that’s going up the anus or down unto the thighs.
And tanner 5 is the full adult amount of pubic hair.
You can also notice that the penis is growing and the testicles are growing,
that’s to be expected and the reason
or commoner where you can actually measure size of testis.
Girls progress in a similar manner.
Tanner 1 is no pubic hair, tanner 2 is scanty pubic hair,
tanner 3 is too many to count,
tanner 4 is a full amount of pubic hair around the genitalia,
and tanner 5 is pubic hair
with hair extending down the thighs or up their anus.
In girls, we also score breast development.
These are also called Tanner stages.
And to be clear, if a girl is tanner 3 in her genitalia
that does not necessarily mean she is tanner 3 in her breasts.
Typically, the breasts develop a little bit earlier.
Tanner 1 breast is a normal flat, contiguous areola
with the skin and no breast development at all.
This typically stays this way until about the age of 10.
Then, a patient develops a slight mound and a widening of the areola.
This usually happens between 10 and around 11½.
Then, a child develops what we call mound on mound
where the breast bud is sitting on top of the underlying tissue.
This typically happens around maybe 11½ to 13.
Then the breasts continuous to grow a little bit further.
Develops further, the areola darkens a bit
and this typically happens around the age of 13 to 15.
After 15, we typically expect the fully developed breast which is tanner 5.
So let’s look at some areas where things go wrong.
Where puberty isn't quite going as we would expect
and we might need to make an intervention.
This is the first disorder that I would mention
which is really not a disorder but a variation of normal.
Here’s a child who is 18 months of age, it's a girl.
The mom has brought her in because she has begun growing breasts.
And as I stated before, it's normal to be tanner 2 around the age of 10
and this child is only 18 months of age.
A full exam notes that the child has tanner 2 breasts
but the genitalia are tanner 1.
In other words, there is no pubic hair at all.
This child is growing and developing normal.
The diagnosis here is benign premature thelarche.
This is a benign condition where children start growing breasts very early
but no other signs of puberty are evident.
If this happens,
there’s actually nothing that needs to be done, simply reassurance.
Here’s an example of a child with benign premature thelarche.
You can see the breasts are starting to develop
but this child has no other sequelae of puberty.
So it's a completely benign condition,
breast development is early, there is no genitalia development,
reassurance is indicated, and no testing is needed.