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Precocious Puberty: Advice for Referrers

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Precocious puberty may be suspected when secondary sexual characteristics appear in a girl younger than 8 years or a boy younger than 9 years. It may lead to accelerated skeletal development and a reduction in final adult height. It can have a significant psychosocial and physical impact for children and their parents. Most patients do not require extensive investigations, although a sinister underlying causes such as a tumour should always be considered and excluded. Idiopathic (or true) precocious puberty is common in girls. It is rare in boys, therefore it is more important to investigate and find a cause in boys.

Who to refer
  • Girls with signs of puberty presenting under the age of 8 years
  • Boys with signs of puberty presenting under the age of 9 years
Information to include in the history
  1. Ask specifically about different aspects of puberty
    1. Breast enlargement
    2. Penile enlargement
    3. Development of pubic hair
    4. Vaginal bleeding/onset of menarche
    5. Body odour
    6. Mood swings/behaviour changes

  2. Ask about growth and pubertal onset in the parents and any siblings
    1. Parental heights and age at onset of puberty
    2. Age of onset of menarche in the mother
    3. Is the child outgrowing clothes quickly?

  3. Ask about any systemic features, notably those that may suggest a sinister cause/brain tumour:
    1. Headaches
    2. Nausea/vomiting
    3. Vision disturbance
    4. Polydipsia

  4. Ask about medication & social history
    1. Any history of adoption
    2. Child abuse – especially sexual abuse – is a risk factor for precocious puberty
    3. Any exogenous hormone ingestion
Information to include in the examination
  1. Measure the child’s height & weight and plot on growth chart appropriate for age and sex

  2. Tanner staging may be performed if confident (See:Paediatric Pearls: Useful Puberty Charts)

  3. Examine neurological system
    1. Cranial nerves, including fundoscopy and visual fields
    2. Gait

  4. Examine the skin for any lesions associated with genetic syndromes
    1. Café-au-lait spots (Neurofibromatosis, Mc-Cune Albright syndrome)
    2. Axillary freckling (Neurofibromatosis)

  5. Screen for signs of any chronic disease e.g. anaemia, hypothyroidism, and include a general chest/abdominal examination
Suggestions for management whilst awaiting outpatient appointment
  1. Serum oestrogen and testosterone measurement in girls and boys respectively
  2. FSH/LH measurement
  3. Thyroid function tests in cases where other symptoms suggest hypothyroidism
  4. Refer parents/children to resources
Resources for parents
  1. NHS | Conditions | Early or delayed puberty 
  2. Health for Young People | Puberty 

It is important to acknowledge both child and parent concerns and recognise the psychosocial impact of symptoms/signs. Parents may particularly worry about how their child copes in school/social settings and attracting unwanted attention.

References/resources for healthcare professionals
  1. A Staten, P Staten. Practical General Practice: guidelines for effective clinical management (available as an ebook) 7th Edition. Elsevier. 2019.
  2. BMJ Best Practice. Precocious puberty. 
  3. Kaplowitz P, Bloch C et al. Evaluation and Referral of Children With Signs of Early Puberty. Pediatrics. January 2016; 137 (1): e20153732. 
Editorial Information

Last reviewed: 31 January 2024

Next review: 31 January 2027

Author(s): Nike Osifodunrin, Consultant Medical Paediatrics

Co-Author(s): Rafi Ahmed, GPST