Peds

Question 1

thelarche

Answer 1

is the appearance of breast tissue

Usually the first and most obvious sign of early puberty

Question 2

Adrenarche

Answer 2

is the activation of the adrenal cortex for the production of adrenal androgens, and typically occurs before the onset of puberty.

Pubic and axillary hair may appear before, at about the same time, or well after the appearance of breast tissue

Question 3

menarche

Answer 3

is the age of onset of the first menstrual period – later in puberty

Question 4

Pubarche

Answer 4

is the appearance of pubic hair, but sometimes used interchangeably with adrenarche

Question 5

race and pubertal timing

Answer 5

African American girls begin puberty earlier than Caucasian girls

Question 6

measurement of male genitalia

Answer 6

: early sign of puberty: testicular length is more than 2.5 cm or testicular volume (with Prader orchidometer beads) is 4 mL or more

Question 7

when does puberty begin?

Answer 7

Age 8 for girls
Age 9 for boys

• early puberty is seen in girls with increased BMI and often more in black girls

Question 8

girls breast development stages:

Answer 8

Stage 1
prepubertal

Stage 2

- Breast bud stage with elevation of breast and papilla
- enlargement of areola

Stage 3

- Further enlargement of breast and areola
- no separation of their contour

Stage 4
Areola and papilla form a secondary mound above level of breast

Stage 5
Mature stage: projection of papilla only, related to recession of areola

Question 9

tanner for girls pubic hair

Answer 9

Stage 1
prepubertal

Stage 2
Sparse growth of long, slightly pigmented hair, straight or curled, along labia

Stage 3
Darker, coarser and more curled hair, spreading sparsely

Stage 4
Hair adult in type, but covering smaller area than in adult; no spread to medial surface of thighs

Stage 5
Adult female in type and quantity, with horizontal upper border

Question 10

tanner for boys pubic hair

Answer 10

Stage 1
prepubertal

Stage 2
Sparse growth of long, slightly pigmented hair, straight or curled, at base of penis

Stage 3
Darker, coarser and more curled hair, spreading sparsely

Stage 4
Hair adult in type, but covering smaller area than in adult; no spread to medial surface of thighs

Stage 5
Adult male in type and quantity, with horizontal upper border

Question 11

tanner for boys external genitalia

Answer 11

Stage 1
prepubertal

Stage 2
Enlargement of scrotum and testes; scrotal skin reddens and changes in texture

Stage 3
Enlargement of penis (length at first); further growth of testes

Stage 4
Increased size of penis with growth in breadth and development of glans; testes and scrotum larger, scrotal skin darker

Stage 5
Adult genitalia

Question 12

best way to evaluate precocious puberty

Answer 12

evaluate with bone age

Question 13

incomplete precocious puberty

Answer 13

Premature pubarche and premature thelarche are two common, benign, normal variant conditions that can resemble precocious puberty but are nonprogressive or very slowly progressive.

• Premature thelarche refers to the isolated appearance of breast development, usually in girls younger than 3 years; (under 3 is usually ok, if there is nothing else going on - above age 4 is problematic )
• Of note, 10% of girls with benign idiopathic thelarche eventually develp true central precocious puberty requiring treatment
• premature pubarche refers to appearance of pubic hair without other signs of puberty in girls or boys younger than 7-8 years (usually progression is slow, so ultimate height is okay)

Question 14

central precocious puberty

Answer 14

Gonadotropin-dependent–> have activated the whole HPA axis change

• ** Idiopathic central precocious puberty > 80 percent (a diagnosis of exclusion) - if girls have it, its usually not a big deal : almost all idiopathic cases occur in girls
• ** boys, if they have precocious puberty, need to investigate for a tumor

CNS abnormalities:

• hypothalamic hamartomas: benign tumors that secrete GnRH
• tumors
• CNS injury
• congenital anomalies

Question 15

how to determine central vs peripheral Central precocious puberty

Answer 15

Central precocious puberty can be distinguished from peripheral precocious puberty by measuring LH levels.

In central precocious puberty (GDPP), basal LH levels are often elevated into the pubertal range and show a pubertal (heightened) response to GnRH stimulation.

In peripheral precocious puberty (GIPP), the LH level is low at baseline and fails to respond to GnRH stimulation.

Question 16

findings of precocious puberty in girls

Answer 16

breast enlargment is usually the first and most obvious sign

pubic and axillary hair may appear before, at about the same time, or well after the appearance of breast tissue

axillary odor, growth spurt, enlargment of the clitoris (indicates sig. androgen excess), mild acne

Question 17

boys change in prevovious puverty

Answer 17

The earliest sign of central precocious puberty (CPP) is enlargement of the testes, which depends on increased production of follicle-stimulating hormone (FSH); testicular length is more than 2.5 cm or testicular volume (with Prader orchidometer beads) is ***4 mL or more

other signs:
- penis growth, reddening and thinning of scrotum, increaseed pubic hair, growth spurt, acne, voice change

Question 18

peripheral precocious puberty

Answer 18

1/5 as common

ovarian cysts and tumors: large functioning follicular cyst of the ovaries is the most common cause of peripheral precocious puberty in girls

testicular/leydig cell tumors

adrenal gland tumors

Question 19

what are androgenic effects?

Answer 19

Acne, hirsutism, increased muscle mass, and clitoromegaly in females –> will focus the differential diagnosis toward androgenic causes of precocious puberty.

Question 20

esetrogenic effects?

Answer 20

Breast development and changes in the vaginal mucosa are signs of estrogen exposure.

Question 21

what is the first step in the work up for precocious puberty?

Answer 21

bone age - evaluate nondominant hand and wrist

• helps determine if should be treated or not, if their bone plates have already fused, won’t be able to change their height

Question 22

what labs are done with precocious puverty?

Answer 22

stimulate GnRH stimulation test to see if there is an increase in LH

in GIPP: , the LH level is low at baseline and fails to respond to GnRH stimulation.

In central: basal LH levels are often elevated into the pubertal range and show a pubertal (heightened) response to GnRH stimulation.

Question 23

what to worry about for boys younger than 9 w/ PP?

Answer 23

The younger the child with central precocious puberty, the greater the chance of finding CNS pathology (among children younger than 6 years).

*** For boys younger than 9 years, the incidence of CNS findings is much higher than in girls, and MRI should be part of the evaluation.

Note: For healthy girls aged 6-8 years with no signs or symptoms of CNS disease, the likelihood of finding a tumor or hamartoma is only about 2%; therefore, this test may be unnecessary depending on the clinical situation.

Question 24

treatment for central precocious puberty

Answer 24

Primary goal of treatment for GDPP is to allow a child to grow to a normal adult height.

Medical:
GnRH analogs or agonists
Example: Leuprolide
- Increases final adult height

Question 25

hypothalamic hamartoma

Answer 25

Classically a triad of precocious puberty, developmental delay, and seizures

prognosis has impiroved over the last 20 years

Question 26

• tanner staging of breast
• tx of central precocious puberty
• african american girl
• benign thelarchy
• investigate boys
• central vs. peripheral

Answer 26

8 questions total