Eight-year-old Amara Purohit was just another happy go lucky child studying in Class 3 at a school in New Delhi when the sudden lockdown was announced in March 2020. But a few months of staying indoors, with little or no physical activity, brought about many changes in her appearance. “She had gained weight but had not grown taller. There were hair in her pubic area, axillary areas and more hair on arms and legs. There was a change in body odour. These tell-tale signs alarmed me, and I went to see the paediatrician as soon as the lockdown was lifted, but it was a tad too late. The girl seems to have hit puberty, albeit a lot early, announced the paediatrician, and as a mother that was terrifying to me,” says her mother Anshula Purohit. The paediatrician referred Amara to a paediatric endocrinologist. The little girl went through the grind of blood tests, ultrasonography, and X-ray to ascertain the actual status of the impact of hormonal changes on her body. The reports weren’t encouraging, and soon, the girl had her first period. But Amara isn’t the only one to have gone through precocious puberty, as it is called in medical terminology, and many others in similar age groups have suffered the same fate. The worst part is that girls are immature to handle the pressure, and the changes in their bodies leave them emotionally wrecked.
Amara’s paediatric endocrinologist Dr Vaishakhi Rustagi says, “Since June 2020, there has been a sudden rise in the cases of early puberty in girls, especially in the urban population. Last year, I saw about 7 to 8 cases of early puberty per week, which has risen to almost two to three cases per day. 40% of the girls who visited me with early puberty were in the age group of 8-9 years. I have close to 150 such cases in my clinic’s database.”
Dr Jugal Gada, an endocrinologist at Bhatia Hospital, Mumbai, adds that in most populations, the mean age of onset of puberty is around 10.5 years in females and 11.5 years in males. “We usually define early puberty if it starts before eight years in females and nine years in males,” says Dr Gada.
A study published in the Italian Journal of Pediatric Medicine in November 2020 studied the increased incidence of precocious and accelerated puberty in girls during and after the Italian lockdown for the COVID-19 pandemic.
The study aimed to evaluate the frequency of precocious puberty and the rate of pubertal progression in girls during and after the lockdown. The results were compared with data for the same period over the last five years. The study considered possible correlations between lockdown conditions and trends in the data. It showed an increased incidence of newly diagnosed central precocious puberty (CPP) and a faster rate of pubertal progression in patients with a previous diagnosis, during and after lockdown compared to last year. The study hypothesised that triggering environmental factors, such as the BMI and the use of electronic devices, were enhanced during the lockdown, stressing their possible role in triggering/influencing puberty and its progression. “However, more studies are needed to determine which factors were involved and how they interacted,” it had noted.
Though there is no study in the Indian context so far, it is evident that even girls in India are hitting puberty at an increasingly early age. Positive family history is recognised as a predisposing factor for early or precocious puberty in a few cases. Sharing her experiences, Dr Sweta Budyal, Senior Consultant, Endocrinologist & Diabetologist, Fortis Hospital, Mulund, says, “There is a sudden surge of girls presenting premature puberty among the age group 6 to 8 years. Astonishingly, these young girls are progressing through the stages of puberty quite rapidly. 50% of all the girls with early puberty who came for consultation during the lockdown had the onset of menstrual cycles, the final stage in pubertal maturation. There is an increased incidence of early puberty and a delayed presentation of the same as well.”
Early tell-tale signs for parents
Raina Adlakha was alarmed by her paediatrician, whom she met in May 2020, for her seven-year old’s stomach pain. “He was shocked to see the premature growth in my daughter. He was quick to refer me to a paediatric endocrinologist who suggested a battery of tests. Her bone age was that of a 10-year-old, and likewise for other parameters. Cumulatively, these hinted towards the onset of puberty in another six months, and there was little time on hand,” says Adlakha.
Forewarned is forearmed, so if the parents are quick to spot the changes in their child’s body, it will help them deal with it better when the need arises and, in some cases, control or arrest the pubertal progression as well.
Many factors affect puberty development, namely: increased adiposity (fat mass), family history, nutrition, and social factors and lastly, ethnicity. “In girls, the earliest sign of puberty is the development of breast (thelarche); few girls start with pubic hair development (pubarche) first. After that, there is an increase in the height spurt with further progress in developing the breast and pubic hair and finally, menarche,” says Dr Gada. On the other hand, Dr Budyal says, “The first and most common indication for most girls is the development of breast buds, which eventually become fuller in the later stages of puberty.”
Another mother, Amita Verma, got alarmed all of a sudden when her skinny eight-year-old had started showing growth in her body. “I went to see the paediatrician. I showed him the hair in her underarms. He quickly sensed that it was a case of central precocious puberty. I hadn’t heard of it before. He told me to see an endocrinologist at the earliest, and I am glad that I did. Her height wasn’t increasing as much but other signs of early puberty were clearly visible,” says Verma.
Any secondary sexual characters such as breast development, hair growth under the arms or in the pubic area before the age of eight years in girls and before the age of nine in boys, and the first period before 10 years are alarming signs. “Development of acne on the face, back or arms or change in body odour before the age of eight in girls and nine in boys is another sign to look for in children. The rapid growth could be indicated by the sudden change in the size of shoes, clothes, and rapid fall of teeth, marking the effect of sex hormones on growth. A sudden increase in hunger can also be a sign of early puberty as growth spurt is associated with increased appetite,” explains Dr Rustagi.
Tests to ascertain early puberty
The first step in assessing such children is to thoroughly go through their health history to help a doctor understand the chronology and time frame of events. “A careful physical examination will further ascertain the puberty stage, its impact on height, and rule off severe brain disorders leading to premature puberty. The procedure essentially involves a battery of hormonal tests, bone age assessment, and pelvic sonography. An MRI of the brain is needed to strike out serious neurological reasons for premature puberty in selected girls,” emphasises Dr Budyal.
Once these results are out, the doctors usually assess the mental and emotional state of the parents and the child to decide the treatment if no secondary causes are found. “The most important part is that there is not much height growth once menarche starts, which becomes the most crucial concern for us. Hence picking these signs early is very important,” says Dr Gada. The parents have an essential role to play here.
Menses usually start within 12 to 18 months from the first sign of puberty. “However, post lockdown, I have seen girls progressing as fast as 8 to 9 months and reaching Menarche,” warns Dr Rustagi.
Dr Gada couldn’t agree more with Dr Rustagi. He says that there has been a trend of earlier menarche in India over the last decade or so, and girls of around 9-10 years are having menarche.
Decoding the process
Puberty begins when the brain starts producing the gonadotropin-releasing hormone (GnRH). This hormone reaches a small bean-shaped gland called the pituitary at the base of the brain. Once there, GnRH triggers the production of more sex hormones. For females, it is estrogen in the ovaries for females and testosterone in the testicles for males.
Dr Rustagi highlights that the causes of early puberty could be because of ingestion of exogenous hormones orally or through the skin. Or it could be because of the internal production of hormones by a sex organ. “Most cases of early puberty are idiopathic, meaning without a cause. However, some children can have causes like tumours in the abdomen or the brain. Here it is vital to differentiate the type of puberty, which further helps decide which child needs treatment,” she says.
However, the doctors are baffled at the cause of the early onset of puberty among children. It’s not clear as to what could be the reason for this phenomenon. “I presume it has something to do with the psychological, emotional, and physical changes in children during the pandemic. The trajectory of this presentation is rapid progression to achieve the final stage of puberty, i.e., menarche with fast physical growth. This, in turn, will cause curtailment of the final height in girls due to the closure of growing ends of the long bones from increased exposure to estrogen,” claims Dr Budyal. On the other hand, Dr Gada observes that one factor that could play a role in this could be the increased prevalence of obesity/overweight and lifestyle changes.
Among the many reasons, the increased screen time and weight gain at a peri-pubertal age among girls drive early puberty. “The pandemic stress has also aggravated the number of cases of early puberty. These patients are avoiding visiting the hospitals and doctors, so they are picked up late, adding to the woes,” rues Dr Rustagi.
To reduce the risk of developing precocious puberty, parents have to encourage the child to eat healthy food, exercise daily and maintain their weight. Another thing to be mindful of is keeping the child away from external sources of estrogen and testosterone, such as prescription medications for adults in the house or dietary supplements containing estrogen or testosterone that could trigger early puberty in children.
Dr Rustagi lists three reasons to seek medical guidance in taking treatment in cases of early puberty. “The first one is to treat the underlying cause such as a tumour, etc. if there are any. The second is to ensure proper height for the child. Third, it is a psychological burden for a child under 10 years to handle menses every month. So we need to look into all of it and make this transition smooth for a child,” says Dr Rustagi.
To check the physical and mental health repercussions of children, Dr Budyal suggests timely evaluation of children by an endocrinologist. Also, the best way to avoid this is to regularly follow up with the paediatrician, and if there are signs of early puberty, the doctors will treat them with the help of an endocrinologist, elucidates Dr Gada.
Adhlakha’s little girl was put on a treatment plan in June 2020 for three years that involved hormonal injections to “pause the onset of puberty.” The treating endocrinologist decided the dosage and duration at which the child was to be given the injection. My daughter received injections at the interval of six weeks initially, and for the last three months, she’s taking it at a gap of three months. “Her height has improved, and from 132 cm last year before the start of treatment, she now stands at 138 cm. The other signs of puberty are also under control,” says the partly relieved mother.
Treatment for early puberty needs attention because it can ensure that the child achieves a good final height and doesn’t go through an emotional upheaval in dealing with bodily changes, which may affect the child’s self-esteem and lead the child into the throes of depression.
Early puberty isn’t a rarity anymore. “It needs early identification by parents and urgent medical attention to prevent any further complications or underlying causes detrimental to the child’s health,” states Dr Budyal.
Nutritionist Voomika Mukherjee says, “Nutrition is one of the most critical factors affecting pubertal development.” It is because…
- Increasing childhood obesity alters the levels of hormones responsible for the acceleration of pubertal timing.
- Physical inactivity may decrease melatonin levels, which can also trigger pubertal development.
- Intake of fluoride in the water supply reduces circulating melatonin and triggers the early onset of puberty.
- High protein intake elevates IGF-1 levels and promotes growth, which could accelerate the onset of puberty.
- Eating foods treated with pesticides and genetically engineered could be a factor as well.
- Using food storage in plastics like Bisphenol A (BPA), a synthetic chemical that acts as a synthetic estrogen, may speed up pubertal development.
- A diet rich in processed foods and fast food is disruptive to normal physical development.
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