Byline: ELIZABETH SIMPSON, THE VIRGINIAN-PILOT
One Norfolk mother couldn't believe her eyes when she noticed her 6-year-old daughter's breasts starting to develop.
She took the girl to the pediatrician, who referred her to an endocrinologist, Dr. Marta Satin-Smith, at Children's Hospital of The King's Daughters. Satin-Smith prescribed lupron, a hormone that put the brakes on puberty.
The girl's development is definitely on the young side, but not as unusual as once thought.
Pediatric guidelines used to cite the norm for the first signs of puberty in girls - breast development and pubic hair - at 10 or 11. In the 1990s, however, American pediatricians began noticing more patients showing those signs as early as 7, and among black girls, as early as 6.
Dr. Paul Kaplowitz, an endocrinologist at the Medical College of Virginia in Richmond, said his referrals rose sharply during that decade. ``The increase was not in the younger 3- and 4-year-olds, but in the borderline girls who were 6 and 7,'' he said.
Such observations from pediatricians and endocrinologists led to a national study in 1997 of 17,000 girls ages 3 to 12. It found that girls showed signs of development earlier than the guidelines pediatricians were using.
That study - which Norfolk's CHKD participated in - set the usual age for breast development at 9 for white girls and 8 for black girls, and said girls who showed signs a few years younger were still within the normal range. The age of menstruation stayed about the same as that in previous guidelines, at 12 1/2 to 13 years.
Fewer studies have been done on boys because the signs of puberty are more subtle.
The research on girls has drawn national media attention, but experts in the field have not always agreed on what it means. Satin-Smith notes, for example, that the earlier guidelines were based on a 1960s study of British girls, whereas the U.S. population has a much larger proportion of blacks, who - for reasons yet to be fully understood - tend to go through puberty earlier.
But there is little disagreement about one trend influencing the onset of puberty: America's increase in overweight children.
The 1997 study of American girls found that larger and heavier girls developed breasts and pubic hair earlier than their thinner peers.
Kaplowitz believes this might explain what he sees as a dramatic increase in younger girls going through puberty during the past decade.
Dr. Glenda Karp, too, believes girls are exhibiting signs of puberty earlier than a decade ago. When she began her work as a pediatrician 18 years ago, about one in eight girls would show breast and pubic hair development before the age of 8. Now it's more like one in seven, and for black girls, one in three.
She said she believes these girls should be encouraged to hang on to their childhoods for as long as possible.
``The people around them and their friends need to respect them for who they are, and not how they look,'' said Karp, who practices at Tidewater Children's Associates in Virginia Beach and Chesapeake. ``We're bombarded by MTV and sexually explicit advertising, so you have a 7- or 8-year-old who wants to look like Britney Spears, and now she has the body to do it.''
Karp advises parents to talk to their children early about puberty changes - particularly if they see their daughters developing breasts - but to insist that they dress and act appropriately for their age rather than their development.
``When they're 7 and 8, they need to be establishing their confidence, making friendships with other girls, instead of talking about becoming a woman. If they start their periods, we should be saying, `You're a young girl who got her period sooner than most,' instead of saying, `Now you're a woman.' ''
Another local pediatrician, Dr. Robert Johnson, said girls he's treated in Virginia Beach and Norfolk over the past 20 years have shown little change in the onset of puberty.
But Ingried Price-Albee confronts the issue daily in her workplace. She's a Norfolk Health Department nurse based at Jacox Elementary School, which serves children through the fifth grade.
She believes girls are developing sooner than they did at her age. ``I remember being flat as board until forever. I thought I was never going to get my menstrual period.''
Today, though, it's not uncommon for her to see 8- and 9-year-old girls who are developing breasts, whose hips are rounding, and who look more provocative than their flat-chested classmates.
Older boys are paying more attention to them, and sometimes the girls play along and tell them they're older than their true age.
``They have adult bodies, but their minds are young,'' Price-Albee said. ``They are not mature emotionally or socially.''
She keeps a stash of sanitary pads for girls who begin their first periods at school, an event that's not at all unusual among fourth-graders.
First, she gets permission from the parents to talk with the girls about starting their period. ``Ninety-eight percent of the time, they want you to go ahead and talk with them.''
Still, fourth-graders have a hard time understanding. ``Some of them don't have a clue as to what's really going on.''
She said puberty is usually explained in family life education in the fifth grade.
The studies on puberty, and subsequent media attention, have fueled much debate over the reasons why some girls might be experiencing puberty earlier than expected. Many theories have been floated.
Some scientists have studied whether pesticides in foods and chemicals in plastics could break down compounds that spur estrogen, or mimic hormones that trigger the start of puberty. Another theory points to milk and beef from livestock fattened with growth-stimulating hormones. There's even been speculation over whether sexualized messages in today's MTV media culture jump-start hormones.
Satin-Smith and Kaplowitz say the rise in overweight children is the theory with the most scientific backing, although the reasons remain unclear.
One possibility is that fat cells produce a protein called leptin that may encourage early breast development. Also, higher levels of insulin could stimulate sex hormones.
Satin-Smith said the new standards for what constitutes precocious puberty have made referrals more difficult. Previously, children under 8 would almost automatically be put on the hormone lupron. Now it's done on a case-by-case basis.
A study by Kaplowitz published in 1999 in Pediatrics says that girls who are 6 to 8 and showing signs of development should not be considered abnormal. He believes that hormone treatments, which cost $6,000 to $10,000 a year, are usually unnecessary for these girls. They typically will start menstruating two or three years later, giving parents plenty of time to prepare their children for the event.
``I've found that once parents know it's not outside the normal range, they have a more relaxed attitude about it,'' he said.
When young girls are referred to Satin-Smith, she first screens them for medical problems, such as tumors in the reproductive system or brain, that could be throwing off normal hormone production.
If a girl is simply showing signs of early puberty, Satin-Smith talks with
the family about the options. One concern has been that children who go through puberty early may have fewer years to gain height. Kaplowitz, however, said there's little evidence to show that such girls fail to reach normal height by adulthood.
The emotional status of a girl also must be considered. One study showed that girls who enter puberty early experience more emotional problems than those who don't.
``If it's an 8-year-old girl going through puberty who can handle it and doesn't have a problem looking womanly and having a period at 10, then there's no need to put her on lupron,'' said Satin-Smith, who is also an assistant professor of pediatrics at Eastern Virginia Medical School.
However, not all girls meet that standard.
The Norfolk mother of the 6-year-old early bloomer said the lupron gave her daughter some needed years to mature emotionally. And there have been few side effects from the monthly hormone injection.
In about five months, the girl, who is now 9, will be taken off the lupron.
Reach Elizabeth Simpson at 446-2635 or liz@pilotonline.com
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