Referral Guidelines are peer reviewed guidelines developed to assist referring providers in their approach to a patient presenting with common signs or symptoms suggestive of an endocrine condition, and when to refer to Pediatric Endocrinology.
Symptoms/signs:
Before age 8 yrs (female) or 9 yrs (male):
- Pubic hair (coarse, curly)
- Axillary hair
- Body odor
- Absence of breast tissue development, vaginal discharge (in girls) or penile enlargement, scrotal development, testicular enlargement (in boys)
Other considerations:
- Absence of growth acceleration
- Family history of early puberty
- Exogenous exposures to androgenic hormones
- Increased prevalence with obesity and specific ethnic groups
Refer to differential diagnosis section
Blood tests:
- DHEAS
Radiologic studies:
- Bone age x-ray
Other tests to consider after consultation with Pediatric Endocrinology:
- 17OH progesterone*
- LH*
- FSH*
- Total testosterone*
*Pubertal laboratory tests should be obtained in the early AM using sensitive pediatric assays only
Urgent:
- Significantly elevated DHEA-S for age
- Bone age greater than 2 SD above chronologic age
- Signs of rapid virilization
Routine:
- normal labs and bone age within 2 SD of the norm for chronologic age
- Previous growth data/growth charts
- Pertinent medical records
- Recent laboratory and radiologic studies (including actual copy of bone age)
Normal variants:
- Premature adrenarche
- Benign pubic hair of infancy
- Fine, straight to curly hair, normal laboratory findings, normal linear growth, minimal to no progression of pubic hair growth, pubic hair typically falls out by 2 years of age
Adrenal:
- Congenital adrenal hyperplasia
- Exogenous androgen exposure
- Adrenal tumor
A thorough medical history, physical examination, and appropriate laboratory assessment are essential to be able to rule out other underlying medical conditions associated with early pubic hair/body odor.
Most presentations of early pubic hair or body odor will be benign. However, there is a higher risk of true pathology with pubic hair and/or body odor development in children of younger ages.
DHEA-S levels are often mildly elevated for age.
There has been an association of early adrenarche and subsequent development of polycystic ovarian syndrome (PCOS) in adolescent girls.
Obesity may also predispose to early adrenarche.
Kaplowitz P, Bloch C. Evaluation and Referral of Children with Signs of Early Puberty. Pediatrics 2016;137(1):e20153732. https://pediatrics.aappublications.org/content/137/1/e20153732
Michelle Knoll
December 2022