Johns Hopkins Pediatric PEAC Curriculum 2022-23

Normal and Abnormal Adolescent Growth and Development: SUMMARY

• The hypothalamic-pituitary-gonadal (HPG) and hypothalamic-pituitary-adrenal

(HPA) axes are responsible for many of the changes that occur during puberty,
including gonadarche and adrenarche respectively.
• In males, testicular growth is the first sign of puberty (average onset of 11.5
years of age), while in females thelarche (breast budding) is the first sign of
puberty (average onset of 9.5-10.5 years of age).
• For females, peak height velocity usually occurs about 1 year after thelarche and
about 1 year before menarche. Menarche generally occurs at SMR 4 breast
development.
• Due to the 2-year lag in attaining peak height velocity for males, males are
usually taller on average than females.
• Peak height velocity correlates more with sexual maturity rating stage than
chronologic age. Therefore when predicting mature height, growth trajectory
and SMR stage should be taken into consideration.
• Puberty is considered delayed, precocious, or abnormal when there is significant
deviation (at least 2.5 standard deviations) from the attainment of normal
pubertal milestones or sequence.
• Workup for short stature should be initiated if your patient has not attained peak
height velocity by 16 for males and by 14 for females. You should consider
whether your patient has short stature with or without pubertal delay when
considering the differential diagnosis, along with an assessment of linear and
weight growth velocity.
• Workup for delayed puberty should be initiated if: there is no testicular
enlargement by 14 for males, no breast buds by 14 for females, no menarche by
16 for females, or more than 5 years have elapsed between initiation and
completion of the puberty sequence.
• GnRH, LH, and FSH are important lab tests that can help differentiate between
hypergonadotropic and hypogonadotropic hypogonadism. However if clinical
symptoms suggest a unifying diagnosis, test for the underlying condition as
appropriate (i.e. karyotype for Turner syndrome)
• Workup for precocious puberty should be initiated for any male achieving genital
stage 2 before 9 years of age and is more likely to be a pathologic process.
Workup for precocious puberty should be initiated for any female with breast or
pubic hair development before 8 years of age, although controversy exists on
whether or not to consider ethnic differences in this definition.
• In about 50-65% of adolescent males, there can be gynecomastia with a peak
incidence at 14 years of age or genital stage 3-4 and usually resolves by genital
stage 5 or within 2 years of onset.
• Understanding cognitive development, (the progression from concrete thinking
to more abstract, formal operational thinking) is important to consider when
caring for adolescent patients.