320 LEADING ARTICLE

Endocrinology • The specialists need to communicate ...... effectively and declare in what situa- Arch Dis Child: first published as 10.1136/adc.86.5.320 on 1 May 2002. Downloaded from tions the “analogue” will or will not be given. Does it or does it not enhance Precocious puberty: a parent’s growth generally or specifically? • How can the profession help the child perspective and the parents in dealing with difficult situations at school and so- E O’Sullivan, M O’Sullivan cially? ...... • Given the devastating effect on the parents and the child, how can the How bad can it get? profession assist them with proactive advice and assistance? e are writing as parents of a may now be irrelevant, but in any case it young girl who “suffers” from doesn’t, in his view, enhance final height The answer to the last question is cur- Wprecocious puberty and we use attainment. rently being worked on at the Child the word suffers without reservation Growth Foundation. Best Practice Guide- despite the fact that: lines are being prepared to assist chil- “Now the shock is turning dren and parents in understanding the • Puberty is a normal process to dismay, anger, and range of issues that these conditions • No underlying cause triggering her frustration” surface. They are also aimed at the medi- puberty has been determined. cal profession to assist them in helping Our daughter started to show physical patients and their families. A copy of the signs of development, for example, Eighteen months of consultations and full survey is available on the ADC web- breast development combined with divided opinions pass before we can site. The Best Practice Guidelines are 1 pubic hair, at 6 ⁄2 years, and within a year commence treatment—during which available from cgfl[email protected]. experienced her first period. We were our daughter is continuing to develop. This article was produced to challenge devastated by this event, as our local Monthly periods, moodiness, greasy the profession to prevent this type of general practitioner had told us that skin, acne, but most critically accelerated situation recurring. We know that preco- there was nothing to worry about, and bone maturation, reducing the scope for cious puberty is a rare condition, is not that we were imagining and exaggerat- further height attainment. At last, our life threatening, and the NHS always ing things. Our ongoing concerns for an third specialist consultant agrees to needs more resources—but surely we explanation and regular visits to the sur- organise the treatment and we proceed can’t let these issues go unanswered? gery were seen as pushy and demanding. down this new route. Surely confronted with this period, an Our daughter’s periods stop, her skin Arch Dis Child 2002;86:320–321 obvious sign of female maturity arriving improves, moodiness reduces, and our very early, we would get help and child comes back to us. She even prefers ...... Authors’ affiliations support. Regrettably, it didn’t get any an injection to a period and her confi- http://adc.bmj.com/ easier. dence with her peers returns to previous E O’Sullivan, M O’Sullivan, Romford, Essex, UK The good news was that the general levels. She is normal again! But to what paediatrician to whom we were first end and at what cost? Our daughter Correspondence to: Mr E O’Sullivan, 176 Brian referred was really helpful. He confirmed finished her 12 months treatment early Road, Chadwell Heath, Romford, Essex RM6 5BS, UK; [email protected] that he had rarely encountered the this year and her recent final bone age test condition before but would organise par- now confirms that “too little was done too ticular tests to discount any underlying late”. So what is the net effect after three The full survey can be viewed causes for this early growth, such as cra- and a half years? I will leave you to imag- on the ADC website on September 25, 2021 by guest. Protected copyright. nial or ovarian tumours. Our shock with ine what we think of most of the medical these possibilities was diminished by the profession we have encountered. speed of his tests and his effectiveness in During this time we have been aided communicating to the three of us as by the Child Growth Foundation which results came in. Fortunately no under- conducted a major survey of parents lying cause was identified and we were with children affected by precocious ...... COMMENTARY ...... referred to a paediatric endocrinologist. puberty. The results showed that only Confusion was about to reign again. 45% of paediatricians’ and 83% of paedi- The specialist recommended that our atric endocrinologists’ ratings by parents his article shows the plight of daughter, who has “central precocious were in an “adequate” to “very good” parents with a child who has preco- puberty”, should receive analogue treat- range. In other words, the above story is Tcious puberty—girls less than 8 ment (with gonadotrophin releasing not at all atypical. years, boys below 9 years. One is left in hormone analogue) to suppress her The key issues for the profession to no doubt that this is an alarming and accelerated development and enhance address, deriving from the survey, are: frightening situation that can cause her height potential. Growing up early, difficult initial visits to doctors because General practitioners should not dis- he explains, will result in compromised • of its relatively low frequency in such a regard diagnostic symptoms and final height. Before commencing this florid form and also because of the issue should listen to parents. They should treatment we seek a second opinion from of whether there is something sinister or not belittle the condition or its con- another paediatric endocrinologist. We serious as an underlying cause. In cerns. find that an insufficient range of tests practice, even in girls of 6 years, it is have been organised to discount any • The roles of the paediatricians and the unusual to find a brain or ovarian underlying cause. We need to reconfirm paediatric endocrinologists need to be tumour when there is a normal sequence the diagnosis before starting treatment differentiated to avoid delay and to of puberty development, albeit acceler- with such an analogue. The treatment improve efficiency. ated. It has been argued that early sexual

www.archdischild.com LEADING ARTICLE 321 development is becoming more common it was pointed out that there is no strong The survey carried out by the Child in recent years, but the evidence for this evidence base on which to judge these Growth Foundation is helpful: Arch Dis Child: first published as 10.1136/adc.86.5.320 on 1 May 2002. Downloaded from 1 is poor, as shown by Viner. decisions. The issue of which patients to • General practitioners should certainly Most general paediatricians con- treat with analogue treatment is dis- refer urgently and listen to parents. fronted with a young child showing cussed by Brook2 in his textbook on pae- signs of puberty would initiate early diatric endocrinology; he favours treat- • As discussed, the roles of paediatri- investigations, such as checking gonado- ment in younger patients. His view is cians and paediatric endocrinologists trophin and oestradiol levels, thyroid that the question of treatment or no need to be distinguished. function, β HCG, prolactin, and a bone treatment should be based on assess- • Should analogue treatment be given? age and a pelvic ultrasound. Depending ment of growth prognosis and the child’s Further research is needed to look into on local facilities they may well organise psychology maturity. The psychological the issue of whether it enhances a magnetic resonance imaging (MRI) aspects of the condition on a young child growth potential. Many would agree scan of the mid brain and pituitary area. and their family are easy to underesti- that the growth argument with pre- They would determine whether the mate by professionals. mature fusion of the epiphyses has sequence of puberty development was If treatment is to be given, there is been unintentionally exaggerated in normal, plot growth carefully, exclude now another controversial issue of the past. any signs of raised intracranial pressure, whether a standard intramuscular injec- • The parents ask about help for the and look for any abnormal pigmentation tion on a 3–4 week basis should be given, child and the parents in dealing with to suggest McCune–Albright syndrome. or whether a slow release preparation this difficult situation at school and It is likely that a second opinion will be should be given every 2–3 months—the socially; this must be a key role for the sought from a paediatric endocrinolo- efficacy of the latter was shown by Child Growth Foundation. Hopefully gist. One of the key things during this Patterson and colleagues.3 In the past the most paediatricians would look in the difficult time for the parents is effective issue of advanced bone age was given as CaF (Contact a Family) directory to communication of what is going on, and a strong reason for starting treatment to look up the support groups in such a what investigations are to be undertaken prevent premature fusion of epiphyses situation. Community paediatric and why. and short final height stature, but the nursing teams also have a support role The paediatric endocrinologist should evidence for this in children with later in giving advice at school and at home. be in a position to continue the discus- onset is inconclusive. The parents at this • How can the professionals assist with sions initiated by the general paediatri- meeting felt it frustrating and difficult to giving proactive advice and assist- cian, decide whether further tests are accept that doctors from different teach- ance? needed, and will no doubt discuss the ing hospitals had divergent views. With Have a look at the full survey by the issue of blocking treatment. Unfortu- this background the issue of communi- Child Growth Foundation and their Best nately,as shown at a national meeting on cating well with parents is crucial. Practice Guidelines. Treatment for this premature sexual maturation organised In the case of this young girl the rare but devastating condition for par- by the Child Growth Foundation in Lon- parents mentioned that a second paedi- ents and children is still somewhat don in 2000, there was no strong atric endocrinology opinion was sought. unpredictable. Do write in with your consensus view among endocrinologists It is not clear why they felt this was nec- views and comments. about how extensive investigations essary, but it did result in delay of treat- http://adc.bmj.com/ should be and how aggressive analogue ment which was eventually commenced blocking treatment should be with gona- 18 months after onset of periods. The dotrophin releasing hormone analogues. parents state candidly that it doesn’t ...... Some endocrinologists argue that MRI take much to imagine their views of the N Mann, Commissioning Editor brain and pituitary scanning has a very medical profession. The Child Growth low pick up rate in girls unless very Foundation has a difficult role as it needs young, and there was disagreement to support parents with this frightening REFERENCES about whether this test should be under- condition, give background literature 1 Viner R. Splitting hairs. Arch Dis Child on September 25, 2021 by guest. Protected copyright. taken at 7–8 years, although nearly all and information, and sometimes give 2002;86:8–10. 2 Brook CGD. Clinical paediatric agree that at 61⁄2 years girls should have suggestions of where to go for second endocrinology, 3rd edn. Oxford: Blackwell an MRI scan, as well as all boys below 9 opinions. There is of course an inherent Science Ltd, 1995:257–62. years. danger in second or third opinions, as 3 WF Patterson, E McNeill, S Read, et al. Views about whether children should there may be conflicting views which Efficacy of Zoledex LA (goserelin) in the treatment of girls with central precocious or have blocking treatment were more vari- may cause confusion and delay treat- early puberty. Arch Dis Child able, with quite a wide range of opinions; ment. 1998;79:323–7.

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