precocious puberty in children
Introduction
Introduction to pediatric female precocious puberty Premature precocious puberty (premature precocious puberty), that is, puberty development is significantly advanced, because each normal child has a large variation in the onset of puberty development, it is difficult to determine the absolute limit of normal and precocious puberty at the beginning of puberty. It is generally believed that the girl has a mammary gland before the age of 8 years. Any one or more secondary sexual characteristics such as enlargement, pubic hair growth, mane growth, or menarche begin before the age of 10, that is, female precocious puberty, and some scholars advocate that children's puberty and sexual development are earlier than the average normal child development. Precocious puberty is more than 2 or 2.5 standard deviations, and female precocious puberty accounts for about 0.2% of all women. basic knowledge Probability ratio: the probability of a young girl is 0.6% Susceptible people: children Mode of infection: non-infectious Complications: ovarian cysts
Cause
Pediatric female precocious puberty
Dietary factors (15%):
Due to social progress, the current family living conditions have become superior, nutrition has improved, diseases have decreased, and children's growth and development have accelerated, leading to an increase in sexual development and sexual maturity.
Environmental factors (20%):
At present, the industrial pollution of the society is increasing, and the food also contains a large amount of pesticide pollution or hormonal pollution. These pollution residues are a cause of precocious puberty in children after being passed through the skin or directly consumed.
Physical and chemical factors (15%):
Hormone-containing foods, many of the vegetables and poultry now contain a lot of hormones. Some sex hormones will cause precocious puberty when they enter the human body indirectly. Both experts pointed out that they do not approve of high-fried foods for children. Food, including foreign fast food and barbecue.
Blind tonic (10%):
Tonic is one of the culprit causing precocious puberty in children. "Some parents often give their children an appetite-increasing, brain-healthy health care product. As everyone knows, these supplements often contain hormones, which can cause hormones in children's blood. The level rises, leading to precocious puberty in children.
Other factors (8%):
Contraceptives and cosmetics lead to precocious puberty information. The current society is a highly developed information society. Children can not only obtain a large number of sexually suggestive pictures from television, but also access sexual information from newspapers and on the Internet.
Prevention
Pediatric female precocious puberty prevention
There are many causes of precocious puberty, but some factors can be avoided.
Many parents like to wash dishes with detergent, and their practical baking soda can also play a role in cleaning oil. Because detergents, pesticides, and plastics produce environmental hormones. These contaminants may contain estrogen, which may be induced by water, food, and skin into the body.
In the diet, don't give your children anti-seasonal fruits and vegetables. Many of these fruits and vegetables are ripened with hormones. Some very large turtles and scutellaria should not be allowed to eat. In addition, hormones will accumulate in the endocrine glands such as the animal's gonads. It is best not to give the children the internal organs.
Children eat less tonic. For example, Hass oil is also a good medicine for lungs and cough, but children can't eat. Hass oil contains a lot of hormones, and children who eat too much can cause precocious puberty.
In addition, cosmetics and contraceptives used by parents should also be placed. There have been many cases in the clinic where the child secretly uses the mother's breast cream or eats the contraceptive, which leads to precocious puberty.
Complication
Pediatric female precocious complication Complications ovarian cysts
Generally no complications, but the osteophytes are closed in advance, and the last one is short. Some precocious puberty manifestations of depression or hyperactivity may have ovarian cysts.
Symptom
Symptoms of precocious puberty in children, common symptoms, pubic hair, early development, vaginal bleeding, ovarian cysts, osteophytes, early closure, masculinization
1. Clinical features
(1) General characteristics: The initial female precocious girl is much taller than the normal girl of the same age, but because the estrogen level rises prematurely, the epiphysis closes prematurely, resulting in the last short stature, which grows quickly but continues The time is short, so the sooner the disease starts, the shorter the height is, the normal precocious girl is generally in normal health. The behavior of sexually precocious girls, sexual psychology and mental development are in line with their actual age. Some precocious girls are depressed and unwilling to Social contact, or behavior is too aggressive, arrogant, true sexual precocious girls with normal menstruation and ovulation, may have fertility, and occasionally the same situation occurs in the same family, is a cryptogenic or dominant inheritance.
(2) Premature breast development: generally occurs in 1 to 3 years old, followed by 3 to 5 years, most of the breast development is not progressing, about 1/3 of the patients' breasts gradually return to normal, about 1/10 of the girls' breasts continue to increase Many girls have ovarian cysts, less than 10mm in diameter, detected by B-ultrasound, no pubic hair, no change in uterus size, the cause of estrogen is slightly higher, FSH level is higher than LH level, FSH is increased after GnRH stimulation, LH is not Elevated, the girl's general health, growth and final height are not affected.
(3) Premature hair: 4 to 8 years old, pubic hair or armpit hair, no other puberty development, due to increased adrenal gland secretion of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) .
(4) Menarche is too early: 9 years ago, girls have periodic vaginal bleeding, and there is no other estrogen excess, E2 level is 37 ~ 74pmol / L (10 ~ 20pg / ml) or can not be measured, ovarian Some follicles are larger than 10mm in diameter, degenerate after development, without breast development, no hair, no early growth, no premature osteophyte closure, no follicular maturation or fertility, and frequent periodic bleeding and spontaneous stop. The cause is unknown, vaginitis, foreign body and injury in the vagina, papilloma, blood disease, etc. should be excluded.
2. Classification and characteristics
(1) True precocious puberty:
1 Female secondary sexual development: breast development can reach Tanner stage III, stage IV (Table 1), pubic hair and mane appear, the shape is like adult women (hip width).
2 height situation: early than the same age children.
3, external genital development: the labia majora is full, the uterus accounts for 2/3 of the total uterus, and the cervix accounts for 1/3.
3 can be ovulation menstruation: menstrual rules, when the basal body temperature is biphasic, indicating ovulation menstruation.
(2) pseudo precocious puberty:
1 same sex precocious:
A. Female sexual development is incomplete, or accompanied by irregular vaginal bleeding, caused by exogenous estrogen, areola, nipple and labia minora are brown.
B. Signs of primary disease: such as pelvic mass, multiple bone fiber dysplasia, brown pigmented spots on the skin, their size, shape and number are different, and prone to fracture.
2 heterosexual precocity:
A. The masculine performance: girls appear beards, larynx, hemorrhoids, hairy, clitoral enlargement and other masculine performance.
B. Adrenal disease or ovarian tumor.
Examine
Pediatric female precocious puberty check
1. Determination of sex hormones and gonadotropins: The secretion of sex hormones and gonadotropins has obvious age characteristics. FSH in the blood of 2 years old male and female children, estradiol in boys and testosterone in boys are higher, 2 years old After the puberty began to decline again, the blood testosterone <1.75nmol / L, estradiol <37.5pmol / l, girls testosterone <0.7nmol / L, estradiol <75.0pmol / before the start of puberty L, true precocious puberty, LH, FSH increased, and there are periodic changes, circadian fluctuations before the establishment of periodic feedback relationship, elevated during nighttime sleep, serum FSH, LH, testosterone in children with idiopathic precocious puberty And the content of estradiol is higher than that of normal children of the same age, but there is no overlap between the normal high limit and the pathological low limit, so there is no strict limit, so the diagnostic reference value is small (especially early), if necessary, DHEAS is determined. The relationship between progesterone, 17-hydroxyprogesterone, HCG, DHEAS and actual age and bone age can reflect the adrenal function, which is helpful for the diagnosis of true precocious puberty. When gonadotropin is not elevated, estrogen should be elevated. Consider ovarian or adrenal tumors Heterogeneous HCG secretion should be considered in the apparent increase of the hormone, and elevated blood progesterone is suggested to be a luteal tumor.
2. GnRH or clomiphene stimulation test: can understand the functional status of the hypothalamus-pituitary.
(1) GnRH stimulation test: LH is seen 30 minutes after the injection of GnRH in true precocious puberty, FSH is increased by 2 times or more than the basal value, while pseudo precocious puberty and hypothalamic-pituitary-gonadal axis function are not fully mature. Non-reactive or low-response, premature breast development, the response of this test is a significant increase in the peak of FSH, and LH reaction is not obvious, in the past, the simple reaction to promote LH, can identify premature breast development and central sex Early maturity, in recent years, the study found that infants under the age of 4 years with simple breast development, the peak LH reaction can be >20: U / L, so that infants under 4 years old can not be identified by LH reaction alone to identify simple mammary gland Early development and central precocious puberty, but combined with FSH to judge the response of GnRH stimulation, generally considered central precocious puberty, LH/FSH>1 after GnRH stimulation, and simple mammary gland development, LH/FSH<1 .
(2) Clomiphene stimulation test: It has certain value for judging the maturation of the hypothalamic-pituitary-gonadal axis, but it has been used less frequently. Before the test, FSH and LH were used as the basal level, followed by taking clomiphene 100mg continuously. After 5 days, the FSH was retested on the 6th day. If the baseline value increased by 50% after LH, the hypothalamic-pituitary-gonadal axis matured, which was helpful to identify true and pseudo precocious puberty.
3. Determination of urinary 17-ketone: patients with congenital adrenal hyperplasia or adrenal cancer, increased urinary 17-ketone, feasible dexamethasone inhibition test, urinary 17-ketone increase in patients with adrenal cancer can not be inhibited by low-dose dexamethasone, congenital Adrenal hyperplasia has elevated plasma 17-hydroxyprogesterone in different types, elevated plasma 11-deoxycorticosterone, and increased gestational gestational glycerol.
4. FT3, FT4 and TSH measurements help to reflect thyroid function.
5. Vaginal exfoliated cell smear to check estrogen levels, true precocious puberty, estrogen levels change periodically, while pseudo precocious puberty is persistently elevated.
6. If the basal body temperature is biphasic, it indicates ovulation, which is true precocious puberty.
7. X-ray photograph of the left wrist was used to determine the bone age. Those with bone age exceeding the actual age of 2 years old were considered as precocious puberty, and those with delayed bone age indicated hypothyroidism.
8. X-ray photograph of the saddle, fundus, visual field examination, etc., to help to understand whether there is intracranial lesions, calcification on the saddle to suggest craniopharyngioma, calcification of the pineal gland and enlargement of the sella, deformation suggesting intracranial tumor, intracranial Tumors can cause optic edema and visual field changes in the fundus.
9. EEG, brain topographic map: When the brain organ lesions, there are often abnormal changes, EEG diffuse abnormalities, including abnormal slow wave with paroxysmal activity and sharp waves, spikes and other changes.
10. Abdominal and pelvic B-ultrasound, can understand the adrenal gland and ovary, uterine size and morphology, and ovarian conditions.
11. CT and MRI examination: CT and MRI head examination can understand intracranial lesions, especially help to identify intracranial tumors. It is also valuable for the exclusion of secondary precocious puberty, and the above-mentioned examination of idiopathic true precocious puberty It is normal, and it is also valuable for the identification of adrenal tumors and ovarian tumors. Some people use MRI to diagnose central precocious puberty according to the degree of concave surface in the upper pituitary (level 1 obvious depression, grade 2 mild depression, grade 3 flat, 4 Grades are slightly convex, and grade 5 is obviously protruding. It is considered that pituitary grading is of great value in the diagnosis of precocious puberty in prepubertal children. Those with grade 4 or higher can be highly suspected of central precocious puberty.
Diagnosis
Diagnosis and diagnosis of precocious puberty in children
The disease depends on detailed medical history, comprehensive physical examination and necessary laboratory examinations and other auxiliary examinations, and requires careful follow-up observation to diagnose the cause. Idiopathic precocious puberty can only be completely excluded. The disease that causes precocious puberty can be diagnosed. During the follow-up, special attention should be paid to the possibility of early and slow-moving subclinical intracranial tumors. Children with precocious puberty caused by organic brain lesions, endocrine changes and bone age The characteristics are similar to those of idiopathic, but special examinations such as CT, MRI, EEG, EEG topography, and head X-ray may reveal abnormal signs, and there may be intracranial instruments before or after the development of sexual characteristics. The corresponding symptoms and signs of sexual diseases.
In the early stage, only the development of the mammary gland is difficult to distinguish from the premature development of the simple mammary gland. If the rigorous follow-up observation is not difficult, the size of the precocious puberty and the size of the ovary are significantly increased. The LH/FSH after GnRH stimulation is often >1, while the simple mammary gland Premature uterus, the size of the ovary has not changed, and LH/TSH is often <1 after stimulation. For those with early adrenal function, attention should be paid to the identification of adrenal hyperplasia and androgen-producing tumors. The former only shows pubic hair and pubic hair. Now, there will be no other sexual development, while the latter is accompanied by increased body hair, height, weight, rapid growth, early bone age, hemorrhoids, and thick voice.
