This is an important subject and one that some parents are uncomfortable discussing. However, precocious and delayed puberty can be associated with underlying medical problems, or, cause physical and emotional responses that need to be addressed to best support the child and their development.
Puberty begins when the hypothalamus (a part of the brain) releases a hormone called gonadotropin releasing hormone (GnRH). This hormone tells the pituitary gland, an oval shaped gland at the base of the brain, to release gonadotropic hormones called luteinizing hormone (LH) and follicle stimulating hormone (FSH). This signaling process then results in the ovaries producing estrogen and the testicles producing testosterone.
Cerebral Palsy and Early Puberty: Precocious Puberty
This is when a child’s body begins changing into that of an adult earlier than expected.
Children with neurodevelopmental disabilities like cerebral palsy could experience changes related to early puberty at least 20 times more often than their peers without cerebral palsy. There is limited information about this subject but there are screening tools and treatments available to manage certain types of early puberty and its symptoms.
There are two common types of early signs of puberty that we will discuss here including central precocious puberty (CPP) and premature adrenarche.
What is Central Precocious Puberty (CPP)?
CPP is the early activation of the hypothalamic-pituitary-gonadal-axis (HPG). It is called “central” because the puberty is being driven by the brain. Injuries to the central nervous system can cause central precocious puberty (CPP), so having cerebral palsy is a risk factor for this condition.
CPP seems to progress particularly rapidly in cerebral palsy. When the diagnosis of CPP is made in children with cerebral palsy, a great percentage of them already have an advanced pubertal stage and higher levels of certain hormones associated with pubertal development.
There are some hypotheses that intense activation of the hypothalamic-pituitary-gonadal axis in CP might be due to interference’s in the number of neurotransmitter pathways involved in controlling these hormones.
How is CPP Diagnosed?
- Physical exam- measurement of height and weight; assessment of sexual development such as breast development, penile and testicular size, and pubic and other body hair.
- Hand and wrist x-rays to determine “bone age”. This shows how old the skeleton “thinks” the child is.
- Blood tests to check hormone levels
- GnRH stimulation test- Gonadotropin releasing hormone is injected and then blood tests are drawn to measure the body’s response. This is the confirmatory test for CPP.
- Depending on these results, imaging such as MRI of the pituitary gland or ultrasounds of the ovaries or testicles might be needed.
Since there may be other interference in growth that may complicate the diagnosis and treatment of CPP, it’s important for providers to explore additional variables related to having cerebral palsy that could contribute to changes in stature.
What Treatments are Available for CPP?
CPP is treated with medications called GnRH agonists. These medications, which vary in terms in how frequently they are given, block the activation of pubertal GnRH hormones. They can delay puberty until a more typical age, but no medicine can stop puberty altogether.
The common primary goals in the management of CPP include:
- Delaying the advancement of bone age to maximize adult height:
Children with precocious puberty may first grow quickly compared with their peers, but because their bones mature more quickly than normal, they often stop growing earlier than usual. This can cause them to be shorter than average when they reach adulthood. Medically we are unsure of the impact of this disturbance in height development for children with cerebral palsy. Currently, there are also questions about the effectiveness of existing treatments on preserving height in individuals with CP. It’s important to discuss these concerns and the latest evidence with your child’s medical team.
- Stopping secondary sexual development and menstruation:
CPP causes early development of sexual organs and the early onset of menstruation. This can be an overwhelming experience for a child, especially when their peers are not going through the same changes., or for young girls who are still learning to manage their own hygiene.
- Addressing potential social and emotional difficulties:
Girls and boys who begin puberty long before their peers may be very self-conscious about the changes occurring in their bodies. It may affect their self-esteem and emotionally wellbeing. In addition, as the brain enters puberty there are a host of changes in mood and behavior. Researchers are still learning about how a younger child is affected by these kinds of changes.
What is premature adrenarche?
In contrast to central precocious puberty, premature adrenarche is driven by the early release of hormones from the adrenal glands, rather than the ovaries or testes. These are mild “male”-type hormones, but are normally present both in girls and boys.
- Appearance of pubic and/or underarm hair in girls younger than 8 years or boys younger than 9 years
- Noticeable underarm odor and development of acne
- Sometimes accelerated height growth.
A diagnosis of premature adrenarche is made when these symptoms are present but without the simultaneous early development of breasts in girls or genital enlargement in boys.
Treatment for Premature Adrenarche
There is no treatment for premature adrenarche. Therefore, once the pubic and/or underarm hair develop, they will not go away. Treatments typically used for CPP are not effective for premature adrenarche.
The most helpful therapies for premature adrenarche are to address the symptoms such as using deodorant for control body odor and acne medications. Girls with premature adrenarche do not begin menstruating early.
Cerebral Palsy and Early or Delayed Puberty: Delayed puberty
Some boys and girls with delayed puberty are simply late maturers, but once they start, puberty will progress normally. This is called constitutional delayed puberty and is more common in boys. Often, this runs in families, so it is more likely to occur if the mother started her periods after age 14 (the average is about 12 ½) or if the father began puberty later than their peers, or kept growing after age 18. (Healthy Children n.d.)
Some children start puberty later because of a lack of the pituitary hormones called gonadotropins. This can occur when there are other pituitary deficiencies as well, including growth hormone.
In cerebral palsy it’s possible that nutrition may play a role in the late onset of puberty for some individuals.You may discuss this possibility with your child’s developmental or general practitioner. Referral to an endocrinologist may help identify reasons for delayed puberty and they can discuss any available targeted interventions.
For more information, download our free cerebral palsy tool kit.
Resources for Discussing Puberty
Discussing puberty with your child: The Healthy Bodies website by Vanderbilt University
References and Sources
- Robertson, C. M., Morrish, D. W., Wheler, G. H., & Grace, M. G. (1990). Neonatal encephalopathy: an indicator of early sexual maturation in girls. Pediatric neurology, 6(2), 102–108. https://doi.org/10.1016/0887-8994(90)90042-y
- Mayo Clinic Staff. (2021, February 15). Precocious puberty. Retrieved June 10, 2021, from https://www.mayoclinic.org/diseases-conditions/precocious-puberty/symptoms-causes/syc-20351811
- Bruzzi, P., Messina, M., Bartoli, A., Predieri, B., Lucaccioni, L., Madeo, S., . . . Iughetti, L. (2017, July 16). Central precocious puberty and response to GNRHA therapy in children with cerebral palsy and moderate to Severe Motor Impairment: Data from A Longitudinal, case-control, MULTICENTRE, Italian study. Retrieved June 10, 2021, from https://pubmed.ncbi.nlm.nih.gov/28791047/
- Bruzzi, P., Messina, M., Bartoli, A., Predieri, B., Lucaccioni, L., Madeo, S., . . . Iughetti, L. (2017, July 16). Central precocious puberty and response to GNRHA therapy in children with cerebral palsy and moderate to Severe Motor Impairment: Data from A Longitudinal, case-control, MULTICENTRE, Italian study. Retrieved June 10, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5534302/
- Bruzzi, P., Messina, M., Bartoli, A., Predieri, B., Lucaccioni, L., Madeo, S., . . . Iughetti, L. (2017, July 16). Central precocious puberty and response to GNRHA therapy in children with cerebral palsy and moderate to Severe Motor Impairment: Data from A Longitudinal, case-control, MULTICENTRE, Italian study. Retrieved June 10, 2021, from https://www.hindawi.com/journals/ije/2017/4807163/
- Duan, Y., De Luca, V., & Seeman, E. (1999, February 01). Parathyroid hormone deficiency and excess: Similar effects on trabecular bone but differing effects on cortical bone. Retrieved June 10, 2021, from https://academic.oup.com/jcem/article/84/2/718/2864560
- Eugster, E. (2019, March 28). Treatment of central precocious puberty. Retrieved June 10, 2021, from https://academic.oup.com/jes/article/3/5/965/5421014
- American Academy of Pediatrics and Pediatric Endocrine Society, T. (2014, November 21). Precocious Puberty: When Puberty starts early. Retrieved June 10, 2021, from https://www.healthychildren.org/English/ages-stages/gradeschool/puberty/Pages/When-Puberty-Starts-Early.aspx
- American Academy of Pediatrics and Pediatric Endocrine Society, T. (2015, June 9). Delayed puberty in Boys: Information for parents. Retrieved June 10, 2021, from https://www.healthychildren.org/English/ages-stages/gradeschool/puberty/Pages/Delayed-Puberty.aspx
- American Academy of Pediatrics and Pediatric Endocrine Society, T. (2015, August 26). Premature ADRENARCHE: Information for parents. Retrieved June 10, 2021, from https://www.healthychildren.org/English/ages-stages/gradeschool/puberty/Pages/Premature-Adrenarche-Information-for-Parents.aspx
- Calcaterra, V., Cena, H., De Silvestri, A., Di Mitri, M., & Pelizzo, G. (2019, October 23). Disorders of puberty in Severely Neurologically Impaired Children: Is delayed puberty an Underestimated Problem? Retrieved June 10, 2021, from https://www.frontiersin.org/articles/10.3389/fped.2019.00462/full
- Worley, G., Houlihan, C., Herman-Giddens, M., O’Donnell, M., Conaway, M., Stallings, V., . . . Stevenson, R. (2002, November). Secondary sexual characteristics in children with cerebral palsy and moderate to severe motor impairment: A cross-sectional survey. Retrieved June 10, 2021, from https://pubmed.ncbi.nlm.nih.gov/12415027/