Delayed Puberty/Delayed Sexual Development

It can be upsetting for a child to not be growing and developing physically as quickly as his or her peers. It’s usually nothing to be worried about, but having your child evaluated by a doctor can help set both of your minds at ease.

Delayed puberty is defined differently for boys and girls:

• Boys: lack of increase in testicle size by age 14
• Girls: lack of breast development by age 13

Here’s what you need to know about delayed puberty:

• There’s a lot of variation in terms of what’s a “normal” time to start puberty.
• A specialist, such as an endocrinologist, is often able to detect signs that puberty has started, even if it doesn’t look that way to you, your child, or even your child’s pediatrician.
• Delayed puberty can be caused by an underlying medical condition (e.g., celiac disease or a hormone deficiency).
• There’s often a hereditary component to delayed puberty. If a parent was late in starting puberty, it’s more likely that his or her child might be, too.
• In the overwhelming majority of cases, if treatment with hormones is required, it successfully jumpstarts puberty.

While delayed puberty is actually defined by signs (lack of increase in testicle size by age 14 or lack of breast development by age 13), we often see children who come in for an evaluation because they’re concerned that they’re not growing as quickly as their peers.

My child has developed pubic hair and body odor, but still no breast development. Should I be concerned?

Your child could have pubic hair and body odor but still meet the definition for delayed puberty, so she should be evaluated.

This is because while they tend to happen around the same time, development of breasts and development of public hair/body odor are two separate processes, each triggered by their own hormones. The diagnosis of delayed puberty only takes into account the process and the hormones that lead to breast development.

A few different things can cause delayed puberty.

Constitutional growth delay (CGD)

• CGD is a temporary delay in skeletal growth, which keeps a child from being as tall as his peers, at least for a while.
• Among boys, around 60 percent of the time, delayed puberty is caused by constitutional growth delay.
• It’s hard to say for sure, but CGD is thought to affect around twice as many boys as girls.
• CGD is a normal variant of growth, but may still make a child feel distressed.
• As we grow up, our bones “mature.” If a child has CGD, a doctor can look at an X-ray of his hand and wrist, and see that his bones appear “younger” than expected for his chronological age.
• CGD is often inherited. If one or both parents were “late-bloomers,” it’s likely that their child may be, too.
• Kids with CGD go through puberty and reach an appropriate adult height, just not as quickly as their peers do.

An underlying medical condition

These might include:

• Cardiac conditions
• Celiac disease (which affects a child’s ability to gain weight, making it harder to grow at the same rate as his peers)
• Conditions that prevent the hypothalamus or pituitary gland from sending the “start puberty” signal
• Conditions that prevent the ovaries or testes from being able to respond to the “start puberty” signal
• Certain genetic conditions, such as Klinefelter’s syndrome in boys and Turner syndrome in girls

Some psychiatric medications can contribute to delayed puberty, too.

The first step in treating your child is forming an accurate and complete diagnosis. Your child’s doctor will most likely start by taking the child’s medical history, including questions about the family’s medical history, and performing a physical exam. Other tests might include:

• Bone age examination: a simple X-ray of the left hand and wrist that allows doctors to look at your child’s skeletal development, which changes over time. If your child’s “bone age” — the age indicated by your child’s skeletal development — is lower than his chronological age, it could be a sign of constitutional growth delay (CGD), which is a variation of normal development.

• Blood tests: to measure hormone levels, including estrogen and testosterone, and screen for underlying disorders if appropriate

It can sometimes be difficult to determine what’s causing a child’s delayed puberty. An extreme case of CGD might delay puberty so long that it appears that it might be caused by an underlying medication condition. 

Sometimes doctors prescribe hormone replacement therapy to see whether they can trigger puberty. Whether this works or not often provides information about what caused the delayed puberty, but it’s far from foolproof — even CGD will sometimes fail to respond to an initial hormone trigger.

After all tests are complete, we will meet with you and your family to discuss the results and outline the best treatment options.

At Boston Children's Hospital, we consider you and your child integral parts of the care team and not simply recipients of care. You and your care team will work together to customize a plan of care for your child.

We can treat delayed puberty with hormone therapy. Even if your child has constitutional growth delay (CGD) and will progress through puberty at his body's own rate, having puberty “jump-started” through hormone treatment may contribute greatly to his overall well-being. You, your child's doctor, and your child will discuss whether this is the right option for him.

Each child is different, but depending on how old your child is and what's causing his delayed puberty, we might see him every four to six months throughout childhood to make sure that there are no problems or complications.