Pediatric Examination and Board Review (60 page)

(C) premature thelarche

(D) prepubertal gynecomastia

(E) Klinefelter syndrome

6.
The first sign of puberty in a girl is which of the following?

(A) menarche

(B) axillary hair development

(C) pubic hair development

(D) growth spurt

(E) appearance of breast buds

7.
The first sign of puberty in boys is which of the following?

(A) growth spurt

(B) testicular enlargement

(C) appearance of pubic hair

(D) appearance of facial hair

(E) voice change

8.
If this child is a 4-year-old girl, the differential diagnosis includes which of the following?

(A) precocious puberty

(B) normal puberty

(C) premature thelarche

(D) premature adrenarche

(E) A and C

9.
A 6-year-old boy with precocious puberty is more likely to have which of the following than a 6-yearold girl with precocious puberty?

(A) neurologic disorder

(B) idiopathic precocious puberty

(C) congenital adrenal hyperplasia

(D) gonadal tumor

(E) adrenal tumor

10.
At which Tanner stage of breast development in girls does the areola and papilla form a secondary mound above the level of the breast?

(A) Tanner stage 1

(B) Tanner stage 2

(C) Tanner stage 3

(D) Tanner stage 4

(E) Tanner stage 5

11.
The Tanner stage of breast development at which a girl is most likely to get menarche is which of the following?

(A) Tanner stage 1

(B) Tanner stage 2

(C) Tanner stage 3

(D) Tanner stage 4

(E) Tanner stage 5

12.
The normal time range in girls from breast budding until the appearance of menarche is which of the following?

(A) 2-2.5 years

(B) 0.5-1 year

(C) 3-3.5 years

(D) 1-1.5 years

(E) 2.5-3 years

13.
The average age of menarche for North American white girls is which of the following?

(A) 10.7 years

(B) 11.5 years

(C) 12 years

(D) 12.7 years

(E) 13.3 years

14.
The average growth remaining once a girl has experienced menarche is which of the following?

(A) 0.5 inch

(B) 1 inch

(C) 2 inches

(D) 3 inches

(E) 4 inches

15.
A boy experiences his maximal pubertal growth spurt at which of the following times?

(A) before testicular enlargement

(B) shortly after pubic hair development

(C) shortly after axillary hair development

(D) before penile enlargement

(E) in late puberty

16.
Which of the following is a gonadotropin-dependent process?

(A) premature thelarche

(B) central precocious puberty

(C) premature adrenarche

(D) premature pubarche

(E) B and C

17.
Which of the following would you expect in a girl with premature thelarche?

(A) growth spurt

(B) tall stature

(C) pubic hair

(D) normal growth velocity

(E) advanced bone age

18.
Which of the following would you not expect in a child with premature pubarche?

(A) signs of virilization

(B) normal bone age

(C) pubic hair development

(D) normal growth velocity

(E) axillary hair development

19.
Which of the following would not be expected as a consequence of untreated, rapidly progressive, central precocious puberty?

(A) tall stature as a child

(B) tall stature as an adult

(C) short stature as an adult

(D) advanced bone maturation

(E) psychological difficulties

20.
Pubertal gynecomastia occurs in what percentage of boys?

(A) less than 10%

(B) 20%

(C) 25%

(D) 35%

(E) more than 40%

ANSWERS

1.
(C)
Normal puberty. The appearance of any signs of puberty before the age of 8 years in a girl is considered precocious. Thus an 8
¹
/
₂
-year-old girl with breast development would be in the early range of normal for pubertal onset. Recent studies suggest that girls may be going into puberty at a younger age. Premature thelarche is the early appearance of breast development without any other signs of early puberty, and premature pubarche is the early appearance of pubic hair alone. The term
premature
adrenarche
is used when there is isolated pubic hair development and biochemical evidence of maturation of the adrenal gland (increase in dehydroepiandrosterone [DHEA]-sulfate level).

2.
(D)
Assure her it is normal. It is not unusual for breast development to begin unilaterally in both boys and girls. In addition, most women have asymmetric breasts. If the breast anlage (breast bud) is removed surgically, no breast will form on that side. Simple assurance that this is a normal process is the proper way to proceed.

3.
(E)
History of medications in the house. Estrogencontaining creams and contraceptive pills can cause isolated thelarche in girls. Thus it is important to determine if the child could have been exposed to these as a cause of the breast development.

4.
(B)
Normal puberty. The appearance of pubic hair after the age of 8 in girls would not be considered precocious.

5.
(D)
Prepubertal gynecomastia. A boy with 2-cm testicles is not yet in puberty; thus this would not be considered precocious puberty or pubertal gynecomastia. Prepubertal gynecomastia is rare and almost always abnormal. Etiologies include testicular, adrenal, and human chorionic gonadotropin (hCG)-secreting tumors, exogenous estrogen exposure, familial aromatase excess syndrome, or idiopathic gynecomastia.

6.
(E)
Appearance of breast buds. The typical sequence of development of secondary sexual characteristics in girls is breast budding, appearance of pubic hair, peak height velocity, and menarche. Pubic or axillary hair can occur before breast budding as a normal variant.

7.
(B)
Testicular enlargement. Enlargement of the testicles in boys to 2.5 cm in long diameter (or 4 mL in volume) is the first sign of puberty. Testicular enlargement is largely due to an increase in Sertoli cells and seminiferous tubular volume with a small contribution by Leydig cells. Pubic hair typically develops approximately 1 year after testicular enlargement. The growth spurt, appearance of facial hair, and voice change occur later in puberty in boys.

8.
(E)
A and C. Both precocious puberty and premature thelarche can present with isolated breast development. Thus this child would need to be followed closely for the appearance of other signs of puberty.

9.
(A)
Neurologic disorder. Boys are more likely to have a neurologic disorder leading to precocious puberty than girls. Approximately 95% of true precocity in girls is idiopathic. However, it is important to rule out a neurologic disorder as a cause of precocious puberty in both sexes.

10.
(D)
Tanner stage 4. The Tanner staging system consists of five categories describing the sequence of puberty, from a prepubertal child to adult development. Tanner staging of breast development in girls is shown in
Table 38-1
.

11.
(D)
Tanner 4. Girls typically are at stage 4 for breast development (areolar mounding) when they experience menarche.

12.
(A)
The answer is 2-2.5 years. Although the timing of pubertal onset is variable, the timing from breast budding to menarche in girls is typically between 2 and 2.5 years.

13.
(D)
The answer is 12.7 years.

14.
(C)
The answer is 2 inches.

15.
(E)
In late puberty. The difference between the mean height of men and women is related to the timing and peak of the pubertal growth spurt in boys and girls. Because the pubertal growth spurt is later for boys, they are taller on average once they start the growth spurt in late puberty. In addition, boys experience a greater peak height velocity than girls, leading to their greater adult stature. The typical sequence of development of secondary sexual characteristics in boys is testicular growth, pubarche, penile growth, and peak height velocity.

16.
(B)
Central precocious puberty, which results from early activation of the hypothalamic-pituitarygonadal axis.

17.
(D)
Normal growth velocity. Premature thelarche is the isolated appearance of breast development with a peak prevalence in the first 2 years of life. It is not associated with any other signs of puberty, such as a growth spurt, pubic hair development, or advanced bone maturation. The early breast development usually spontaneously regresses. These girls need to be followed closely for evidence of early puberty because breast development is the first sign of puberty in girls.

TABLE 38-1.
Tanner Stages of Breast Development

18.
(A)
Signs of virilization. Premature pubarche describes the isolated appearance of pubic hair before the age of 8 in girls and 9 in boys in the absence of other signs of puberty or virilization. Although this is thought of as a benign problem that does not need treatment, more recent studies suggest that many girls with a history of early pubic hair development go on to have problems with hirsutism, acne, and irregular menstrual periods during adolescence.