Timing and definitions
Puberty is considered delayed when the child has not begun puberty when two standard deviations or about 95% of children from similar backgrounds have.In North American girls, puberty is considered delayed when breast development has not begun by age 13, when they have not started menstruating by age 15, and when there is no increased growth rate. Furthermore, slowed progression through the Tanner scale or lack of menarche within 3 years of breast development may also be considered delayed puberty.In the United States, the age of onset of puberty in girls depends heavily on their racial background. Delayed puberty means the lack of breast development by age 12.8 years for White girls, and by age 12.4 years for Black girls. The lack of menstruation by age 15 in any ethnic background is considered delayed.In North American boys, puberty is considered delayed when the testes remain less than 2.5 cm in diameter or less than 4 mL in volume by the age of 14. Delayed puberty is more common in males.Although absence of pubic and/or axillary hair is common in children with delayed puberty, the presence of sexual hair is due to adrenal sex hormone secretion unrelated to the sex hormones produced by the ovaries or testes.The age of onset of puberty is dependent on genetics, general health, socioeconomic status, and environmental exposures. Children residing closer to the equator, at lower altitudes, in cities and other urban areas generally begin the process of puberty earlier than their counterparts.
Others
Growth hormone is another option that has been described, however it should only be used in proven growth hormone deficiency such as idiopathic short stature. Children with a constitutional delay have not been shown to benefit from growth hormone therapy. Although serum growth hormone levels are low in constitutional delay of puberty, they increase after treatment with sex hormones and in those cases, growth hormone is not suggested to accelerate growth.Subnormal vitamin A intake is one of the etiological factors in delayed pubertal maturation. Supplementation of both vitamin A and iron to normal constitutionally delayed children with subnormal vitamin A intake is as efficacious as hormonal therapy in the induction of growth and puberty.More therapies are being developed to target the more discreet modulators of the HPG axis including kisspeptin and neurokinin B.In cases of severe delayed puberty secondary to hypogonadism, evaluation by a psychologist or psychiatrist, as well as counseling and a supportive environment are an important supplemental therapy for the child. Transition from pediatric to adult care is also vital as many children are lost during transition of care. Outlook
Constitutional delay of growth and puberty is a variation of normal development with no long-term health consequences, however it can have lasting psychological effects. Adolescent boys with delayed puberty have a higher level of anxiety and depression relative to their peers.