The typical adolescent, endowed with the impatience and insecurities of youth, would probably insist that any nanosecond that doesn’t bring an increase in height, breast size or beard growth qualifies as delayed puberty. Medicine has its own definitions: for boys, no testicular enlargement by the age of thirteen; and for girls, no breast development by thirteen or no menarche by sixteen.
Pubertal delay affects more boys than girls. And it probably affects boys more than girls in terms of how they see themselves. Girls who are slow to develop often seem to acclimate better than boys in similar circumstances. Perhaps that’s because girls start the growth spurt earlier. They may be shorter and younger looking than other girls their age, but they blend in just fine with the boys, who are still a year or so away from the countdown to puberty. A girl’s main worry, says Dr. Marianne Felice, “is that puberty is never going to come.”
Most cases of delayed puberty are simply variants of normal development and not cause for alarm. Generally speaking, the “late bloomers” usually catch up to their peers, and sometimes surpass them. Half of all adolescents who experience such constitutional delays have a parent or sibling whose growth followed a similar pattern.
Nevertheless, when puberty seems overdue, a child should be examined by a pediatrician. Any of a number of medical conditions can slow the process of maturation. Signs that pubertal delay may be due to a disease include an abrupt change in growth or arrested development, in which puberty starts then stalls. Complaints of headaches, vision problems and other neurological symptoms may indicate a disorder of the central nervous system.
One of the most common culprits is malnutrition brought on by diseases, medications or eating disorders. Inflammatory bowel disease, a chronic and potentially serious condition, frequently delays puberty and stunts growth in young people by interfering with metabolism: The inflamed intestines cannot adequately absorb the nutrients from food.
According to endocrinologist Dr. Norman Spack, “With the marked increases in the use of stimulants and other medications that, as a side effect, suppress appetite, we’re seeing a lot of children whose pubertal delay is indirectly initiated or aggravated by the fact that they’re not consuming enough calories.” Stimulants are widely prescribed to manage attention deficit hyperactivity disorder, or ADHD.
How Pubertal Delay Is Treated
Unless delayed physical development is found to have an organic cause, reassurance from your pediatrician is the best medicine for your youngster. For instance, the pediatrician can point out to a boy that his testicles have grown in size, the first sign of male puberty but one that is rarely noticed by the boy himself. “Enlargement of the testicles tells us that the system has been switched on and that sexual maturity is going to come,” says Dr. Spack. “Very often, parents will bring in a youngster who is upset that he hasn’t started to grow yet.” The physician can confirm that in fact the process of puberty is under way. “That examination alone usually reassures a child about what is going to happen and at what pace.”
Sex Hormone Therapy
Under rare circumstances, after a thorough diagnostic workup, a pediatrician might recommend several months of male or female sex hormones, to give a boy or girl a chemical “nudge” through sexual maturity. Candidates for hormonal therapy would include older teens who exhibit early signs of puberty but “haven’t gotten going yet,” as Dr. Mark Scott Smith puts it. Another consideration is the impact late development is having on a teenager emotionally and socially. “I usually reserve it for the youngster who is truly suffering,” says Dr. Spack. Boys receive injections of testosterone, while girls are prescribed tablets of estrogen and progesterone, the other female sex hormone. The dose is comparable to the amount of sex hormone a youngster’s body would normally produce. “The hormone therapy gets kids started just enough that we can then back off and let them take off on their own,” says Dr. Smith, “without changing where they are going to end up.”
Another of the chemicals released by the brain’s pituitary gland is growth hormone (GH). Some youngsters’ pituitaries are impaired and secrete too little. This condition, referred to as hypopituitarism, severely stunts growth. Injections of synthetic growth hormone have enabled thousands of people to reach the adult height that their heredity intended.
Short stature has many causes other than GH deficiency. Initially it was believed that only people with abnormally low levels of endogenous growth hormone—produced by the body—would respond to growth-hormone therapy. But the genetically engineered products have also benefited youngsters on kidney dialysis during the time that they await a kidney transplant as well as those with Turner syndrome. Girls with Turner syndrome make growth hormone, but their bodies appear to be resistant to it.
So what’s to prevent anyone who wants to add a few inches to his height from marching on down to the doctor’s office and demanding growth hormone? Dr. Stephen LaFranchi, head of pediatric endocrinology at Oregon Health Sciences University in Portland, remarks, “I’ve had a few experiences where parents requested growth-hormone treatment when it wasn’t appropriate for their child. We had to explain that, by and large, growth-hormone treatment is given only to kids who are proven to have pituitary growth-hormone deficiency.”
Aside from hypopituitarism, chronic renal failure and Turner syndrome, “all other uses of growth hormone are considered investigational,” says Dr. LaFranchi. Insurance companies do not pay for experimental treatments, and at six or seven subcutaneous injections per week for four to five years, GH therapy is prohibitively expensive: approximately $30,000 annually. That factor alone should limit inappropriate use.
Here are two others: Though short-term treatment has produced few, if any, side effects, synthetic growth hormone has been on the market only since the mid-1980s, and nothing is known about what its long-term effects might be, so it seems foolish to use it for any but medically necessary situations. Furthermore, heredity is a more powerful determinant of stature than synthetic growth hormone. So much as a boy might long to be six feet tall, if his parents are short he’s likely to be short too. That’s the way genetics work!