The most common signs of precocious puberty are premature adrenal function (early onset of pubic hair and/or foxiness), precocious puberty (progressive breast development, usually occurring before the age of 2 years), and fatty deposits in the breasts. In girls, there is significant breast development, which can be identified as adipose tissue upon careful palpation. Symptoms of precocious puberty may be insidious, but early recognition of pubertal symptoms can help primary care providers refer patients to pediatric endocrinologists, according to new guidelines for evaluating pubertal symptoms. The age at which puberty begins declines, a trend that began to stabilize in the 1950s. Currently, precocious puberty is defined as the development of secondary sexual characteristics in girls under the age of 8 and boys under the age of 9. Dr. Paul Kaplowitz and his colleagues from the American Academy of Pediatric Endocrinology chapter wrote that no testing or interviewing is required and that most children who show signs of precocious puberty show only typical growth and development. The most common symptoms of precocious puberty were early onset of adrenal function (pubic hair and/or foxing early in life), precocious puberty (progressive breast development, which usually occurs before age 2) and breast fat deposition,” the researchers wrote. In girls, there is significant breast development, which can be identified as adipose tissue upon careful palpation.” Race and weight have significant effects on pubertal developmental changes. Black girls appeared to enter puberty earlier than white girls. The researchers wrote “Therefore, the evaluation of girls for symptoms of precocious puberty must take into account BMI and race/ethnicity.” They suggest that boys presenting with penile or testicular enlargement before age 9 could be considered precocious to ensure timely referral. With elevated dehydroepiandrosterone sulfate (DHEA-S) levels, usually 30-150 mcg/Dl, the appearance of early pubic hair growth and/or onset of foxiness, absence of clitoris, penile growth or testicular enlargement, referral or additional testing is usually not necessary. Radiologic bone age screening may help rule out precocious puberty. Similarly, infants with pubic hair development but no or insignificant genital growth do not require any laboratory testing. The authors write that it is unclear how the necessary testing and follow-up will be performed when breast gland tissue is touched in girls younger than 2 years of age, but it is reasonable to delay hormonal and pelvic ultrasound testing for most girls. After ruling out underlying trauma or tumor, if prepubertal vaginal bleeding is nonrecurrent or persistent, this bleeding is usually benign. Overweight and obese girls with significant early breast development can be excluded from progressive precocious puberty on clinical examination if no glandular tissue is found at the areola and there is no estrogen stimulation around the nipple or areola. Central precocious puberty (CPP): The authors write that the diagnosis of central precocious puberty (CPP) may be “progressive breast development”. Rarely in boys, the diagnosis may be testicular and penile enlargement by age 9. The researchers noted, “Typical evaluations include a family history assessment, as CPP is inherited from the parents; rapid growth in the mother at or before age 10 years after menarche or in the father before age 12 years suggests autosomal dominant inheritance. Doctors should ask families about such issues as whether the child has been exposed to birth control pills, estrogen ointment or testosterone gel, certain essential oils such as lavender and tea tree oil, and other potentially exogenous steroid hormones. The researchers write, “Families should also be asked about the presence of any central nervous system symptoms, including severe frequent headaches or near visual impairment, and a history of CPP disorders, including brain tumors, meningitis, CNS trauma, cranial irradiation, hypoxic-ischemic injury, histiocytosis, and neurofibromatosis.” Diagnostic evaluation for central precocious puberty typically includes bone age determination, basic laboratory testing for follicle-stimulating hormone, luteinizing hormone, estradiol, and testosterone levels, and possibly pelvic ultrasound, although these tests may be done by a pediatric endocrinologist. Expert Comment: There are many variations in the development of puberty, depending on the family, the child, and other factors. For example, a relatively thin and unstimulated child with symptoms of puberty may be too early for puberty to occur at age 9 or 9.5 years. Central precocious puberty may be idiopathic, but conditions that stimulate premature activation of puberty in the brain, such as car accidents, meningitis, radiation, or whatever, will likely occur at any age. The initial steps in the evaluation of precocious puberty are an assessment of family history followed by a thorough physical examination to determine what factors activate the onset of puberty, such as central, peripheral or exogenous hormone production/exposure. In addition, they will observe the development of puberty to help determine if the pubertal findings are normal variants or if a little additional guidance and evaluation is also needed.