Marcia E. Herman-Giddens

Secondary sexual characteristics in boys: data from the Pediatric Research in Office Settings Network.

BACKGROUND: Data from racially and ethnically diverse US boys are needed to determine ages of onset of secondary sexual characteristics and examine secular trends. Current international studies suggest earlier puberty in boys than previous studies, following recent trend in girls. METHODS: Two hundred and twelve practitioners collected Tanner stage and testicular volume data on 4131 boys seen for well-child care in 144 pediatric offices across the United States. Data were analyzed for prevalence and mean ages of onset of sexual maturity markers. RESULTS: Mean ages for onset of Tanner 2 genital development for non-Hispanic white, African American, and Hispanic boys were 10.14, 9.14, and 10.04 years and for stage 2 pubic hair, 11.47, 10.25, and 11.43 years respectively. Mean years for achieving testicular volumes of ≥3 mL were 9.95 for white, 9.71 for African American, and 9.63 for Hispanic boys; and for ≥4 mL were 11.46, 11.75, and 11.29 respectively. African American boys showed earlier (P < .0001) mean ages for stage 2 to 4 genital development and stage 2 to 4 pubic hair than white and Hispanic boys. No statistical differences were observed between white and Hispanic boys. CONCLUSIONS: Observed mean ages of beginning genital and pubic hair growth and early testicular volumes were 6 months to 2 years earlier than in past studies, depending on the characteristic and race/ethnicity. The causes and public health implications of this apparent shift in US boys to a lower age of onset for the development of secondary sexual characteristics in US boys needs further exploration.

Association of coexisting vaginal infections and multiple abusers in female children with genital warts

All 11 girls less than 12 years of age presenting to the pediatric clinic between 1980 and 1986 with genital warts were evaluated by the Child Protection Team for possible sexual abuse. Nine of the 11 girls had condylomata acuminata, and two had verruca vulgaris. Ten of the 11 had historical and/or physical evidence other than the warts that confirmed sexual abuse. Six girls had coexisting vaginal infections such as bacterial vaginosis and infections due to various pathogens including Neisseria gonorrhoeae, Trichomonas vaginalis, Ureaplasma urealyticum, and Mycoplasma hominis. These six girls were known (three) or suspected (three) of being abused by multiple perpetrators. None of the five girls with a known or suspected single abuser had coexisting vaginal infections (P = less than 0.02, Fishers exact test). We conclude that almost all genital warts in girls are sexually transmitted and that girls presenting with anogenital warts should be evaluated for other genito-vaginal infections and sexual abuse. Multiple vaginal infections in childhood, with organisms that are sexually transmitted or associated with sexual activity, may be a marker for abuse by multiple perpetrators.

Is race or ethnicity a predictive factor in Shaken Baby Syndrome

OBJECTIVE Previous studies have concluded that shaken baby syndrome occurs more often among Whites than among Blacks. The purpose of this study was to determine whether race is a predictive factor in Shaken Baby Syndrome when population and referral patterns are considered. METHODS A retrospective medical record review of closed head injuries due to child abuse during the time period January 1992 to July 1997 was conducted at three pediatric tertiary care medical centers in North Carolina. Patients included children, ages 0-4 years, identified from medical record reviews and child abuse databases. Only North Carolina residents were included. The specific rates of shaken baby syndrome in Whites versus non-Whites in the referral area were computed. RESULTS The difference in the rate of shaken baby syndrome from the referral area was not statistically significant among Whites versus non-Whites (26.7/100,000 versus 38.6/100,000, p = .089) Most of the perpetrators were male (68%), and most victims (76%), lived with their mothers and biologic father or mothers boyfriend. CONCLUSION Race was not a significant factor in predicting shaken baby syndrome in the referral area studied, and therefore is not a useful factor in targeting groups for intervention.

Timing of Puberty in Overweight Versus Obese Boys

BACKGROUND AND OBJECTIVE: Studies of the relationship of weight status with timing of puberty in boys have been mixed. This study examined whether overweight and obesity are associated with differences in the timing of puberty in US boys. METHODS: We reanalyzed recent community-based pubertal data from the American Academy of Pediatrics’ Pediatric Research in Office Settings study in which trained clinicians assessed boys 6 to 16 years for height, weight, Tanner stages, testicular volume (TV), and other pubertal variables. We classified children based on BMI as normal weight, overweight, or obese and compared median age at a given Tanner stage or greater by weight class using probit and ordinal probit models and a Bayesian approach. RESULTS: Half of boys (49.9%, n = 1931) were white, 25.8% (n = 1000) were African American, and 24.3% (n = 941) were Hispanic. For genital development in white and African American boys across a variety of Tanner stages, we found earlier puberty in overweight compared with normal weight boys, and later puberty in obese compared with overweight, but no significant differences for Hispanics. For TV (≥3 mL or ≥4 mL), our findings support earlier puberty for overweight compared with normal weight white boys. CONCLUSIONS: In a large, racially diverse, community-based sample of US boys, we found evidence of earlier puberty for overweight compared with normal or obese, and later puberty for obese boys compared with normal and overweight boys. Additional studies are needed to understand the possible relationships among race/ethnicity, gender, BMI, and the timing of pubertal development.

Childbearing Patterns in a Cohort of Women Sexually Abused as Children

Previous studies have suggested that women with a history of sexual abuse are more likely to become pregnant as adolescents than nonabused peers. We examined a cohort of 734 mothers ages 12 to 42 selected from 1985 to 1987 for participation in a longitudinal investigation for any relationship between sexual abuse prior to age 18 and childbearing characteristics, including their age at the birth of their first child as well as parity. Thirty-two percent reported sexual abuse. After controlling for poverty, race, maternal education, marital status, and age, there was no significant difference between the abused and nonabused mothers in their age at first birth; however, parity was higher for the sexually abused group. Fifty-five percent of mothers with a sexual abuse history had had more than one child as opposed to 39% of the nonabused mothers (p < 0.0001).

Prevalence of secondary sexual characteristics in a population of North Carolina girls ages 3 to 10

Abstract Little data on the prevalence of secondary sexual characteristics in young children exist despite common assumptions that longitudinal studies such as Marshall and Tanners 1 provided this information. To have a basis on which to compare the development of sexually abused girls, we undertook a cross-sectional prevalence study of 525 girls ages 3–10 from five county health departments and two private practices who presented for a physical examination. Clinicians after training recorded pubertal stages according to Tanner. Although the literature states that less than 1% of girls have breast development or pubic hair prior to age 8, we found a much higher percent: at least 25% of the black girls and 9% of the white girls at age 6 had some breast development or pubic hair. Age-adjusted prevalences of breast and pubic hair development were significantly higher in blacks than in whites. This study suggests the need for a large scale survey beginning at an early age to develop racial norms by age and geographical area.

Navigating Recent Articles on Girls' Puberty: Where Should Our Patients Go for Evaluation?

first day. This can cause hypernatremia, which, similar to hyponatremia, results in brain injury or death (as pediatricians active 40 years ago vividly remember). To restore ECF before maintenance therapy is begun, many emergency departments initially give isotonic saline, 5 mL/kg per hour for 6 to 12 hours. After this, maintenance needs often can be met by oral fluids, but they will be safely met by IV maintenance therapy when given in recommended amounts. We proposed the more robust response of giving isotonic saline at a rate of 10 mL/kg per hour for 2 to 4 hours. This rapidly and safely expands ECF, suppresses ADH if elevated, and initiates normal urine flow.

The Enigmatic Pursuit of Puberty in Girls

* Abbreviations: BCERC — : Breast Cancer and the Environment Research Centers NHANES — : National Health and Nutrition Examination Survey PROS — : Pediatric Research in Office Settings Nuances of puberty, the actual trigger, influencing factors, secular and tempo changes, continue to plague us. Uncertainty, as in quantum physics, may continue. Niels Bohr concluded decades ago that what you see depends on how you look. In the robust Breast Cancer and the Environment Research Centers (BCERC) study in this issue of Pediatrics by Biro et al, onset of Tanner 2 breast development is the main end point.1 This article adds to studies providing the unsettling findings that the age of onset of breast development, in synch with, though not entirely explained by, the “obesity epidemic,” has continued to drop. It will inspire continued investigations of causes and implications for psychosocial public health. Remedies will follow. The 1997 cross-sectional Pediatric Research in Office Settings (PROS) study on 17 000 US girls, followed by nationally representative data from the National Health and Nutrition Examination Survey III (NHANES), reported earlier onset of secondary sexual characteristics in girls over the previous several decades.2 The considerable controversy and angst generated by these findings led to lay and scientific essays and studies here and abroad. … Address correspondence to Marcia E. Herman-Giddens, PA, DrPH, 1450 Russell Chapel Rd, Pittsboro, NC 27312. E-mail: mherman-giddens{at}unc.edu

Tick-borne diseases in the South-East need human studies: Lyme disease, STARI and beyond.

To the editor: Stromdahl and Hickling have presented a valuable review of human tick-borne diseases (TBD) in the south-east in their recent article, ‘Aetiology of Tick-borne Human Diseases with Emphasis on the South-Eastern United States’ (Stromdahl and Hickling, 2012). Interestingly, they also supply new data from the Department of Defense gathered from military bases in the south. Southerners will benefit from their warning of increased risk of contracting a growing number of TBDs including Lyme disease and that medical providers’ tick-related knowledge is usually weak. As pointed out, the lone star tick, Amblyomma americanum, is now the most abundant tick in the south-east and is certainly the most aggressive. This tick and Ixodes scapularis are now sympatric over much of the Eastern United States. Amblyomma americanum was noted to have extended as far north as New Jersey 30 years ago (Schulze et al., 1984) and has now surpassed I. scapularis populations there (Schulze et al., 2005). It reached Maine at least 15 years ago (Keirans and Lacombe, 1998). The lone star tick is responsible for much human misery, controversy and, because of so many unknowns, improperly treated human conditions. Amblyomma americanum tick larvae have not been thought to transmit human pathogens, as stated in the review. It is hoped that researchers will look at the question of whether the spirochaete Borrelia miyamotoi, not mentioned by the Stromdahl and Hickling, may be vectored by the lone star tick. In other ticks, transovarial and transstadial transmission has been documented for this spirochaete (Scoles et al., 2001; Barbour et al., 2009). In Tennessee, a study found that 70% of studied turkeys were infested with juvenile A. americanum, and 58% were positive for the B. miyamotoi in either tissue or blood (Scott et al., 2010). In Russia, Borrelia miyamotoi has been shown to cause human disease manifesting as influenza-like illness with high fever, a relapsing febrile illness pattern in some and occasional (EM) rashes Erythema migrans (Platonov et al., 2011). If B. miyamotoi can even occasionally be vectored by lone star ticks, it could account for some of the Lyme-like illness seen in the south because many southerners can get dozens to hundreds of bites in a season, especially if a nest of newly hatched larvae is encountered. The enigma of Lyme-like disease in the south-east persists, especially in the form of southern tick-associated rash illness (STARI) or Masters disease. It may be the time to reinvestigate whether the lone star can occasionally transmit Borrelia burgdorferi because it is known to occasionally carry this organism. The oft-mentioned borreliacidal action of A. americanum saliva (Ledin et al., 2005) is not 100%– after 48 h, just under 13% of saliva-exposed B. burgdorferi were still alive, not 0%. Given the frequency of lone star tick bites, some B. burgdorferi could possibly pass through to a human. One of several studies on whether lone star ticks can transmit B. burgdorferi based part of their finding of lack of transmission on only three ticks, stating the lone stars did not feed well on rodents. In the same study, Dermacentor virabilis had some susceptibility but did not maintain the infection transstadially (Piesman and Happ, 1997) suggesting this tick be restudied, as well. Unfortunately, the dogma that there is little to no Lyme disease in the south continues to be repeated by numerous publications citing flawed case report numbers and ‘confirmed’ by studies seeking to prove the dogma. Because there is so much Lyme-like illness in the south as well as documented Lyme disease, we need studies that question how Lyme disease is being transmitted in the south-east. It is known that locally acquired cases do occur, that there is more genetic variation in southern strains of Borrelia burgdorferi sensu lato (Lin et al., 2001) than northern, that the spirochaete is well established in many areas (Lin et al., 2001; Clark, 2004; Harrison et al., 2010; Smith et al., 2010) and that the ‘northern’ tick-borne organisms Anaplasma phagocytophilum and Babesia microti are established in some areas of the south (Clark, 2012a; Clark et al., 2012b). Some northern areas endemic for Lyme disease now have endemic A. americanum populations. STARI cases in these areas are likely to be subsumed as Lyme disease (except in the rare case the lone star tick is brought in by the patient), leading to artificially high reports of Lyme disease (Feder et al., 2011). Erythema migrans (EM) rashes tend to be accepted as Lyme disease cases for public health reporting in the north regardless of presumed county of acquisition or travel history. Reporting differs in the south. For example, North Carolina now has three counties endemic by the Centres for Disease Control (CDC) criteria for Lyme disease; thus, physician-diagnosed EM rashes in these counties meet LD reporting criteria. EM patients who are residents

Puberty Is Starting Earlier in the 21st Century

Determining trend directions in ages of pubertal charateristics with certainty in U. S. studies is not possible because studies using similar methods and measurement techniques do not exit, with the exception of the menarcheal data from the government surveys. Taking the methodological differences into account, the data for girls since the 1940s support a continued decline, through less steep than that during the later 1800 s and early 1900s as based on menarcheal data. Modern girls appear to start development 5 months to a year earlier than those of 30 to 50 years ago with a longer tempo from onset to menses. The data from NHES and NHANES on menarche are exactly comparable and show a statistically significant drop of over a month per decade in the last 30 years to 12.34 years of age for white girls and 12.06 for black girls. Fewer studies exist for boys and the data are only cautiously suggestive of lessening trend. Testicular measurement has not been used in U. S. studies. Data since the 1940s show a very slight downward trend in onset of public hair growth for white boys. The most recent NHANES data on genitial growth would indicate a younger age as compared with several decades ago (onset of G2 now 10.1 and 9.5 years of age for white and black boys respectively from the 1988–1992 data set) however; the reliability of the assessments has been questioned. The American Academy of Pediatrics Pediatric Research in Office Settings study in the field since 2006 will provide much needed data.