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Melanie: There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole. And today, we are talking about potential puberty and growth issues. This is an important show for all parents who might be worried about their kids' growth to listen to.

Joining me in this panel are Dr. Zoltan Antal, he's the Chief of Pediatric Endocrinology and the Director of the Pediatric Diabetes Program in the Division of Pediatric Endocrinology at Weill Cornell Medicine; and Dr. Tiffany Schumaker, she's an Assistant Professor of Clinical Pediatrics at Weill Cornell Medicine and an assistant attending pediatrician at NewYork Presbyterian Phyllis and David Komansky Children's Hospital Weill Cornell Medical Center.

Doctors, thank you so much for joining us today. And Dr. Schumaker, I'd like to start with you. Can you give us a brief overview of normal growth patterns, typical growth before and after puberty. I know, and parents listening know, not all children are the same, but give us, you know, what's sort of normal, what ballpark growth patterns are.

Dr Tiffany Schumaker: Absolutely. So I'm going to start with just normal ages of puberty, because we get asked that a lot. The normal age for a girl to be in puberty is anywhere from about eight to 13 years of age. And the average age to reach your period is about 12-1/2 in the US. And in boys, it's a little bit later, somewhere from about nine years of age to 14 years of age. And I only bring this up because typical growth is sort of dictated by this. So, typical growth before puberty is about two inches per year and, during puberty, is somewhere between three to five inches per year. Now, girls have puberty earlier than boys and also girls have a bigger growth spurt at the beginning of puberty and boys tend to have their bigger growth spurts towards the end of their pubertal development.

Growth slows down at the very end of puberty for both girls and boys. And a lot of people ask about, after you reach your period, how much you grow after that, and typically girls grow about one to three inches after they get their period.

Melanie: So that means if a child is 18, are they done growing? I'm just asking for myself here.

Dr Tiffany Schumaker: No, that's a really good question. So, in a girl typically, yes. So these are all average numbers, but typically girls are done growing or nearly done growing after they get their period and most girls get their periods somewhere between 12 and 13. So by 18 years of age, most girls are done growing. In boys, the question's a little bit harder because more commonly in boys than girls, there can be delayed puberty.

And if your puberty is delayed and you're sort of outside of that window of nine to 14, you can grow until -- this is a very different concept than we're used to -- but you can grow until your bones are about 17 years of age in a boy. But everybody's bones accelerate at different rates. So a boy might reach a bone age of 17 at a chronological age of 19. So boys can grow a little bit later. So 18, I would say most boys are done growing, but it really depends on the age of your bones at your chronological age of 18.

Melanie: Well, I'm going to certainly let my kids know about this. And Dr. Antal, I'd like you to speak about some of the stages of puberty and can puberty affect human growth and development. And if so, I mean, you're both in pediatric endocrinology, which is such a great field, can you tell us a little bit about that? And tell us a little bit about your field.

Dr Zoltan Antal: Absolutely. Yes. Thank you. I think I agree with you. It is a great field, and it's certainly something that every parent has to deal with at one point or another for their children, because all children will go through puberty, right? So when it's time to think about this, I think all parents have questions for their primary care provider, their pediatrician. And many parents make their way to us because they have additional more specific questions about their children.

As far as stages of puberty, it's a little bit difficult to be a hundred percent sure when your child is in puberty, hormonally speaking, because the hormones are often there in the background before you can see anything physically. Typically, the first sign that a girl is in puberty is the onset of breast development. She may feel or experience breast budding, which is often tender and painful. And ultimately, that will progress and continue as she gets older, that's typically the first physical evidence of puberty, but sometimes behind the scenes, the hormones have already started rising.

Same for boys, the equivalent in a boy is enlargement of testicle size, which certainly many parents will not as readily see, for instance, visually, because that's part of an examination that may need to be done by a physician to be able to identify that, but those are the two initial stages of puberty.

And then, subsequent stages build on that. So there are other physical changes, like hair development, acne, deepening of the voice. And ultimately for girls, there's the landmark reaching of the menstrual period and the semi-equivalent in boys really probably of where the voice begins to deepen.

And I just would like to say that those are a mixed bag of symptoms. So they may not occur in an exact sequence. Sometimes you get body odor first, sometimes you get underarm hair or pubic hair first, sometimes there's breast development or testicular enlargement first. So they may begin at different points, but those are the typical areas of puberty that people notice physically.

We give them numbers. So endocrinologists have found a way to categorize stages of puberty. Stage I basically means no real physical or hormonal evidence of puberty. And then we go through stages II through V. And what you would typically consider a physically adult-appearing, sexually-developed mature body habitus is what we refer to as stage V.

Dr Tiffany Schumaker: In addition, a lot of parents come to us and say, "Our pediatrician told us that our child is Tanner 1 or Tanner 2, Tanner 3, Tanner 4, Tanner 5." And these are the stages that Dr. Antal is referring to. They're called Tanner stages. So a lot of parents come into our office after they've been referred to us by their pediatrician, and they are curious what Tanner stages are, and that is exactly what Dr. Antal is describing.

Melanie: That's probably one of the most comprehensive descriptions of puberty and growth at that time of a child's age that I have really ever heard. So that was excellent, both of you. Thank you. And so Dr. Schumaker, is there this growth window? And if so, when do parents worry that their kids are not really hitting that? You mentioned that they get referred from their pediatrician, primary care provider. When does something like that happen?

Dr Tiffany Schumaker: That's a excellent question. And it's probably one of the most common referrals that we get regarding growth. So, I'll start off by just saying that a lot of the referrals that we get or when a parent should be worried is when they're either seeing a child growing slower than they had been in the previous year. For example, they were previously at the 50th percentile and then the next year at their pediatrician well-child check, they were at the 30th percentile. That would be something that I would be concerned about because most children even before puberty are staying on a pretty steady line. So if you're on the 50th percentile one year, you should be near the 50th percentile the next year. So that would be one reason for a referral to an endocrinologist.

Another reason for a referral is, for example, if you are discrepant from your genetic potential, meaning that your entire family is very tall, your mom and dad are quite tall and you have a child that is below the curve or very discrepant from what their parents should have given them in terms of genetics, that would be another reason for referral.

And in terms of referral for puberty, obviously going over the ages, either puberty that you're noticing your child before the ages that we spoke about, so before eight in a girl or before nine in a boy, or very delayed, meaning that you have not seen any breast development or testicular enlargement by 13 in a girl or 14 in a boy would warrant a referral.

In terms of this growth window, that's a more complicated question. But in terms the actual window, children grow before and during puberty. And once puberty is over, the growth window tends to slow and then come to an end. So really the biggest marker we have, which is a bit more complicated and more complicated to explain to parents, is this concept of a bone age. So we often get parents that come in and either have brought us an x-ray of their child's hand from their pediatrician, which tells me their bone age, or they come in after reading online that they would like their child to have a bone age. What a bone age means is that it is a measure of your child's actual age, what their bones think they are, which is not always in line with the chronological age.

And the reason why this concept is so important is because the window of growth is until your bones are about 14 in a girl and then about 17 in a boy. So that window of growth that we all talk about is anytime before 14 in a girl, a bone age of 14, or a bone age of 17 in a boy. And obviously, the earlier you address problems of growth, the better the outcomes are because we could treat you and/or address the problems earlier.

Dr Zoltan Antal: Yeah, absolutely. And I would echo that. I think that many children are going to find their own tempo of growth and puberty. And like Dr. Schumaker says, I find it very difficult to explain exactly one particular window of time. Many parents have been told or are aware that they should bring their children before puberty. But there's a lot of time before puberty. So probably age three or four in many children isn't the time yet, because they're still very young and have a lot of room for growth. But I would agree again that I think it depends really on how a child is growing. And the sooner you address a child's whose growth has slowed down, the sooner you can identify any underlying issues. And certainly, I think the bone age will help in many ways quantify the question of the window of growth.

Dr Tiffany Schumaker: And I'll echo that and say that I'm not saying that every child needs a bone age, because oftentimes when you come to our office, we don't think it's necessary. But that's just the more scientific way to know when your window of growth is open or closed.

Melanie: These are such important points for parents. And as a parent whose kids were on the fifth percentile all the way through growing, I know that it can be concerning. And Dr. Antal mentioned breast buds and things. Can you speak, Dr. Antal, about some of the issues that might crop up that they ask you about?

Now, I know in my own family and parents that I know, the daughters get concerned when they do develop those buds. There's bumps. There's lumps. They're like worried about breast cancer at 13 years old, but really some of these things are just what the body's doing, correct? Can you tell us some of the things that go on, whether it's self-esteem, curiosity, mood swings, all of those things?

Dr Zoltan Antal: Yes, absolutely. And I think those are really important points that we often talk about a lot. I find, you know, as a parent myself, again, I find that parents bring in a lot of questions that are very, very relevant, like how will the onset of puberty affect my child's mood, their focus, their behavior. What do I expect at that time? There's this expectation often that the start of hormones will create a very significant change in a child.

And one of the things that we want to point out is that this change in puberty, this evolution over the Tanner stages, is a long process. I mean, the average time from starting the earliest sign of puberty until the time a child has sort of neared or completed pubertal development is a minimum of three years typically and can be as long as five years. In fact, the most recent trend that we're seeing in girls is the onset of earlier breast budding physically, but not necessarily the earlier onset of menstruation. So I often tell parents that there may be a very prolonged period during which you see physical signs of puberty, but it doesn't mean your daughter's going to reach her menstrual cycle early, nor does it mean that the surge of hormones will be so rapid that it will overwhelm him or her and not allow them to sort of continue to participate in their social events and schooling and other activities the same way. So I think that's important for parents to know.

In terms of questions, I find that many children actually handle the physical changes of puberty very, very well, both overall healthy children as well as -- you know, this question often comes up -- children with physical or mental disabilities, how will this impact them? I think the vast majority of children do very, very well.

In situations where children have precocious puberty, where they begin to develop before age eight, that may not be the case. The hormones in a much younger child may affect emotion and physical responsiveness to these changes a little bit differently. And those are the cases where we do sometimes think about whether slowing the progression of puberty medically would be appropriate.

Curiosity is natural and normal physically during adolescence and we try to explain to parents that that's a normal process. Likewise fear is normal. What is this new lump? What is this new growth? Even boys in the middle of puberty will have breast budding, that's a very normal process. I think that should be anticipatory guidance provided by all pediatricians so that boys are not afraid.

So I think it's very important to think about all of these things in advance, normalize it for children, explain to them that this is all something that everyone goes through during adolescence. And if the parents or the children have concerns, to openly talk about them at the visit. And I will say this, I very much think that parents should allow their children to be present for these conversations. And this is just my opinion, but based on my experience, I find that children do extremely well when they're present, when they're listening and when they can hear what this is all about.

I understand parents who are fearful want to protect their children and want to leave them outside the room for these conversations. But I actually think that children get more worried that way and think something is wrong. And when they hear this is a normal, natural hormonal process, they respond very well and do very well moving forward.

Dr Tiffany Schumaker: I completely agree, and that it's very nice to see. I think it's a trend now for a lot of parents to become much more open with their children and talk about puberty and pubertal changes even before they occur. And I think that's been a very nice trend and I think there's a lot of books and things like that to actually read with your children prior to the pubertal onset so that it could be a much more open conversation between parents and children.

Melanie: I'd love to give you each a chance for a final thought for parents. So, Dr. Antal, I'd like to start with you. Just kind of briefly, we don't have a lot of time, but just briefly speak about some of the treatment options that are out there for parents that do really worry. And for kids that are having growth issues, I mean, what's going on in your field? Tell us about some of the options you might consider with parents.

Dr Zoltan Antal: Absolutely. So I think that there are two different treatments that people think about. One is accelerating growth in children who are not growing properly. So that would be a child who is going through puberty, but maybe has an underlying medical condition that we identify or perhaps we can't identify, but truly leads to them growing slowly. Typically, that is growth hormone, but there are considerations for that for children who are not growing at an adequate rate during puberty. And then specifically targeting pubertal development, there's the opportunity to slow or stop the hormonal process or the hormonal flow, which is causing puberty to progress. So in other words, you can slow or stop the progression of puberty.

I think those are frequently not necessary. Most children do very well without them. But those are opportunities to slow down the process of puberty or to improve on the height potential of children. And I think that what is great is that over time we have learned more and more that these treatments are effective and they're helpful in many children. Equally importantly, we've learned that very often, they're not necessary. And so just identifying that things are going properly, providing the right anticipatory guidance is the key. But really parents should know that if there is a concern and something is identified, that there are ways to help your children during these crucial years, reach their height potential and also help them adjust in the right tempo and the right timing to their pubertal development.

Melanie: And Dr. Schumaker, last word to you, what would you like parents to know about navigating the difficult time of pre-pubescent, pre-teen, teenagers, puberty, and then just right after, because this is just such a whirlwind time for families. And we've learned more and more about the teenage brain and what they're going through, and it can be quite a confusing time for all. So give us your best advice, what you'd like parents to know, and really when you think it's important that they speak with a pediatric endocrinologist.

Dr Tiffany Schumaker: So my biggest message to parents regarding pubertal development is basically just to be open and to answer questions ideally before the onset of puberty, just to normalize all of this. And once pubertal changes start in boys or girls, if there are any questions, meaning it's too early, it's too late or even if everything seems normal, but the children have questions, that pediatric endocrinologists are available and we are happy to answer questions and figure out if there is any pathology or anything to worry about, or if this is just normal development. But I think the biggest thing is just to be open with your children and have them feel open to ask you questions, just to make sure that they're feeling comfortable with how they're developing.

Melanie: That's great advice and getting the kids involved is such a good point that Dr. Antal made. And thank you both for joining us today and sharing your incredible expertise for parents. To learn more about the Division of Pediatric Endocrinology, you can visit weillcornell.org/pedsendo. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download subscribe, rate, and review Kids Health Cast on Apple Podcasts, Spotify and Google Podcasts. For more health tips like you got here today, visit weillcornell.org and search podcasts. And don't forget to check out our Back To Health series. I'm Melanie Cole.