Sedentary lifestyle and precocious puberty in girls during the COVID-19 pandemic: an Italian experience

Precocious puberty, pandemic and beyond

WHO declared SARS-COVID19 a pandemic in March 2020. Most governments declared health emergency states and implemented various measures. Since then, changes in the reasons for medical consultations were observed in healthcare institutions. Pediatric endocrinologists perceived an increase in the number of consultations related to early or accelerated CPP during the months following the lockdown that different governments had established. Several papers reported the increment in incidence in Central Precocious Puberty, especially in girls. Reports from different parts of the world highlighted a two to threefold rise in the number of cases of precocious puberty treated in Pediatric Endocrinology Centers. This trend of CPP incidence strongly suggests that changes in habits and the environment in which boys and girls were immersed during the lockdown, have played a significant role in triggering the early onset of the gonadotrophic axis.

Navigating Pubertal Goldilocks: The Optimal Pace for Hierarchical Brain Organization

Adolescence is a timed process with an onset, tempo, and duration. Nevertheless, the temporal dimension, especially the pace of maturation, remains an insufficiently studied aspect of developmental progression. The primary objective is to estimate the precise influence of pubertal maturational tempo on the configuration of associative brain regions. To this end, the connection between maturational stages and the level of hierarchical organization of large-scale brain networks in 12-13-year-old females is analyzed. Skeletal maturity is used as a proxy for pubertal progress. The degree of maturity is defined by the difference between bone age and chronological age. To assess the level of hierarchical organization in the brain, the temporal dynamic of closed eye resting state high-density electroencephalography (EEG) in the alpha frequency range is analyzed. Different levels of hierarchical order are captured by the measured asymmetry in the directionality of information flow between different regions. The calculated EEG-based entropy production of participant groups is then compared with accelerated, average, and decelerated maturity. Results indicate that an average maturational trajectory optimally aligns with cerebral hierarchical order, and both accelerated and decelerated timelines result in diminished cortical organization. This suggests that a "Goldilocks rule" of brain development is favoring a particular maturational tempo.

COVID-19 lockdown and the rate of central precocious puberty

PURPOSE

The aim of our study was to compare the incidence of idiopathic central precocious puberty (CPP) in our highly specialized Endocrinological Center before and after the onset of COVID-19 lockdown; we also aimed to identify any potential difference between girls with CPP from the two different time periods.

METHODS

We retrospectively analyzed the auxological profile of 49 girls with idiopathic CPP: 30 with pre-lockdown onset and 19 with post-lockdown onset of the disease. We collected patients' characteristics (medical history, physical examination, baseline and dynamic hormonal assessment, bone age, pelvic ultrasound) and compared them between the two groups.

RESULTS

We registered an almost threefold increase in CPP incidence in the 2020-2021 period compared to the previous six years. In post-lockdown patients we found a trend for an earlier diagnosis in terms of both chronological age (p 0.0866) and days between the onset of first pubertal signs and diagnosis (p 0.0618). We also found that post-lockdown patients had a significantly lower hypothalamus-pituitary-gonadal axis activation (lower ∆LH% after GnRH test, p 0.0497), a significantly lower increase in bone age calculated at RUS with TW3 method (p 0.0438) and a significantly reduced ovarian activation in females (lower delta-4-androstenedione levels, p 0.0115). Interestingly, post-lockdown patients were born from mothers with an older age at menarche (p 0.0039).

CONCLUSIONS

Besides confirming a significant increase in new diagnoses of CPP in the post-lockdown period, our findings among Post-lockdown girls also suggest a less progressive form of CPP and a stronger environmental influence compared to genetic background in determining the timing of pubertal onset.

Increases in pediatric cholecystectomy during the COVID-19 pandemic: An interrupted time series analysis

BACKGROUND

Historically, cholecystectomy is infrequently performed in children. Lifestyle changes, delays in healthcare access, and increases in childhood obesity occurred during the COVID-2019 pandemic. It is unclear whether these changes impacted pediatric gallbladder disease and the need for cholecystectomy.

METHODS

A retrospective study of children ≤18 years old undergoing cholecystectomy from January 1, 2016, to July 31, 2022, at a tertiary children's hospital was conducted. On March 19, 2020, a statewide mandatory coronavirus disease 2019 stay-at-home policy began. Differences in children undergoing cholecystectomy before and during the pandemic were identified using bivariate comparisons. An interrupted time series analysis identified differences in case volume trends.

RESULTS

Overall, 633 children were identified-293 pre-pandemic and 340 pandemic. A majority were female sex (76.3%) and Hispanic (67.5%), with a median age of 15 years (interquartile range: 13.0-16.0). Children who underwent cholecystectomy during the pandemic had significantly higher body mass index (28.4 versus 25.8, P = .002), and obesity (body mass index >30) was more common (45.3% versus 31.7%, P = .001). During the pandemic, significant increases in complicated biliary disease occurred-symptomatic cholelithiasis decreased (41.5% versus 61.8%, P < .001) and choledocholithiasis (17.9% versus 11.6%, P = .026), gallstone pancreatitis (17.4% versus 10.6%, P = .015), and chronic cholecystitis (4.7% versus 1.0%, P = .007) increased. The number of cholecystectomies performed per month increased during the pandemic, and on interrupted time series analysis, there was a significant increase in month-to-month case count during the pandemic (P = .003).

CONCLUSION

Cholecystectomy case volume significantly increased during the coronavirus disease 2019 pandemic, possibly secondary to increases in childhood obesity. Future studies are needed to determine whether this increased frequency of pediatric cholecystectomy is representative of broader shifts in pediatric health and healthcare use after coronavirus disease 2019.

Early Puberty Trend during the COVID-19 Pandemic in Singapore: A Retrospective Review in a Single Tertiary Centre

Objectives

We aimed to study the trend of referrals for precocious puberty during the COVID-19 pandemic compared to pre-COVID years, explore the differences in the demographic and clinical features, and evaluate the contributing factors.

Methodology

The cases referred for assessment of PP from 2018-2021 to our endocrine centre were grouped into pre-COVID (2018-2019) and COVID (2020-2021) years. Cases fulfilling the diagnosis of PP included the onset of thelarche <8 years in females and 4 ml testicular volume <9 years in males. The PP was further differentiated as Isolated Thelarche (IST) and Central Precocious Puberty (CPP). Early menarche was defined as menarche <10 years old.

Results

There were more referrals for PP and more diagnosed as CPP during the COVID-19 pandemic, predominantly among females. There were more endocrine tests done and more cases received treatment. None of the abnormal magnetic resonance imaging (MRI) pituitary findings required surgical intervention. The body mass index (BMI) was found to be positively associated with the risk of getting CPP with a crude-odd ratio (COR) of 1.8, P <0.001, and early menarche (COR 2.1, P <0.001).

Conclusion

We found a significant increase in the referrals of PP and diagnosis of CPP during the COVID-19 pandemic. Higher BMI was found to be associated with CPP and early menarche.

Effects of Blue Light on Puberty and Ovary in Female Rats

Objective

This study was designed to examine the effect of blue light exposure and exposure time on puberty in an animal model.

Methods

Eighteen 21-day-old female Sprague Dawley rats were divided into three equal groups which were: control group (CG); blue light-6 hours (BL-6); and blue light-12 hours (BL-12). CG rats were maintained with 12/12-hour light-dark cycles. The animals in BL-6 and BL-12 were exposed to blue light of wavelength 450-470 nm and intensity of 0.03 uW/cm2 for 6 and 12 hours, respectively. Exposure to blue light continued until the first signs of puberty. Serum follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol, testosterone, dehydroepiandrosterone sulfate (DHEA-S), leptin and melatonin were measured. Subsequently the ovaries and uterus were examined histomorphologically.

Results

The median day of puberty start was 38, 32 and 30 for the CG, BL-6, and BL-12 groups, respectively (p=0.001). FSH, testosterone, DHEA-S, and leptin concentrations of all groups were similar. However, LH and estradiol concentrations in BL-6 were higher compared to CG (p=0.02). There was a negative correlation between blue light exposure, exposure time, and melatonin concentrations (r=-0.537, p=0.048). Ovarian tissue was compatible with puberty in all groups. As blue light exposure time increased, capillary dilatation and edema in the ovarian tissue increased. Prolonged exposure was associated with polycystic ovary-like (PCO) morphological changes and apoptosis in granulosa cells.

Conclusion

These results suggest that exposure to blue light and the duration of exposure induced earlier puberty in female rats. As the duration of blue light exposure increased, PCO-like inflammation, and apoptosis were detected in the ovaries.

Clinical Management and Therapy of Precocious Puberty in the Sapienza University Pediatrics Hospital of Rome, Italy

Puberty identifies the transition from childhood to adulthood. Precocious puberty is the onset of signs of pubertal development before age eight in girls and before age nine in boys, it has an incidence of 1/5000-1/10,000 with an F:M ratio ranging from 3:1 to 20:1. Precocious puberty can be divided into central, also known as gonadotropin-dependent precocious puberty or true precocious puberty, and peripheral, also recognized as gonadotropin-independent precocious puberty or precocious pseudopuberty. Thus, the main aim of this narrative report is to describe the standard clinical management and therapy of precocious puberty according to the experience and expertise of pediatricians and pediatric endocrinologists at Policlinico Umberto I, Sapienza University of Rome, Italy. In the suspicion of early sexual maturation, it is important to collect information regarding the age of onset, the speed of maturation of secondary sexual features, exposure to exogenous sex steroids and the presence of neurological symptoms. The objective examination, in addition to the evaluation of secondary sexual characteristics, must also include the evaluation of auxological parameters. Initial laboratory investigations should include serum gonadotropin levels (LH and FSH) and serum levels of the sex steroids. Brain MRI should be performed as indicated by the 2009 Consensus Statement in all boys regardless of chronological age and in all girls with onset of pubertal signs before 6 years of age. The gold standard in the treatment of central precocious puberty is represented by GnRH analogs, whereas, as far as peripheral forms are concerned, the triggering cause must be identified and treated. At the moment there are no reliable data establishing the criteria for discontinuation of GnRH analog therapy. However, numerous pieces of evidence suggest that the therapy should be suspended at the physiological age at which puberty occurs.

Pediatric endocrinopathies related to COVID-19: an update

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the seventh coronavirus to be linked to human disease. The SARS-CoV-2 virus may have several pathophysiologic interactions with endocrine systems, resulting in disruptions in glucose metabolism, hypothalamus and pituitary function, adrenal function, and mineral metabolism. An increasing amount of evidence demonstrates both the influence of underlying endocrine abnormalities on the outcome of COVID-19 and the effect of the SARS-CoV-2 virus on endocrine systems. However, a systematic examination of the link to pediatric endocrine diseases has been missing.

DATA SOURCES

The purpose of this review is to discuss the impact of SARS-CoV-2 infection on endocrine systems and to summarize the available knowledge on COVID-19 consequences in children with underlying endocrine abnormalities. For this purpose, a literature search was conducted in EMBASE, and data that were discussed about the effects of COVID-19 on endocrine systems were used in the current study.

RESULTS

Treatment suggestions were provided for endocrinopathies associated with SARS-CoV-2 infection.

CONCLUSIONS

With the global outbreak of COVID-19, it is critical for pediatric endocrinologists to understand how SARS-CoV-2 interacts with the endocrine system and the therapeutic concerns for children with underlying problems who develop COVID-19. While children and adults share certain risk factors for SARS-CoV-2 infection sequelae, it is becoming obvious that pediatric responses are different and that adult study results cannot be generalized. While pediatric research gives some insight, it also shows the need for more study in this area.

Role of luteinizing hormone urinary levels in the diagnostic and therapeutic management of female central precocious puberty

BACKGROUND

Diagnosing central precocious puberty (CPP) requires an integrated approach based on clinical, biochemical and instrumental data. The diagnostic gold standard is represented by GnRH (gonadotropin-releasing hormone) stimulation test. Some undoubted limitations of this procedure led the international scientific community to look for cheaper and less invasive alternative diagnostic methods, such as luteinizing hormone urinary levels (uLH) measurement. This study aims to define the reliability of urinary LH levels as a biomarker of pubertal development, both concerning the initial diagnostic management and the monitoring of patients with central precocious puberty undergoing therapy with GnRH analogues. Furthermore, the study plans to detect the potential association between LH peak serum (pLH) and urinary LH in patients undergoing diagnostic tests with GnRH and to identify a possible cut-off of uLH that may be suggestive of ensued successful hormonal stimulation.

METHODS

The study includes 130 female patients with suspected precocious puberty or in follow-up during suppressive therapy. After the collection of the informed consent, the patients underwent clinical evaluation, auxological assessment, and hormone assays (basal levels of LH, FSH, and oestradiol; GnRH stimulating test in patients with suspected precocious puberty; urinary LH assay on the first-morning urine sample, collected after waking up).

RESULTS

Two uLH cut-off values have been identified: the first of 0.25 UI/L [C.I. 95% 0.23-0.27], able to distinguish between pubertal and pre-pubertal patients, the second of 0.45 UI/L [C.I. 95% 0,20 - 0,70] suggestive of occurred hormonal stimulation in patients with diagnosis of CPP at GnRH test. All 30 patients with CPP in follow-up during suppressive therapy presented uLH values ≤ 0.45 IU/L (pU < 0.05), and uLH collected in prepubertal group control.

CONCLUSIONS

uLH assays on the first morning urine specimen could be considered a low-cost and minimally invasive tool for precocious puberty diagnosing and monitoring, making possible to be easily performed even by a general pediatrician. Thus, this could help referring only selected patients to pediatric endocrinologists. After an appropriate validation, this approach could reasonably reduce hospital attendance and costs of performing more invasive procedures, with a more significant emotional impact on the pediatric patient.

Endocrinological Involvement in Children and Adolescents Affected by COVID-19: A Narrative Review

Since the advent of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, an increased incidence of several endocrinological anomalies in acute-phase and/or long-term complications has been described. The aim of this review is to provide a broad overview of the available literature regarding changes in the worldwide epidemiology of endocrinological involvement in children since December 2019 and to report the evidence supporting its association with coronavirus disease 2019 (COVID-19). Although little is known regarding the involvement of endocrine organs during COVID-19 in children, the current evidence in adults and epidemiological studies on the pediatric population suggest the presence of a causal association between the virus and endocrinopathies. Untreated transient thyroid dysfunction, sick euthyroid syndrome, nonthyroidal illness syndrome, and hypothalamic-pituitary-adrenal (HPA) axis and central precocious puberty have been observed in children in acute infection and/or during multisystem inflammatory syndrome development. Furthermore, a higher frequency of ketoacidosis at onset in children with a new diagnosis of type 1 diabetes is reported in the literature. Although the direct association between COVID-19 and endocrinological involvement has not been confirmed yet, data on the development of different endocrinopathies in children, both during acute infection and as a result of its long-term complications, have been reported. This information is of primary importance to guide the management of patients with previous or current COVID-19.

Precocious Puberty Diagnoses Spike, COVID-19 Pandemic, and Body Mass Index: Findings From a 4-year Study

Context

Since the COVID-19 outbreak, the number of girls with suspected precocious puberty has increased.

Objective

To compare the incidence of idiopathic central precocious puberty (ICPP) during COVID-19 with that of the previous 4 years.

Methods

Anthropometric, biochemical, and radiological parameters were collected between January 2016 and June 2021 from 133 girls who met the Rapidly Progressive ICPP criteria (RP-ICPP).

Results

We found a higher incidence of RP-ICPP between March 2020 and June 2021 (group 2) compared with January 2016 through March 2020 (group 1) (53.5% vs 41.1%); 2021 showed the highest annual incidence (P < .05). Group 1 and group 2 differed in age at diagnosis (7.96 ± 0.71 vs 7.61 ± 0.94; P < .05), mean Tanner stage (2.86 ± 0.51 vs 2.64 ± 0; P < .05), and in the time between the appearance of thelarche and diagnosis (0.93 ± 0.75 vs 0.71 ± 0.62 years, P < .05). There was an increase in the number of girls aged <8 years in group 2 and a significantly higher number of girls aged >8 years was found in group 1 (42 in group 1 vs 20 in group 2, P < 0.05). Overall body mass index SD score showed higher values ​​in group 2 (1.01 ± 1.23 vs 0.69 ± 1.15; P = .18), which spent an average of 1.94 ± 1.81 hours per day using electronic devices; 88.5% of this group stopped any physical activity.

Conclusions

A spike in new diagnoses of idiopathic (1.79-fold higher) and RP-CPP coincided with the COVID-19 pandemic. The incidence of RP-ICPP was 1.3-fold higher during COVID-19 with a trend toward an increase in body mass index SD score. The expanding use of digital devices and the reduction of daily physical activity represent possible risk factors.

Endocrine manifestations of COVID-19 in children: A scoping review

In this review, we explore associations between SARS CoV-2 infection and the endocrine system and metabolism in children and adolescents. PubMed, Scopus and Google scholar databases were searched to identify published data on endocrine manifestations of COVID-19 in children up to 31 March 2023, including diabetes, obesity, puberty, thyroid disorders, adrenal disorders and pituitary disorders. Data on changes in disease pattern/ incidence, disease control, and other effects due to the COVID-19 pandemic, as well as effects of pre-existing endocrine conditions on severity of COVID-19 infection are presented, and practice points and research needs provided under each section.

Is blue light exposure a cause of precocious puberty in male rats?

Purpose

Our study aimed to examine the effects of blue light exposure on prepubertal male rats' puberty and testis tissue.

Methods

Eighteen 21-day-old male Sprague Dawley rats were divided into three groups consisting of six rats in each group: Control Group (CG), Blue Light-6 hours (BL-6), and Blue Light-12 hours (BL-12). CG rats were maintained with 12/12-hour light-dark cycles. The rats of BL-6 and BL-12 were exposed to blue light (450-470nm/irradiance level 0.03uW/cm2) for 6 hours and 12 hours, respectively. Rats were exposed to blue light until the first signs of puberty. The ELISA method was used to analyze the serum levels of FSH, LH, testosterone, DHEA-S, leptin, ghrelin, melatonin, glutathione, glutathione peroxidase, and malondialdehyde. Testes were dissected for histomorphological examination.

Results

The medians of the pubertal entry days of the CG, BL-6, and BL-12 were 38^th, 30^th, and 28^th days, respectively. (p:0.001) The FSH, LH, and testosterone concentrations of all groups were similar. The FSH concentration increased as the LH concentration increased (r: 0.82 p: 0.001). The serum LH concentration increased as serum testosterone, and DHEAS decreased, respectively (r: -0.561, p: 0.01) (r:-0.55 p:0.01). Testicular lengths and weights of the BL groups were smaller compared to CG (p: 0.03),(p: 0.04). GPx was higher for BL-6 and BL-12 than the CG (p:0.021, p:0.024). Testis tissue was compatible with the pubertal period in all groups. As the blue light exposure time increased, spermatogenesis was suppressed, and capillary dilatation and edema in the testis tissue increased.

Conclusion

Our study is the first to show the effects of blue light exposure on male rats' puberty process. And we showed that exposure to blue light and the duration of exposure lead to precocious puberty in male rats. The blue light exposure suppressed spermatogenesis, marked vasodilatation in the interstitial area of the testis, and disrupted the integrity of the basement membrane. These findings intensified with increasing exposure time.

The Effect of Physical Exercise during COVID-19 Lockdown

The COVID-19 pandemic has exerted an effect on the general population that went over every expectation. To explore the effect of physical exercise (PE) during the national lockdown in Italy, a survey was drawn up and administered to a sample composed of 208 subjects. The questionnaire comprised 81 multiple-choice items, including sociodemographic data, health-related questions, and assessment of physical exercise, satisfaction with life, depression, and personality. The purpose of this study is to explore the role of physical exercise during the outbreak following the present hypothesis: first, if a link exists between the time spent on physical exercise during the lockdown and the perceived health condition, depressive and somatic symptomatology, and life satisfaction; second, to find associations among the SF-12 component summaries and the other psychological outcomes; and finally, to explore how physical and psychological variables are predictive of PCS-12 and MCS-12. The results showed that both vigorous and moderate physical exercise was strongly correlated with psychological variables, with statistically significant negative correlations found between age and physical exercise. Additionally, significant positive correlations were observed between physical exercise and mental health indices, such as MCS-12 and SWLS, whereas negative correlations were found with BDI, PCS-12, and SOM-H. The correlation analysis also revealed that physical and individual mental health summaries were associated with psychological outcomes, with statistically significant negative correlations found between PCS-12 and MCS, PCS-12 and SOM-H, and MCS-12 and BDI scores. Regression analysis showed that physical activities and psychological status both had a direct influence on perceived mental and physical well-being during the lockdown, accounting for 56.7% and 35.5% of the variance, respectively. The p-values for the significant correlations ranged from <0.05 to <0.01. Overall, these findings highlight the importance of physical exercise and psychological well-being in maintaining good health during the pandemic.

Early onset of puberty during COVID-19 pandemic lockdown: experience from two Pediatric Endocrinology Italian Centers

OBJECTIVES

During COVID-19 pandemic lockdown, reports of evaluations for suspected precocious puberty significantly raised. We aimed to assess the increase of precocious puberty in patients referred to Pediatric Endocrinology Units of Brescia (Italy), to determine clinical characteristics of patients undergoing a GnRH stimulation test before and during lockdown and evaluate the role of environmental factors in pubertal development.

METHODS

Clinical and biochemical data of patients undergoing GnRH stimulation test were collected and stratified in two groups: March 2019 - February 2020 (Period 1) and March 2020 - February 2021 (Period 2).

RESULTS

A total number of 391 evaluations for suspected precocious puberty were identified in the two study periods: 183 (46.8%) first visits during Period 1, and 208 (53.2%) in Period 2. Sixty-one patients underwent a GnRH stimulation test (4.1% of first consultations) before the SARS-CoV2 pandemic, and 93 children (8.7%) after the lockdown. Thirty-four new diagnoses of central precocious puberty were registered during Period 1 (2.3%), vs. 45 new cases (4.2%) in Period 2. During lockdown patients evaluated for suspected precocious puberty underwent a stimulation test at younger age than those evaluated before pandemic (median age of 8.2 years vs. 8.4, p=0.04). In Period 2, children showed a median bone age advancement of 0.61 years vs. 1.06 of Period 1 (p=0.03).

CONCLUSIONS

During the COVID-19 pandemic, we observed an increased proportion of consultations for suspected precocious puberty. These children showed lower bone age advancement than observed in pre-lockdown suggesting the influence of pandemic-related lifestyle changes on pubertal development.

Pandemic and precocious puberty - a Google trends study

BACKGROUND

Recent publications from several countries have reported that more young people (mainly girls) are experiencing precocious puberty (PP)/menarche during the coronavirus disease 2019 pandemic compared to the past. This variation is attributed to the stress of confinement, lack of exercise, obesity and disturbed sleep patterns. A common feature of the relevant papers, however, is the small number of reported cases of PP. Studies have shown that searches for diseases on the internet also reflect to some extent the epidemiology of these diseases.

AIM

To estimate, through internet searches for PP, any changes in the epidemiology of PP.

METHODS

We assessed in Google Trends searches for 21 PP-related terms in English internationally (which practically dwarf searches in other languages), in the years 2017-2021. Additionally, we assessed local searches for selected terms, in English and local languages, in countries where a rise in PP has been reported. Searches were collected in Relative Search Volumes format and analyzed using Kendall’s Tau test, with a statistical significance threshold of P < 0.05.

RESULTS

Internationally, searches for three PP-related terms showed no noticeable change over the study period, while searches for eight terms showed a decrease. An increase was found over time in searches for nine PP-related terms. Of the 17 searches in English and local languages, in countries where a rise in PP has been reported, 5 showed a significant increase over time.

CONCLUSION

Over the study period, more than half of the search terms showed little change or declined. The discrepancy between internet searches for PP and the reported increase in the literature is striking. It would be expected that a true increase in the incidence of PP would also be aptly reflected in Google trends. If our findings are valid, the literature may have been biased. The known secular trend of decreasing age of puberty may also have played a role.

COVID-19 pandemic phases and female precocious puberty: The experience of the past 4 years (2019 through 2022) in an Italian tertiary center

OBJECTIVE

Since the outbreak of COVID-19 pandemic, several centers of pediatric endocrinology worldwide have observed a significant increase in the number of girls presenting with precocious or early puberty. We aimed to compare the incidence rates of female precocious puberty before and during the different phases of COVID-19 pandemic.

METHODS

We have retrospectively analyzed all the consultations recorded in the outpatient clinic database of the Endocrinology Unit of Bambino Gesù Children's Hospital, Rome, Italy, from the lockdown start in March 2020 up to September 2020, in comparison with the consultations recorded in the same months of 2019, 2021 and 2022. Age, height, weight, body mass index, Tanner's pubertal stage and bone age at presentation, birth weight, ethnicity, family history of central precocious puberty (CPP), maternal age at menarche, history of adoption were retrieved from clinical records. Serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH) both at baseline and after gonadotropin-releasing hormone (GnRH) stimulation, and basal estradiol levels were collected.

RESULTS

In 2019, 78 girls with suspected precocious puberty were referred for endocrinological consultation, compared to 202 girls in 2020, 158 girls in 2021 and 112 girls in 2022. A significant increase in the proportion of girls diagnosed with rapidly progressive CPP was observed in 2020, compared to 2019 (86/202 vs. 18/78, p<0.01). In the following periods of 2021 and 2022, a gradual decrease in the number of cases of progressive CPP was evident, so much that the number of cases was not significantly different from that observed in 2019 (56/158 in 2021 and 35/112 in 2022, p=0.054 and p=0.216 respectively, compared to 2019).

CONCLUSIONS

Our research suggests that drastic lifestyle changes, such as those imposed by COVID-19 lockdown, and the consequent stress may affect the regulation of pubertal timing. The remarkable increase in CPP cases observed during the 2020 first pandemic wave seems to be reduced in 2021 and 2022, concurrently with the progressive resumption of daily activities. These data seem to support the hypothesis of a direct relationship between profound life-style changes related to the pandemic and the rise in precocious puberty cases.

Precocious puberty under stressful conditions: new understanding and insights from the lessons learnt from international adoptions and the COVID-19 pandemic

Neuro-biological variations in the timing of sexual maturation within a species are part of an evolved strategy that depend on internal and external environmental conditions. An increased incidence of central precocious puberty (CPP) has been described in both adopted and "covid-19 pandemic" children. Until recently, it was hypothesised that the triggers for CPP in internationally adopted children were likely to be better nutrition, greater environmental stability, and improved psychological wellbeing. However, following data collected during and after the coronavirus (COVID-19) global pandemic, other possibilities must be considered. In a society with high levels of child wellbeing, the threat to life presented by an unknown and potentially serious disease and the stressful environment created by lockdowns and other public health measures could trigger earlier pubertal maturation as an evolutionary response to favour early reproduction. The main driver for increased rates of precocious and rapidly progressive puberty during the pandemic could have been the environment of "fear and stress" in schools and households. In many children, CPP may have been triggered by the psychological effects of living without normal social contact, using PPE, being near adults concerned about financial and other issues and the fear of getting ill. The features and time of progression of CPP in children during the pandemic are similar to those observed in adopted children. This review considers the mechanisms regulating puberty with a focus on neurobiological and evolutionary mechanisms, and analyses precocious puberty both during the pandemic and in internationally adopted children searching for common yet unconsidered factors in an attempt to identify the factors which may have acted as triggers. In particular, we focus on stress as a potential factor in the early activation of the hypothalamic-pituitary-gonadal axis and its correlation with rapid sexual maturation.

Oestrogenic Activity in Girls with Signs of Precocious Puberty as Exposure Biomarker to Endocrine Disrupting Chemicals: A Pilot Study

The relationship between endocrine disrupting chemical (EDC) exposure and Precocious Puberty (PP) was investigated in this pilot study, involving girls with signs of PP (P) and pre-pubertal girls (C). Risk factors for PP were assessed through questionnaires, while 17β-oestradiol (E2) levels and oestrogenic activity were quantified on sera. The oestrogenic activity, expressed as E2 equivalent concentration (EEQ), was applied as EDC exposure biomarker. Questionnaires showed a low EDC knowledge, a high EDC exposure, and a potential relationship between some habits at risk for EDC exposure and PP. EEQs were similar between C and P; however, they were significantly higher in girls living in an urban environment than in girls living in a rural environment, suggesting a potential higher EDC exposure in cities. The results of this pilot study highlighted the need to raise awareness on EDCs and can be considered a starting point to clarify the relationship between EDC exposure and PP.

Critical body fat percentage required for puberty onset: the Taiwan Pubertal Longitudinal Study

PURPOSE

Prepubescent body fat percentage (BFP) is associated with puberty onset; however, the association between the timing of puberty onset and BFP remains unclear. This study aimed to determine whether and how the timing of puberty onset is associated with various anthropometric measures, and to investigate the critical time period of the BFP transition before and after puberty.

METHODS

The Taiwan Pubertal Longitudinal Study (TPLS) has a multicenter, population-based prospective cohort and was established in July 2018 at 4 pediatric departments. We included girls aged 6-14 years and boys aged 9-17 years evaluated as having puberty onset and excluded those with precocious puberty diagnosis. The anthropometric measures were collected every 3 months. The main outcome was age at puberty onset. Data were analyzed between July 2018 and September 2020.

RESULTS

For 153 girls and 83 boys, BFP was significantly related to puberty onset for girls. Longitudinal analysis revealed that BFP in the girls was reduced to less than 18% 6 months before puberty and rapidly increased by 2.85% over 3 months, then exceeding 20% before puberty onset. After puberty onset, BFP was no longer lower than 22%.

CONCLUSIONS

BFP is an essential predictor of age at puberty onset. BFP first decreases and then begins to increase 3-6 months before puberty in girls. Parents and schools could monitor the BFP of prepubescent girls every 6 months to predict puberty onset.

The effects of the covid-19 pandemic on puberty: a cross-sectional, multicenter study from Turkey

BACKGROUNDS

During the Coronavirus-19 disease (Covid-19) pandemic it was observed that the number of girls presenting with early puberty had increased. The aim of this study was to carry out a retrospective evaluation of the characteristics of girls who had been referred for evaluation of precocious puberty in five different pediatric endocrinology units, before and during the pandemic.

METHODS

The study participants comprised 359 girls who were assigned into 2 groups a pre-pandemic group (n:214) and a pandemic group (n:145). Those participants (n:99) who had medical records in the follow-up period were classified into 3 subgroups according to the time of presentation and follow-up visits (group-1: first admission and follow-up visit before the pandemic, group-2: first admission before the pandemic, the follow-up visit during the pandemic, group-3: first admission and follow-up visit during the pandemic).

RESULTS

The age at presentation and age at pubertal onset were both significantly lower in the pandemic group than those in the pre-pandemic group(8.1 vs 8.6, p: < 0.001,7.7 vs 7.9,p:0.013, respectively). There was no significant difference between the body mass index standard deviation scores (BMI-SDS) values of the groups (0.57 vs 0.51, p:0.430). The initiation rate of pubertal suppression therapy at the time of presentation was significantly higher in the pandemic group compared to that of the pre-pandemic group (7.7%vs 27.5%), and in groups-2 & 3 compared to group-1, during follow-up (20%&44%vs 8%).

CONCLUSION

Our research showed that the onset of puberty occurred earlier in the pandemic period compared to the previous year, and the need for pubertal suppression therapy increased during the pandemic.

Current evidence on the impact of the COVID-19 pandemic on paediatric endocrine conditions

Severe acute respiratory coronavirus 2 (SARS-CoV-2) interacts with the host cells through its spike protein by binding to the membrane enzyme angiotensin-converting enzyme 2 (ACE2) and it can have a direct effect on endocrine function as ACE2 is expressed in many glands and organs with endocrine function. Furthermore, several endocrine conditions have features that might increase the risk of SARS-CoV-2 infection and the severity and course of the infection, as obesity for the underlying chronic increased inflammatory status and metabolic derangement, and for the possible changes in thyroid function. Vitamin D has immunomodulatory effects, and its deficiency has negative effects. Adrenal insufficiency and excess glucocorticoids affect immune conditions also besides metabolism. This review aims to analyze the rationale for the fear of direct effects of SARS-Cov-2 on endocrinological disorders, to study the influence of pre-existing endocrine disorders on the course of the infection, and the actual data in childhood. Currently, data concerning endocrine function during the pandemic are scarce in childhood and for many aspects definite conclusions cannot be drawn, however, data on properly managed patients with adrenal insufficiency at present are re-assuring. Too little attention has been paid to thyroid function and further studies may be helpful. The available data support a need for adequate vitamin D supplementation, caution in obese patients, monitoring of thyroid function in hospitalized patients, and confirm the need for an awareness campaign for the increased frequency of precocious puberty, rapidly progressive puberty and precocious menarche. The changes in lifestyle, the increased incidence of overweight and the change in the timing of puberty lead also to hypothesize that there might be an increase in ovarian dysfunction, as for example polycystic ovarian disease, and metabolic derangements in the next years, and in the future we might be facing fertility problems. This prompts to be cautious and maintain further surveillance.

Differences in Puberty of Girls before and during the COVID-19 Pandemic

In the COVID-19 pandemic, there was an increase in consultations for precocious puberty. We aim to analyze differences in female puberty before and during the COVID-19 pandemic. A cross-sectional analytical study was designed at the Pediatric Endocrinology Clinic of the University Hospital of the Federal University of Maranhão in São Luis, Brazil. We included 55 girls with precocious puberty, 22 who started puberty during the pandemic and 33 who started puberty before the pandemic. Clinical, anthropometric, laboratory and imaging variables were compared between groups. Statistics were performed to determine if there was a statistical difference between the groups. Girls with puberty during the pandemic had higher Z-scores for weight (1.08 ± 1.29 versus 0.69 ± 0.83; p = 0.04), lower ovarian volume (1.88 ± 0.95 versus 3.15 ± 2.31; p = 0.01), and smaller differences between thelarche noticed by the parents and the diagnosis (6.63 ± 5.21 versus 12.15 ± 9.96; p = 0.02). The association between precocious puberty during the pandemic with higher Z-scores for weight, lower ovarian volume, and a reduction in the time between the perception of pubertal findings by parents and the diagnosis suggests the influence of the pandemic on the normal time of puberty.

Incidence of central precocious puberty more than doubled during COVID-19 pandemic: Single-center retrospective review in the United States

BACKGROUND AND AIM OF THE STUDY

The frequency of new visits for precocious puberty increased during the Covid-19 pandemic in the pediatric endocrinology clinic at Rady Children's Hospital in San Diego, CA, US. A few recent studies have shown an increase in the frequency of Central Precocious Puberty (CPP) in other centers during this pandemic. This study evaluated the change in incidence of new CPP cases requiring treatment with GnRH agonist (GnRHa) at Rady Children's Hospital during the Covid-19 pandemic and compared it to pre-pandemic years.

METHODS

Data were reviewed retrospectively to compare the number of visits of children newly diagnosed with CPP treated with GnRHa during the Covid-19 pandemic (5/2020-4/2021) and before the pandemic (5/2018-4/2019). Clinical and bone maturation data were evaluated as well as differences in timing from diagnosis to onset of treatment. The incidence of CPP requiring treatment for 5 years prior to the pandemic was also reviewed to evaluate for trends over time.

RESULTS

A total of 92 subjects were included. During pre-Covid year, 28 children (1 boy, 27 girls) were treated with GnRHa for CPP out of 2,340 new endocrinology visits (1.2% of patients seen). During Covid-19 year, 64 children (7 boys, 57 girls) were treated out of 2,261 new visits (2.8%). The incidence of new CPP cases requiring GnRHa during the pandemic more than doubled compared to pre-pandemic. Age at onset of treatment, degree of bone age (BA) advancement, time from diagnosis to onset of treatment, and changes in BMI during the pandemic were not different from pre-pandemic.

CONCLUSION

CPP cases requiring GnRHa treatment significantly increased during the first year of the Covid-19 pandemic. This was not related to increased BMI or delay in onset of treatment. Age at diagnosis, degree of bone age advancement, and time from diagnosis to onset of treatment were all similar during the first year of the pandemic compared to the prior year.

Implicating factors in the increase in cases of central precocious puberty (CPP) during the COVID-19 pandemic: Experience of a tertiary centre of pediatric endocrinology and review of the literature

Sexual development is a complex mechanism activated by the hypothalamic-pituitary-gonadal axis. Over the last one hundred years there has been a decline in the age at puberty onset in industrialised countries. Some Italian studies showed an increase in diagnoses of Central Precocious Puberty (CPP) during the COVID-19 pandemic. It is thus supposed that in this period there was an increased impact of factors that can influence pubertal development. Our retrospective monocentric study aimed to confirm the existence of this phenomenon and analysed possible related factors. We retrospectively evaluated clinical, laboratory, radiological and ultrasound (US) data of 154 girls referred to our Tertiary Centre of Paediatric Endocrinology from January 2019 to April 2021 for different forms of Precocious Puberty. We subdivided the cases into subgroups according to the final diagnosis: CPP, Early Puberty (EP), isolated thelarche and isolated pubarche. The observation period was subdivided into: Period 1, before lockdown (1 January 2019 - 8 March 2020) and Period 2, lockdown and the following months (9 March 2020 - 30 April 2021). Period 2 was further divided into "restrictive lockdown period" (Period 2.1) (March 2020 - 14 June 2020, in which the schools were closed) and "less restrictive lockdown period" (Period 2.2) (15 June 2020 - 30 April 2021). We analysed data regarding the use of electronic devices before and during lockdown in a group of girls with CPP diagnosed in Period 2 and we compared the data with that of a control group. Our data show an increase in the number of new diagnoses of CPP during lockdown and in the following months, compared with the previous period. We also detected a higher use of PCs and smartphones in girls with CPP diagnosed in Period 2, compared with the control group. The percentage of the presence of endometrial rhyme detected during the pelvic ultrasound was higher in girls with CPP in Period 2, compared with the previous period. Based on our data we assume there was an environmental effect on pubertal timing that calls our attention to factors such as food, use of electronic devices and stress. We will need further studies to better understand this data.