4. Puberty

Physical Development: What’s Normal? What’s Not?

​Two boys or girls exactly the same age can start or end puberty years apart, yet still fall within what is considered “normal” growth. The timing and speed of a child’s physical development can vary a lot, because it is determined largely by the genes inherited from the parents.

Teen Growth Pattern

Whatever pattern a teen’s growth follows, it is during the pubertal years that your son or daughter grows tall more rapidly than at any other time in a child’s life.

  • Girls: On average, rapid growth occurs around age eleven and a half, but it can begin as early as eight or as late as fourteen.
  • Boys: Usually trail behind by about two years—this is why thirteen-year-old girls can, for a time, be a head taller than thirteen year old boys.

Here’s What Usually Happens

The hands and feet grow first, frequently causing an awkward body appearance. Until the arms and legs catch up, teenagers may seem to trip over their own feet. Next, the boys’ shoulders and girls’ hips get wider and the trunk of the body lengthens. The bones in the face grow too—particularly the lower jaw—bringing about very noticeable changes.

To help you recognize the many changes that can take place during puberty, first remember that every year since the age of two or three, your child has grown an average of about two inches and gained about five pounds. However, while in puberty you can expect that rate to double.

  • Boys: May grow four inches in twelve months, and by the time his height is complete he may have added thirteen to fourteen inches and forty pounds in three to four years.
  • Girls: May gain nearly ten inches and twenty-five pounds, including three or so inches in the six to twelve months before they begin having menstrual periods.

Growth in both boys and girls slows considerably soon after puberty is complete. Having gained nearly all of their adult height during puberty, once the period of development is over, most teens grow no more than another inch or two. You may need to check with your pediatrician to see if your child has completed his or her pubertal development.

When to Speak to the Pediatrician:

For a boy or girl to be slightly less developed or more developed than other kids the same age is rarely cause for alarm. But if a child seems significantly different from others his or her age, parents should speak with their pediatrician, so that their child can be checked for—and most likely rule out—any medical problems. Chances are, it’s the pediatrician who will bring these differences to the parents’ attention.

Blame It on Hormones

Hormones, chemical messengers produced by the body’s glands, travel through the bloodstream to affect:

  • Growth
  • Sexual characteristics
  • The ability to have children
  • Metabolism
  • Personality
  • Mood swings

Although the trigger that starts puberty is not yet fully understood, sometime between the ages of seven and eleven in girls, and nine and a half to thirteen and a half in boys, the pituitary gland at the base of the brain releases two hormones that signal a girl’s ovaries to start producing the female sex hormone, estrogen, and a boy’s testicles to start producing the male sex hormone, testosterone.

4. Puberty

Physical Changes During Puberty

Puberty is made up of a clear sequence of stages, affecting the skeletal, muscular, reproductive, and nearly all other bodily sys­tems. Physical changes during puberty tend to be more gradual and steady. This is comforting to many parents who feel childhood passes much too quickly.

Changes in Body Composition & Height

Most children have a slimmer appearance during middle child­hood than they did during the preschool years. This is due to shifts in the accumulation and location of body fat. As a child’s entire body size increases, the amount of body fat stays relatively stable, giving her a thinner look. Also during this stage of life, a child’s legs are longer in pro­portion to the body than they were before. On average, the steady growth of middle childhood results in an increase in height of a little over 2 inches a year in both boys and girls. Weight gain aver­ages about 6.5 pounds a year.

A number of fac­tors, including how close the child is to puberty, will determine when and how much a child grows. In general, there tends to be a period of a slightly increased growth rate between ages 6 and 8. This may be accompanied with the appearance of a small amount of pubic hair, armpit hair, mild acne, and/or body odor.

The Influence of Heredity

Perhaps more than any other factor, your child’s growth and ultimate height will be influenced by heredity. While there are exceptions, tall parents usually have tall children, and short parents usually have short children. Those are the realities of genetics.

Concerns About Growth

If your child seems unusually short or tall relative to his friends the same age, talk with your pediatrician. A true growth disorder can sometimes be treated by administering growth hormones; however, this therapy is re­served for young children whose own glands cannot produce this hormone. Doctors do not recommend this treatment for healthy boys and girls who may want (or whose parents may want them) to grow to be 6 feet tall instead of 5 feet 8.

Growth Spurts

Just as height can vary from child to child, so can the timing of a child’s growth. Despite the averages mentioned above, children have a tendency to grow in spurts.  Thus, they may grow faster at times and slower at others.  Some children grow as much as three times faster during a particular season of the year, compared with their “slow” seasons. These individual variations in timing—along with hereditary factors—are largely responsible for the wide variations in size among children the same age. Height differences among children in a typical elementary school classroom can range from 4 to 5 inches.

Although boys and girls are generally of similar height during middle child­hood, that changes with the beginning of puberty. Particularly in junior high school, girls are often taller than their male classmates, but within a year or two, boys catch up and usually surpass their female classmates. About 25 per­cent of human growth in height occurs during puberty.

Nutrition’s Influence on Physical Development

A number of other factors—so-called environmental influences—can affect physical development as well. Nutrition is important to normal growth processes. Parents should make an effort to ensure their child con­sumes a well-balanced diet. A child’s need for calories rises during times of rapid growth, gradually increasing as she moves through middle childhood into puberty. However, if the calories consumed exceed those expended, a child may develop a weight problem.

A Word about Picky Eaters

Some parents worry that their child is not eating enough. Even with what seems to be relatively low food intake, however, children can grow at normal rates.

If your school-age child is a picky eater, do not worry that this frustrating behavior is impairing her growth. These fluctuating eating habits may be due to normal, slow-growth periods or simply uniquely personal, unpredictable preferences or distastes for certain foods.

In general, children outgrow these food preferences without any harm to their physi­cal well-being. As long as a child is gaining weight appropriately (4 to 7 pounds per year) and is eating a healthy variety of foods, his nutritional needs are being met.

The Importance of Regular Exercise  

Children also need to exercise regularly to ensure normal physical devel­opment. Those who spend their free time watching TV, playing video games, or engaging in other stationary activities rather than playing outdoors may have impaired bone growth. When physical activity is in­creased, bones are denser and stronger. However, there is no evidence that a very strenuous exercise program will help your child grow faster or bigger. Running marathons, for example, will not stimulate physical growth.

Pre-Puberty Changes

A number of other changes occur during middle childhood:

  • Children become stronger as their muscle mass increases.
  • Motor skills—in both strength and coordination—improve.
  • A school-age child’s hair may become a little darker.
  • The texture and ap­pearance of a child’s skin gradually changes, becoming more like that of an adult.

How to Discuss These Changes with Your Child

Your child needs to understand the phys­ical changes that will occur in her body during puberty. There are many opportunities during this time of life for you to talk to your child about what she’s experiencing. You should emphasize that these changes are part of the natural process of growing into adulthood, stimulated by hormones (chemicals that are produced within the body).

Keep track of your child’s bodily changes, while fully respecting privacy. As the age ranges above indicate, there are wide variations of “normal” in the time when puberty begins. Remind your child that while her friends will grow at different rates, they will eventually catch up with one another.

4. Puberty

Pelvic Exams

I’m going to the doctor for my first pelvic exam. What should I expect?

There are 2 main parts of your exam: the interview and the pelvic exam.

Part 1—The Interview

Before the pelvic exam, your pediatrician will ask you questions about your health and your periods. So don’t be surprised if you’re asked questions like

  • When did you get your first period?
  • When was your last period?
  • Do you have your periods regularly? How often?
  • How long do they last?
  • Do you have any pain, cramps, headaches, or mood swings with your periods?
  • Do you use tampons, pads, or both?
  • Have you ever had vaginal itching, discharge, or problems urinating?
  • Do you douche? If yes, how often?

Your pediatrician might also ask you about sex. You may be embarrassed or feel like your sex life is nobody else’s business, but your pediatrician needs to know these things to help you protect your health. So be honest! These questions may include

  • Have you ever had any type of sexual intercourse (oral, anal, or vaginal)?

If yes,

  • When was the first time you had sex?
  • Did you want to have sex, or were you forced to have sex?
  • Have you had sex with more than 1 person? If yes, how many people?
  • Have you had sex with men, women, or both men and women?
  • How old were the people you had sex with?
  • Do you use condoms or other types of birth control?

Remember, you can ask questions too. In fact, this is a great time to ask any questions you may have about your period, tampon use, sex, and other stuff. Your pediatrician has lots of good information and can give you advice on making good decisions, the benefits of not having sex (abstinence), and preventing pregnancy and diseases. So don’t be afraid to ask!

Part 2—The Pelvic Exam

OK, so now it’s time for the pelvic exam. You’ll be left alone to undress and put on a gown. There will also be an extra sheet that you can use to cover yourself. Remember, the entire exam only takes about 5 minutes. Some girls think that having a pelvic exam will mean they are no longer virgins, but that’s not true. The pelvic exam doesn’t change whether you are a virgin. It’s also not true that the pelvic exam is a “test” to see if you are a virgin. The exam can be done even if you have never had sexual intercourse, because the opening to your vagina is large enough to allow for the exam.

3 simple steps. Your pediatrician will describe each step of the exam. If you have any questions or feel uncomfortable, let your pediatrician know. Your pediatrician will have a nurse or assistant in the room during the exam. You can ask your mom, sister, or friend to join you if it makes you more at ease—it’s up to you.

Step 1: The vulva (outside of your vagina and surrounding areas). Your pediatrician will begin by looking at the outside of your vagina and surrounding areas to make sure everything looks normal.

Step 2: Inside your vagina. Then your pediatrician will use an instrument called a speculum to look inside your vagina. Specula are about the size of a tampon, made of disposable plastic or sterilized metal, and have no sharp edges.

The speculum will be gently inserted into your vagina. You will feel some pressure, but it shouldn’t hurt. Take deep breaths and try to relax. This will help relax your vaginal muscles and make this part of the test easier.

Once the speculum is inside the vagina, it is opened so that your pediatrician can see your cervix.

Then your pediatrician will use a cotton-tipped swab or a plastic brush to take a small sample of cells from your cervix. Samples are sent for tests, such as the Pap smear, which tests for abnormalities of the cervix. You may also be checked for diseases like gonorrhea and chlamydia with a second cotton swab.

Once everything is collected, the speculum is gently removed. It’s normal to have a little bit of spotting after the Pap smear.

Step 3: Uterus and ovaries. The last step of the exam checks your uterus and ovaries. Your pediatrician will gently insert 1 or 2 gloved fingers into your vagina and press on the outside of your abdomen with the other hand. It’s quick and may feel a little funny, but shouldn’t hurt.

That’s it! Most women are surprised when their pelvic exam is over because it really is that quick.

If your pediatrician finds a disease or any other problem, you may be referred to an OB/GYN (obstetrician/gynecologist). This type of doctor specializes in women’s reproductive health.

Remember, the pelvic exam is an important part of taking care of your health. Ask your pediatrician if it’s right for you.

4. Puberty

Klinefelter Syndrome: A Guide for Families

What is Klinefelter syndrome?

It is a condition in boys caused by the presence of an extra X chromosome. Boys normally have one X and one Y chromosome, but most boys with Klinefelter syndrome have two X and one Y chromosome. It is relatively common, occurring in about 1 of every 500 baby boys. There is a wide range findings in this condition, and many cases are not diagnosed until adulthood.

What are the common signs and symptoms?

The number and severity of symptoms vary widely. The most common reason for suspecting that a boy may have Klinefelter syndrome is when a doctor notices that in late puberty, the testicles are much smaller than what is normal. Boys may have undescended testicles, and the penis may be smaller than average. Most boys with Klinefelter syndrome are tall and have relatively long arms and legs. Although early in puberty, the testicles may produce normal amounts of the male hormone testosterone, this often lags as puberty progresses. This may be accompanied by somewhat less secondary sex characteristics, including decreased body hair or decreased muscle development. Sperm formation may be decreased or absent, and sometimes breast development occurs during puberty.

Some people are only very mildly affected and may not have Klinefelter syndrome diagnosed until they are adults, when they may have difficulty fathering children. Others have problems early in life with delayed developmental milestones or with learning problems during their school years.

How is Klinefelter syndrome diagnosed?

The syndrome is diagnosed by a special genetic blood test called a karyotype or chromosome analysis that shows the presence of an extra X chromosome. At the time of puberty, blood levels of the pituitary hormones follicle-stimulating hormone (called FSH) and luteinizing hormone (LH) increase as a result of decrease in testicular function, and measurement of these hormones aids in making the correct diagnosis.

How is Klinefelter syndrome treated?

If testosterone levels are abnormally low, treatment with testosterone during and after adolescence may help many of the psychological symptoms and may increase secondary sex characteristics. If breast enlargement is a long-term problem, it may be treated surgically. Achieving fertility is more difficult. Special urologic techniques may help in identifying and retrieving sperm cells for fertility treatments. Support groups are available for individuals with Klinefelter syndrome and their families.

What is the long-term outlook?

Despite the range of possible problems seen in boys with this condition, the vast majority do very well. Specific educational interventions may be helpful during school years to overcome learning problems. Although there is no real cure for the condition, many of the symptoms can be treated. Overall, the predictions for long-term health and life expectancy are excellent.

4. Puberty

Delayed Puberty in Girls: Information for Parents

How is delayed puberty in girls defined?

Puberty starts when the pituitary gland begins to produce two hormones , luteinizing hormone (called LH) and follicle-stimulating hormone (called FSH), which cause the ovaries to enlarge and begin producing estrogens. The growth spurt starts shortly after breasts begin to develop, and the first menstrual cycle begins about 2-3 years later. A girl who has not started to have breast development by the age of 13 is considered to be delayed.

What causes puberty in girls to be delayed?

Some girls with delayed puberty are simply late maturers, but once they start, puberty will progress normally. This is called constitutional delayed puberty and is more common in boys than girls. Often, this is something that is inherited from the parents, so it is more likely to occur if the mother started her periods after age 14 (the average is about 12 ½) or if the father was a “late bloomer.”

Decreased body fat is a major cause of pubertal delay in girls. It can be seen in girls who are very athletic, particularly in gymnasts, ballet dancers, and competitive swimmers. It can also be seen in girls with anorexia nervosa, who engage in extreme dieting or binging and purging, because they fear becoming too fat even when they are abnormally thin. Finally, it can be seen in a number of chronic illnesses in which body fat is often decreased.

Some girls with delayed puberty may have problems with their ovaries. The ovaries are either not developing properly or are being damaged. This is referred to as primary ovarian insufficiency. The major cause present at birth is Turner syndrome, in which all or part of one of the two X chromosomes is missing. Most girls with Turner syndrome are also extremely short for their age and may have certain distinctive physical features, such as webbing of the neck, a high-arched palate, or arms that bend outward when extended. However, in most cases, Turner syndrome is diagnosed well before age 13 because of short stature. The major acquired cause of ovarian insufficiency is damage to the ovaries as a result of radiation, usually to treat leukemia or certain other kinds of cancer.

Occasionally, girls may have their ovaries damaged by the body’s immune system. Finally, some girls fail to start puberty because of a lack of the pituitary hormones LH and FSH, also called gonadotropins. This can occur when there are other pituitary deficiencies as well, including growth hormone, or it can be an isolated finding (particularly in a girl who is delayed but not short).

How is delayed puberty in girls diagnosed?

The endocrinologist will order blood tests to measure levels of LH, FSH, and estradiol and, in some cases, other tests. Very high levels of LH and FSH will indicate that the ovaries are not working properly, and the pituitary is trying to stimulate them to work harder. If the cause of the ovarian insufficiency is not clear, a chromosome study or karyotype will be done to see if all or some cells are missing all or part of an X chromosome.

If the LH, FSH, and estradiol are all low, the problem could be either decreased body fat (if one of the risk factors listed above is present) or a permanent deficiency of LH and FSH. Other tests may be ordered if deficiency of multiple pituitary hormones is suspected, and on occasions, a brain MRI may be helpful. A hand X-ray for a bone age is often done, which is typically delayed by 2 or more years, which means that there is still additional time to grow.

How is delayed puberty in girls treated?

In girls with constitutional delayed puberty, breast development will eventually start on its own. Giving estrogens for 4-6 months is sometimes used to help get things started sooner.

  • For girls with delayed puberty and decreased body fat: Sometimes eating more and gaining weight will help get puberty started.
  • For girls with primary ovarian insufficiency or a permanent deficiency of gonadotropins: Long-term estrogen replacement is needed and can be given either in the form of a daily tablet of estradiol or as a patch that needs to be applied to the skin twice a week. Doctors usually start on a low dose and often increase the dose about every 6 months. After 12-18 months, it is typical to start a second hormone called a progestin (for example, Provera) which will, after a few months, result in a period, usually within a day or two of stopping the progestin. You may ask your endocrinologist to discuss with you and your child what is known about your child’s potential for fertility.
4. Puberty

Delayed Puberty in Boys: Information for Parents

How is delayed puberty in boys defined?

Boys can start puberty at a wide range of ages, with 95% starting between the ages of 9 and 14, so we consider puberty delayed when it has not started by age 14. The earliest sign of puberty in boys is enlargement of the testicles, followed by growth of the penis and pubic hair. Puberty happens when the pituitary starts making more of two hormones, luteinizing hormone (called LH) and follicle-stimulating hormone (called FSH), which cause the testicles to grow and produce the male hormone testosterone. The growth spurt usually starts a year or so after the genitals start to enlarge, generally by age 15.

What causes delayed puberty in boys?

By far, the most common cause is constitutional delayed puberty. These boys are generally healthy and will eventually go through puberty if given enough time. In about two thirds of cases, it is inherited from one or both parents. The mother may have had delayed puberty if she started her periods after age 14, and the father may have had delayed puberty if he started his growth spurt late (after age 16) or if he continued to grow after he graduated from high school. Boys with chronic illnesses such as inflammatory bowel disease, sickle cell disease, or cystic fibrosis often mature late.

A smaller number of boys with delayed puberty have a lifelong deficiency of the puberty hormones LH and FSH, a problem we call isolated gonadotropin deficiency (IGD). This is usually a condition present from birth, and many boys with IGD are born with a penis that is smaller than it should be.

Other pituitary hormones in this condition are made normally, and usually growth is normal. Failure to start puberty by age 17 is one sign a boy might have IGD. Another clue is that some boys with IGD also have a poor sense of smell, a condition referred to as Kallmann syndrome. Finally, a few boys with delayed puberty have a problem with the testicles themselves.

Because it is easy to determine the size of the testicles on a physical exam, having very small testicles or testicles that cannot be readily felt is a clue to the condition. There are several causes, including previous surgery for undescended testicles or cancer treatments, which can injure the testicles.

What are the signs and symptoms of delayed puberty in boys?

The key finding is that the penis and testicles do not enlarge by age 14, which is easily noted on physical exam. Often, the testicles have just started to grow but the penis is still small, which suggests that other signs of puberty will appear in the next 6-12 months. Most boys with constitutional delayed puberty are short compared with their peers, but because they have a delayed growth spurt, they usually catch up to other boys by the time they are 18 and have heights in the normal range as adults.

How is delayed puberty diagnosed?

Sometimes just the physical exam is enough, but many doctors will order some tests to confirm what they suspect and to make sure that the problem is not in the testicles. The most common tests to order are testosterone, LH, and FSH first thing in the morning, when the levels in early puberty are usually higher. Adult testosterone levels vary from 250-800 ng/dL, and most boys with delayed puberty have testosterone levels of less than 40. An X-ray of the hand and wrist to determine the bone age is often ordered to help predict adult height, and is typically at least 2 years behind the chronological age, which means that there is more time remaining for growth.

How is delayed puberty treated in boys?

For constitutional delayed puberty, the problem will resolve with waiting and reassurance. However, late-maturing boys are often impatient to start growing and do not want to wait another 6-18 months for the pubertal growth spurt to start naturally. Therefore, many pediatric endocrinologists may offer a brief course of testosterone to “jump-start” puberty.

It is most often given in the form of a monthly injection for several months; different doctors use different doses and numbers of injections. When the boy is seen back after the injections, there is usually a very good gain in height and weight as well as growth of the penis and pubic hair, and puberty will, in most cases, progress without any further treatment.

Studies show that a brief course of testosterone will have no effect on the adult height but will allow the boy to get there faster.

When the problem is either IGD or damage to the testicles, testosterone is still the treatment of choice, but the dose will need to be increased over time and it will need to be continued well into the adult years.

4. Puberty

Cosmetic Surgery in Teens: Information for Parents

Pediatric plastic surgeons perform both reconstructive and cosmetic surgery.

  • Reconstructive surgery repairs a physical defect that affects a child’s ability to function normally (e.g., a cleft palate).
  • Cosmetic surgery aims to improve someone’s physical appearance and is mainly about improving their self-image or confidence.

Age of Consent  

The question of cosmetic (aka aesthetic) surgery in teens can be a thorny subject. There are no specific laws in the United States that prevent teenagers from getting cosmetic surgery; however, parental consent is required for patients under the age of 18. Therefore, the responsibility falls to parents to help their children make the right decision.

Common Cosmetic Surgeries Performed on Teens

Cosmetic surgery can be appropriate in selected teenagers and can be safely done. In 2013, the American Society of Plastic Surgeons (ASPS) published data showing that number of cosmetic surgery done for the teens has actually come down progressively over the years, in contrast to the media reports suggesting otherwise.

For example, in 2013 the ASPS reported that members performed 63,600 surgeries on patients between 13-19 years of age. The most common surgeries included:

  • Breast augmentation (breast implants) – The Food and Drug Administration (FDA) considers aesthetic breast augmentation for patients less than 18 years of age to be an off-label use. The FDA has not approved breast augmentation in patients younger than 18. According to the ASPS, over 8,000 surgeries were performed in 2013 on 18-19 year old girls.
  • Rhinoplasty (nose reshaping) – This is the most requested aesthetic surgical procedure by teens. It can be performed when the nose has completed 90% of its growth, which can occur as early as age 13 or 14 in girls and 15 or 16 in boys.
  • Breast reduction – Frequently, this surgery is performed on girls with overly large breasts that may cause back and shoulder pain, as well as restrict physical activity. Breast reduction usually is delayed until the breasts have reached full development. In some boys, excessive breast development (gynecomastia) can become a significant problem. In those cases, the excess tissue can be removed.
  • Otoplasty (ear pinning) – This surgery is recommended for children as they near total ear development at age five or six.
  • Liposuction

Non-surgical cosmetic procedures

The ASPS reported nearly 156,000 non-surgical cosmetic procedures including botulinum (Botox®) injections, skin resurfacing, and laser treatments of hair, skin and veins.

If Your Teenager Wants Plastic Surgery

  • They must voice a specific concern and have realistic goals. Teens who are able to voice a specific concern and have realistic goals for their outcome are candidates for cosmetic procedures. For example, a teen who notes a hump on the nose and requests to have it removed, has a specific complaint. If that teen’s goal is to have a straight nose and blend in with peers, the outcome is likely to be achieved, so this teen may be a good candidate for cosmetic surgery. It the teenager believes that a straight nose will increase popularity, the goal is unrealistic and the teenager is not a good candidate for surgery.
  • They must show maturity and understand the procedure, risks, and consequences. A good candidate for cosmetic surgery is mature enough to understand the procedure, its risks, and what limitations the recovery period will require. The teenager requesting nasal reshaping who cannot rearrange their sports obligations to allow 6-8 weeks for surgery and healing is not yet ready to commit to the surgery and is not a good candidate for surgery. A mature teenager should also have an understanding of the possible things that can go wrong and be willing to accept that situation should it happen.
  • They must initiate the request for surgery. It is never advisable for a parent to suggest plastic surgery. The idea has to come from the child. Parents may project their own experiences and want to protect their children from emotional harm. If a teen has prominent ears, but is not bothered by them, that teen is not a good candidate even if the ears would respond well to an otoplasty. Parents who request consultation for a teen in this case may tell the doctor, My ears have always bothered me and I don’t want my child to have the same problem.” If the teen is not requesting the surgery, there is no patient consent, even if there is parental consent.
  • ​If your teen asks you about cosmetic procedures– particularly on the ears, nose or breasts – they may be candidates for cosmetic surgery. Explore what they feel they would like to change and why they would like it changed. Research what surgery might be like, what its risks are and how it would affect their activities. If as a parent-teenager team, you feel that cosmetic surgery may be appropriate, ask your pediatrician for a referral to a pediatric plastic surgeon who can explain more about it to you and your child.

Check Credentials

State laws permit any licensed physician to call themselves a “plastic” or “cosmetic” surgeon, even if not trained as a surgeon. Look for certification by the American Board of Plastic Surgery (ABPS). If the doctor operates in an ambulatory or office-based facility, the facility should be accredited. Additionally, the surgeon should have operating privileges in an accredited hospital for the same procedure being considered.

4. Puberty

Concerns Girls Have About Puberty

Girls have pubertal concerns and worries, too, including:

Breast Development

Some girls also have anxieties about breast develop­ment. For example, one breast usually begins to develop before the other. Ex­plain to your daughter that as her breasts develop, it is quite normal for one to be somewhat larger than the other. Breast size is seldom symmet­rical. Also, when a girl first notices the lump beneath one nipple, she may worry that this is cancer; reassure her that one breast is beginning to develop before the other, but if questions persist, consult your daughter’s doctor.

If a girl’s breasts start to develop relatively early, she often feels embar­rassed and self-conscious. To help your daughter feel more comfortable in a situation like this, she may prefer to wear loose-fitting clothing that disguises her early breast development. Also, be willing to buy her a “training bra” when she requests one or when you feel she could use one.


Many concerns about puberty center on menstruation. Spend time helping your daughter prepare for her first period. There is no reason for a girl to be surprised by her first menstrual cycle, not knowing what is happening or why.

Remember, menstruation may begin sooner than you expect. Certainly, once your daughter’s breast development has started, the two of you should fully discuss this topic. If you do not have adequate knowledge, ask your pediatri­cian to refer you to some informational sources. Some pediatricians schedule special educational visits at the time of puberty.

Menstruation Topics to Discuss Your Daughter:

  • Discuss the biology of menstruation, describing it as a normal bodily process.
  • Mention that her periods may be irregular, particularly in the begin­ning as her body adapts to rapid physiological changes.
  • Let her know that several months before her first period, fluid may be secreted by glands within her vagina. This substance may be clear or white in color, and watery to thick in consistency. Tell her not to worry, and that this is normal.
  • Explain that she may experience some cramping before or during her peri­ods. If the cramps become severe, her doctor may have some suggestions for alleviating them, perhaps with physical exercises or medication.
  • Discuss hygiene related to menstrual cycles. Be certain your daughter has the supplies she will need for her first period. Since she may be away from home when that first period begins, discuss how to use pads or tampons. She should understand the need to change pads or tampons several times a day, and that tampons should not be worn overnight. Of course, girls can shower or bathe while menstruating.
  • Many girls will ask if they can participate in activities such as swimming, horseback riding, or physical education classes. Reassure your daughter that she can take part in normal activities while menstruating. Exercise can some­times even ease the cramps associated with periods.
4. Puberty

Concerns Boys Have About Puberty

Boys have pubertal concerns and worries, too, including:

​Voice Change

As their voice box enlarges and the vo­cal cords grow, their voice may “crack” as they speak. While this can be em­barrassing and annoying, it’s a normal part of the growth process.

Wet Dreams

Boys may wake up in the morning to find sticky, damp areas in their pajama pants and sheets. These “wet dreams,” or nocturnal emissions, are caused by an ejacu­lation, not urination, that occurs during sleep and are not an indication that the boy was having a sexual dream. Parents should explain these events to their son without blame, and reassure him you understand that he cannot prevent it from happening. Wet dreams are just part of growing up.

Involuntary Erections

During puberty, boys get erections spontaneously, without touching their penis and without having sexual thoughts. These un­expected erections can be quite embarrassing, especially if they occur in public—at school, for example. Let your son know that these unexpected erections can happen and are normal signs that his body is maturing. Explain that they happen to all boys during puberty, and that over time they will become less frequent.

Breast Enlargement

Many boys experience swelling of the breasts during the early years of puberty. Most often, your son may feel a button like bump under one or both nipples. His breasts may also feel tender or even painful, especially when hit. After a few months—sometimes longer—the swelling will disappear; let your son know that these lumps will rarely  develop into true breasts.

One Testicle Lower than the Other

Uneven testicles, although they may be embarrassing in the boys’ locker room, are both normal and common.

Parents can support their preteen:

As your child approaches and enters puberty, be sensitive to his need for privacy. Preteens often become more modest while they bathe, for example, or change their clothes. Respect this wish for privacy, not only as it relates to their bodies but in other areas as well, such as remembering to knock before entering their rooms.

Preteens also become more sensitive about how they look during this time. Their interest in grooming increases, and they are frequently concerned about their appearance, thanks largely to influence from their peers and advertising messages. Watch for signs of a child who has a negative im­age of their bodies, which in some cases can result in eating disorders.

It is very important to avoid even good-natured teasing of your child’s puber­tal development changes. Most pre-teens will be easily embarrassed if they are teased about the changing shape of their bodies or their deepening voices.