What Is Delayed puberty?

Delayed puberty is a disorder in which the onset of sexual maturation and hormonal changes in adolescence does not occur at the expected time, according to average ages for boys and girls. The average age of male onset of puberty is 12 years, and average female onset is 11years, although it may occur in both sexes from the ages of 9 years onwards.

Most often, when puberty is delayed, it will occur later in adolescence with completely normal development into adulthood. This is referred to as a constitutional delay. Constitutional delay of puberty occurs more commonly in males than females, and there may be a family history in two-thirds of cases.

Delayed puberty may be due to certain medical conditions or hormone imbalances. Chronic conditions may delay puberty due to an inadequate nutritional status that affects the release of hormones needed in pubertal development.

The Gonadotropin Releasing Hormone initiates normal puberty(GnRH). GnRH is produced and secreted by the hypothalamus. The hormone then stimulates the production of Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH) from the pituitary gland. Increasing LH and FSH levels lead to the stimulation of growth of the testes and ovaries, and consequently the production of testosterone and oestrogen respectively.

Male pubertal development is driven by testosterone, while oestrogen drives female development. Hormonal changes may start up to two years before any evidence of the physical changes that are characteristic of puberty.

In males, a portion of testosterone is converted to oestradiol, that assists with skeletal growth. Mild enlargement of breast tissue or tender nipples may occur but is usually transient. Oestradiol has the same effect in girls, as well as promoting uterine and vagina growth, and pelvic widening.

Delayed puberty may be treated, depending on the underlying cause. If no testicular development has occurred at the age of 14 years in males, small doses of testosterone may be given intramuscularly. In constitutional puberty delay, this may trigger the onset of sexual maturation.

Diagnosis of delayed puberty is made on clinical findings and history. Bloods test done include LH and FSH levels, as well as testosterone levels in boys and oestrogen levels in girls. 

What Are The Symptoms Of Delayed puberty?

Delayed puberty in males will be diagnosed with delayed puberty if there is a delay in testicular development after the age of 14 years, or a lapse of more than five years between the start of testicular growth until maturation.

For girls, delayed puberty is diagnosed when there is no breast development by the age of thirteen years, no menstruation by 17 years, or more than five years difference between the onset of breast development and menarche (first menstrual period).

What Are The Causes Of Delayed puberty?

• Constitutional delay (often family history)
• Hormonal disorders: Turner's syndrome (males), Klinefelter syndrome (girls), hyper/hypothyroidism, Addison's syndrome, Polycystic Ovarian Syndrome
• Excess physical exercise in females
• Malnutrition or being underweight
• Chronic diseases such as diabetes mellitus
• Hypogonadotropic hypogonadism
• Pituitary gland disorders
• Central nervous system tumours
• Psychological conditions such as anorexia nervosa and bulimia

What Are The Things One Should Do To Manage Delayed puberty?

• Have delayed puberty investigated? Hormonal and other changeable factors need to be excluded; else it may lead to irreversible stunting of growth.
• Excessive physical training may lead to delayed puberty. Consult with a physician if excessive physical training is suspected to be a cause.

What Are The Things One Should Avoid To Manage Delayed puberty?

• Weight gain and obesity have an effect on puberty. Obesity in boys may lead to pubertal delay, while in girls it may lead to precocious puberty (early onset puberty). It is important to have a normal prepubertal weight.
• Secondary malnutrition due to chronic diseases leads to delayed onset puberty. Dietary counselling or dietician consult is needed in cases where malnutrition is suspected.

What Are The Best Foods For Delayed puberty?

Improper nutrition plays a role in a quarter of cases of delayed puberty.

Calorie intake, as well as nutritional value, is of importance:

• Girls need about 1400 to 2200 cal/day (age 9-13) and 1800 to 2400 cal/day (age 14-18)
• Boys (age 9-13) need 1600-2600 cal/day and ages 14-18, 2000 to 3200 cal/day
• Very active children who engage in vigorous sports training may need up to five thousand calories per day.
• Lean protein sources and low GI carbohydrates are the best sources of high caloric value.

Micronutrient and vitamin availability plays an important role in puberty:

• Adolescents (age 9 -13) need an intake of 1,200 mg of vitamin C, 600 mg of vitamin E and 60 mg of vitamin B6 each day.
• Ages 14 to 18 years need 1,800 mg of vitamin C, 800 mg of vitamin E and 80 mg of vitamin B6 daily
• Food source for vitamins and nutrients:
• Calcium rich foods to assist bone growth- spinach, milk, cheese, fortified cereals
• Iron rich foods to assist in muscle mass and growth- spinach, raisins, legumes, lean red meat, beans
• Protein sources to assist growth and muscle strength- poultry, beef or fish
• Vitamin C rich foods- citrus fruits such as oranges, papaya, melon and lemons. Bell peppers, strawberries.
• Vitamin E rich foods: avocado, butternut, almonds, spinach, sunflower seed
• Vitamin B6 rich foods: fortified cereals, red meat (beef), potatoes

What Are The Worst Foods For Delayed puberty?

• High-fat foods lead to increased hormone imbalances during pre-puberty and puberty. Although obesity may lead to earlier onset of the growth spurt, it can lead to a shorter height and stunting of growth in the long term.
• High salt diet may delay the onset of puberty. A low salt diet may also lead to delayed puberty. Optimal salt balance in a diet is thus needed.
• Fast foods or processed foods are high in calories but low in nutritional value. Processed foods have an increased danger in leading to increased BMI and insulin resistance in adulthood.

What Are The Medicines For Delayed puberty?

What Are The Tips To Manage Delayed puberty?

Sleep balance is essential during puberty and pre-pubertal years. The majority of growth hormones are released within the first two hours of sleep at night. Eight to ten hours of sleep is recommended during adolescence. Quality, as well as the quantity of sleep, is important.