Definition

Puberty is the period when an adolescent undergoes physical changes to become sexually mature. Generally, puberty occurs between the ages of 8 and 13 for girls and 9 and 14 for boys. Puberty involves processes governed by several organs, such as the brain, pituitary gland, and gonads or sex glands. These organs produce hormones that trigger the signs of puberty in the body.

In girls, puberty is dominated by the hormone estrogen, while in boys, it is dominated by the hormone testosterone. An imbalance in the processes regulated by these organs can lead to delayed puberty.

Delayed puberty is when the signs of puberty appear later than the maximum expected age. For boys, it means the absence of puberty signs after the age of 14. Delayed puberty is more common in boys than girls, and there is no exact age at which each child will experience puberty because each child's condition is different.

Characteristics of delayed puberty include the absence of secondary sexual characteristics such as the enlargement of the testicles and penis and the growth of pubic hair. The exact incidence rate of delayed puberty is unknown due to the lack of reported cases in Indonesia. The opposite of delayed puberty is precocious puberty, where the puberty process occurs too early.

Deliberate puberty is not dangerous, and almost all children will eventually grow up healthy. However, for children with delayed puberty who have certain diseases, treating the underlying disease thoroughly is necessary to ensure healthy development into adulthood.

Causes

There are various reasons why a child may experience delayed puberty. Most causes are not precisely known, but common causes include:

• Genetic diseases
• Chromosomal complications
• Tumors in the hypothalamus or pituitary gland
• Chronic illnesses
• Hypopituitarism (underactive pituitary gland)
• Hypothyroidism (underactive thyroid gland)
• Excessive exercise
• Anorexia or other eating disorders such as bulimia
• Androgen insensitivity syndrome (the body's inability to use androgen hormones)
• Abnormal development of the reproductive system
• Low body fat composition
• Diabetes mellitus
• Celiac disease
• Kidney or liver disease
• Inflammatory bowel disease
• Autoimmune diseases, such as Addison's disease
• Undergoing chemotherapy or radiation therapy

Risk Factor

Several risk factors for delayed puberty include:

• Family History

If one parent experienced delayed puberty, the child is more likely to have delayed puberty as well.

• Functional Factors

Functional causes of delayed puberty include hypogonadotropic hypogonadism, where there is a delay in the production of sex hormones by the pituitary gland. As a result, estrogen and testosterone are not produced, delaying puberty.

• Constitutional Growth Delay

This condition affects bone growth, causing the child to be shorter than their peers. More than half of boys with delayed puberty have constitutional growth delay. However, these children will eventually reach puberty and normal growth over time.

• Chronic Illnesses

Any long-term illness can affect a child's growth and development, leading to delayed puberty. Examples include cystic fibrosis, diabetes, kidney disease, asthma, and sickle cell anemia.

• Malnutrition

Poor nutrition can hinder growth and puberty.

• Genetic Diseases

Chromosomal abnormalities can delay puberty.

Symptoms

Symptoms of delayed puberty in boys include:

• Testicles not developing by age 14
• No pubic hair
• Penis not enlarging by age 14
• Short stature and stunted growth
• Bone age younger than the child's actual age

Diagnosis

The diagnosis of delayed puberty involves taking a patient's medical history, physical examination, and additional tests.

During the medical history interview, the doctor will ask about the patient's main complaints, accompanying symptoms, when the complaints started, family medical history, previous illnesses, specific treatments, diet, and daily activities.

In the physical examination, the doctor will check vital signs such as blood pressure, respiratory rate, pulse, and body temperature. The doctor will then conduct a thorough examination from head to toe, measure height and weight, and check pubic hair to indicate puberty progression.

Additional tests may include an x-ray of the hand to estimate bone age, blood tests to check for chronic diseases and chromosomal abnormalities, CT scans, and MRI.

Management

Treatment depends on the cause of delayed puberty. If there is a family history of delayed puberty, no specific treatment may be necessary. If a disease or eating disorder causes delayed puberty, treating the underlying cause can help normalize puberty.

Depending on the patient's condition, treatment for boys may include hormone therapy to stimulate puberty, monitoring growth, and administering testosterone injections to stabilize sex hormone levels. A pediatric specialist should prescribe all medications. Parents play a crucial role in providing physical and psychological support to children with delayed puberty, aiding their treatment, and boosting their confidence and sense of security.

Complications

Complications of delayed puberty in boys are similar to those in girls. Adolescents with delayed puberty may experience stress, decreased self-esteem, and lower academic performance. Early emotional support can prevent these complications. If untreated, delayed puberty can lead to permanent hypogonadism or persistently low sex hormone levels.

Other complications may arise from hormone replacement therapy. Additional complications can include anorchia (absence of testicles), which might require prosthetic testicles, and below-average height.

Prevention

There is no definitive way to prevent delayed puberty, but early detection can facilitate quicker management and prevent further complications. Early detection can be achieved through routine check-ups with a pediatrician and awareness of delayed puberty symptoms.

When to See a Doctor?

If your child's secondary sexual characteristics have not appeared by age 14, consult a pediatric endocrinologist for evaluation.

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