Why have pandemic cases doubled in Italy? The expert replies
The cases of precocious or early puberty observed in the semester March-September 2020 in Italy more than doubled compared to the same period of 2019: this is demonstrated by an observational study coordinated by the Bambino Gesù Hospital which involved the pediatric endocrinology centers of the Gaslini Hospital of Genoa, of the Federico II Polyclinic of Naples, of the Microcitemico Pediatric Hospital of Cagliari and of the Pediatric Clinic of Perugia Hospital. In total, 338 cases were detected against 152 the previous year, with an increase of 122%. The phenomenon mainly affected girls aged around 7. The study, published by Endocrine Connections, confirms the numbers of the previous research of the Department of Endocrinology of the Child Jesus, led by prof. Marco Cappa within the Research Unit of Innovative Therapies for Endocrinopathies (Italian Journal of Pediatrics 2021) and tries to shed light on the causes.
Benedetta de Mattei interviewed the prof. Marco Cappa – Head of UOC Endocrinology of the Child Jesus of Rome – to understand the causes and consequences of precocious puberty and the signs that should not be underestimated.
WHAT IS EARLY PUBLICITY AND THE SIGNS TO BE CAREFUL
First of all it is necessary to distinguish between “precocious puberty” and “early puberty” and the timing of 8 years in females and 9 years in males is fundamental in this sense. In fact, below this age we speak of precocious puberty while above we reenter in anticipated puberty, a para physiological condition and therefore much more similarity to normality. We therefore speak of precocious puberty when the sexual maturation occurs before 8 years in females and before 9 years in males. In the female it means the beginning of the mammary button, that is the presence of an increase in the mammary glandular tissue, while in the male the increase in the volume of the testicles. These are the first signs that you can start analyzing the child to understand if the phenomenon is really anticipated or not. Then some clinical signs in a parent naturally do not see them, for example simultaneously with the appearance of the breast button the size of the uterus also increases and this can only be highlighted through an ultrasound.
WHAT PROBLEMS CAN DETERMINE
A precocious puberty first of all that may be a reduced final stature with respect to the genetic target: for example, if a girl begins puberty at 6 she could have her first cycle after only 2 years, at 8 she will have a very tall stature for the age, but an adult stature lower than the final one, i.e. the height she will reach at the end of the growth. So the problem is that they are apparently very tall girls if we compare them to their age but in the end in their growth history they will be smaller. Furthermore, girls who present with precocious puberty can derive psychological and relational distress from their own, unexpected, bodily changes and from the comparison with their peers.
DIAGNOSIS AND CARE
The diagnosis of precocious puberty is both clinical and instrumental: the doctor evaluates in the child the growth, the presence of the mammary button and also the vaginal mucosa since the latter together with the mammary gland are the target organs of estrogen. Once suspicion is made, hormonal tests are performed, which indicate whether or not there is pubertal activation, a pelvic ultrasound that assesses the size of the uterus and an x-ray of the left hand and wrist that measures age. bone. Normally the bone age at the onset of puberty is around 10 – 10 and a half years, so if a 7 year old girl with breast button and a bone age corresponding to 10 years is probably very affected by pubertal precocity.
In precocious puberty we intervene with drugs able to block the pubertal evolution while in the anticipated one, being a para physiological condition, the therapy must be evaluated case by case; in those in which there is a psychological problem, it is possible to decide on the treatment to slow down the evolution of puberty and postpone the age of menarche.
I STUDY
In our studio the major increase of cases was observed in girls (328 patients in 2020 against 140 in 2019, with an increase of 134%) and especially in the second half of the observation period (92 girls between March and May compared to 236 girls in June and September 2020, with an increase of 156%) . On the other hand, there was no significant increase in the cases in males. The average age of girls observed for precocious puberty in the multicenter study is around 7 years (with no differences between 2019 and 2020). In 2020, a significant increase in rapidly evolving cases of precocious puberty, i.e. those resulting from a specific drug therapy (135 out of 328 girls observed in 2020 compared to 37 out of 140 girls observed in 2019, with a range of increase from 26% at 41%).
THE EMERGED LIFESTYLES
Increased use of electronic devices
In interviews with the families of girls with precocious puberty about eating habits and lifestyle, there has been a significant increase in the use of electronic devices (PC, tablet, smartphone) in 2020 compared to 2019. The increase in the overall weekly use of these devices is attributable to the introduction of DAD (rarely used in primary school before 2020), together with the persistence of their use for leisure in your free time. Increased use of electronic devices, on the other hand, was detected, already in the run-up to the pandemic, in girls experiencing rapidly evolving precocious puberty in 2020.
Reduction in physical activity
The first lockdown of 2020 also caused a drastic reduction in physical activity practiced by children and young people, due to forced domestic confinement. In particular, a more sedentary lifestyle was found in the rapidly evolving precocious puberty subgroup of 2020, which was already evident before the pandemic. Sitting means producing smaller numbers of big men that are secreted through exercise. I’ll give you the opposite example: girls who perform intense physical activity, such as artistic gymnastics or dance at a competitive level, often have a late menarche, unlike sedentary ones who tend to develop earlier; this means that during physical exercise a neuroendocrine activation mechanism is established that can affect the activation of puberty.
Fatigue
More than half of the patient families observed in 2020 reported changes in behavior (59%) and reported a relevant increase in stress-related symptoms (63%). While it is not possible to define causal safe sex, the findings suggest that a stressful event (such as the first lockdown in 2020) may have triggered early pubertal activation in individuals predisposed to a more sedentary lifestyle.
WHAT ADVICE
Every 30 minutes children have to get up from the chair, detach from and do motor activity, obviously as much as it is possible to do at home, so that screen inactivity is interrupted by movement. The second thing is to reduce the DAD as much as possible and fortunately the government is thinking about this.