How to recognize the signs of puberty

Is a breast lump in a 9-year-old cause for concern?

Not for me, or for the office nurse who returned the mother's call. But my nurse still set up a visit because - with a strong family history of breast cancer - the mom said she really would feel better if her daughter was evaluated in our office.

My nurse and I were not worried because of the age of the child and the location of the lump. New one- or two-sided breast lumps that are often tender to touch and seem to spontaneously appear just under the surface of the nipples are known as breast buds. Breast buds are usually the first sign of puberty in healthy young girls. (Though moms tell me that the first telltale sign of puberty occurs when their preteens suddenly notice just how annoying and embarrassing their parents really are.)

My patient's mother was relieved when the checkup was over and I gave her the good news that her daughter was quite fine and simply beginning puberty. Some parents feel they've wasted my time in these cases, but I always look on the visit as a positive - an opportunity to reassure a worried parent and to remind her of the normal physical stages that girls go through.

It's a good way, as well, to introduce the topic of puberty to her daughter and to let my young patient know that breast budding is just the first in a series of normal body changes that she and all her girlfriends will experience. The visit gives me an opening to discuss the basics of body hygiene and to remind the girl of the importance of deodorant use and daily showers. (When moms say it, it's called nagging; when doctors bring it up, it's called advice.)

Though it's not always the case, mom's age at menarche, or the start of menstruation, can often predict her daughter's start time, as many girls begin periods within a year of when their mothers did. Nutritional status and level of physical activity can also play a part in the timing.

In this country, it's thought that widespread improvements in nutrition have contributed to an overall drop in girls' age at menarche compared to their young counterparts living in the early 1900s. It's also noted that slender girls with a long history of involvement in vigorous physical activity such as ballet, running and gymnastics often enter puberty later and start their periods later than their more sedentary peers.

The authors of Nelson's Textbook of Pediatrics note that for American females, the average age of breast bud development is 10 to 11 years, with pubic hair showing up within 6 to 12 months of these early breast changes. Girls follow with a rapid growth spurt around age 11 or 12, which is a reliable clue that the first period is just around the corner. The average age for menarche is 12¾ years - usually 2 to 2 years after breast budding.

Remember, however, that these are average ages. Experts at the American Academy of Pediatrics recognize there is a wide range of normal when discussing pubertal development. For most girls, breast budding, and therefore puberty, begins sometime between ages 8 and 13, with periods generally starting between ages 10 and 16. There are always exceptions to the rule, but if your child seems to be developing outside of these general age ranges - that is, too early or too late - consult with your daughter's doctor to see if a medical work-up is indicated.

• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.