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Worldwide Secular Trends in Age at Pubertal Onset Assessed by Breast Development Among Girls: A Systematic Review and Meta-analysis.

  • Eckert-Lind, Camilla1, 2
  • Busch, Alexander S1, 2
  • Petersen, Jørgen H1, 2, 3
  • Biro, Frank M4, 5
  • Butler, Gary6
  • Bräuner, Elvira V1, 2
  • Juul, Anders1, 2
  • 1 Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. , (Denmark)
  • 2 The International Research and Research Training Centre in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. , (Denmark)
  • 3 Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark. , (Denmark)
  • 4 Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
  • 5 Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
  • 6 Institute of Child Health, University College London Hospital, London, United Kingdom. , (United Kingdom)
Published Article
JAMA pediatrics
Publication Date
Apr 01, 2020
DOI: 10.1001/jamapediatrics.2019.5881
PMID: 32040143


The initial clinical sign of pubertal onset in girls is breast gland development (thelarche). Although numerous studies have used recalled age at menarche (first menstruation) to assess secular trends of pubertal timing, no systematic review has been conducted of secular trends of thelarche. To systematically evaluate published data on pubertal timing based on age at thelarche and evaluate the change in pubertal onset in healthy girls around the world. A systematic literature search was performed in PubMed and Embase of all original peer-reviewed articles published in English before June 20, 2019. Included studies used clinical assessment of breast development in healthy girls and used adequate statistical methods, including the reporting of SEs or CIs. The quality of the articles was evaluated by assessing study design, potential sources of bias, main characteristics of the study population, and methods of statistical analysis. In accordance with PRISMA guidelines, all articles were assessed for eligibility independently by 2 authors. Weighted regression analysis was performed using a random-effects model. Studies examining age at thelarche (development of Tanner breast stage 2) in healthy girls. The literature search resulted in a total of 3602 studies, of which 30 studies fulfilled the eligibility criteria. There was a secular trend in ages at thelarche according to race/ethnicity and geography. Overall, the age at thelarche decreased 0.24 years (95% CI, -0.44 to -0.04) (almost 3 months) per decade from 1977 to 2013 (P = .02). The age at thelarche has decreased a mean of almost 3 months per decade from 1977 to 2013. A younger age at pubertal onset may change current diagnostic decision-making. The medical community needs current and relevant data to redefine "precocious puberty," because the traditional definition may be outdated, at least in some regions of the world.

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