They Grow Up So Fast: Endocrine Society Releases Central Precocious Puberty Guideline

During ENDO 2026 in Chicago, the Endocrine Society will release its latest treatment recommendations, “Central Precocious Puberty: An Endocrine Society Clinical Practice Guideline.” Attendees are encouraged to arrive early at Room W375C at McCormick Place on Saturday June 13 at 4:30 p.m., for this highly anticipated session.   

At ENDO 2025 in San Francisco, researchers from Taiwan reported that consuming certain sweeteners found in some foods and beverages may increase the risk of early puberty in children. Aspartame, sucralose, glycyrrhizin, added sugars – all bad things, triggers especially in children with certain genetic traits. The more of these sweeteners the teens consumed, the higher their risk of developing central precocious puberty. The risk is even higher for girls.

The same ENDO, researchers from Atlanta discovered that certain chemicals in both the mother’s and father’s blood were linked to when their descendants began puberty, with stronger effects seen in the granddaughters’ than in the daughters’ generation. Some chemicals such as phenoxyethanol, a common preservative in personal care products and foods, were linked to earlier puberty, especially when both parents had similar exposures.

A 2023 study published in the Journal of the Endocrine Society revealed that the number of girls diagnosed with precocious puberty increased during the COVID-19 pandemic due to potential risk factors such as increased screen time and less physical activity. Researchers in Italy found 72 cases of precocious puberty before the COVID-19 pandemic (January 2016 — March 2020) and 61 cases between March 2020 and June 2021 — four new cases per month.

Central precocious puberty (CPP) is relatively rare, but it’s becoming increasingly more common and can lead to emotional distress, shorter adult height, and increased risk of future metabolic and reproductive disorders. But pediatric endocrinologists and other researchers and providers are becoming more aware that some kids, especially girls, might just be literally growing too fast.

This month the Endocrine Society published a Clinical Practice Guideline in The Journal of Clinical Endocrinology &Metabolism titled, “Central Precocious Puberty: An Endocrine Society Clinical Practice Guideline,” arguing for a more conservative approach in some patients.  

“In recent decades, cross-sectional data from the United States and Europe have suggested that pubertal milestones are being reached earlier than in prior decades, raising the possibility that the currently employed definition of CPP could be outdated,” the Guideline authors write. “Additionally, in some girls, puberty may be slowly progressive, with a longer duration between thelarche and menarche and achievement of a normal adult height, suggesting that not all patients with CPP as it is currently defined would benefit from aggressive clinical evaluation or treatment.”

“The guideline development process highlighted important knowledge gaps and the substantial need for additional research. Therefore, we expect that the new guideline will have an impact in the evaluation and management of children with precocious puberty as well as in the future research of human pubertal development.” — Ana Claudia Latronico, MD, PhD, Sao Paulo Medical School, Sao Paulo University, Sao Paulo, Brazil

Moving Target

According to Fernando Cassorla, MD, emeritus professor at the University of Chile and president of the Chilean Academy of Medicine, variations in the age of onset and progression of the pubertal process can be a source of significant anxiety for both patients and parents, because comparison with peers and relatives are quite common. This is complicated by the fact that the physiological pubertal process has experienced some changes over the last few decades, as earlier development has become more prevalent, particularly in girls. Thus, pediatric endocrinologists have been discussing whether we should maintain the cut-off point for a chronological age of eight years as the youngest age for the first signs of normal puberty in girls. 

“This has led to a more conservative approach for the management of girls who present with breast development between the ages of seven to eight years, since some of these patients exhibit a variation of the physiological pubertal process, and do not require an extensive work-up and will not benefit from GnRH analog therapy,” Cassorla says.  “This is based on the fact that a complete evaluation for central precocious puberty requires a number of laboratory tests and imaging studies, which should be performed in a selected group of patients.  In a sense, the age for normal pubertal development has become a ‘moving target,’ with many normal girls around the world experiencing their first signs of puberty slightly before their eighth birthday.”

In girls who present with thelarche (Tanner B2) between seven and eight years old, the guideline authors suggest “watchful waiting via periodic physical examinations rather than immediately performing evaluation with laboratory testing and/or radiologic imaging.” Providers should take care to differentiate between thelarche and lipomastia, especially if the girl has overweight or obesity. Providers should also use that watchful waiting time (four to six months) to determine unsustained or slowly progressive puberty from rapidly progressive puberty before starting diagnostic evaluation.

Controversial Clinic Questions

These guidelines will be presented this month at ENDO in Chicago (you may be reading this piece right as you sit to listen to the presentation), and they will be published in JCEM. The authors agree that they should have quite the impact on the field of pediatric endocrinology; an experienced group of pediatric endocrinologists from around the world asked each other several questions, but as the paper states, because of limited resources, they had to narrow it down to 10 of the most controversial.

“[T]he Guideline Development Panel (GDP)’s primary goal was to create a new clinical guideline for CPP with a focus on diagnostic evaluation and treatment considerations,” the authors write. “The GDP recognized the many important clinical questions regarding the diagnosis and management of CPP; however, due to limited resources, 10 of the most controversial clinical questions were prioritized, and three to seven health-related outcomes were selected for each.”

“A complete evaluation for central precocious puberty requires a number of laboratory tests and imaging studies, which should be performed in a selected group of patients.  In a sense, the age for normal pubertal development has become a ‘moving target,’ with many normal girls around the world experiencing their first signs of puberty slightly before their eighth birthday.” — Fernando Cassorla, MD, emeritus professor, University of Chile, Santiago; president, Chilean Academy of Medicine

Ana Claudia Latronico, MD, PhD, professor of endocrinology and metabolism at the University of São Paulo in Brazil and first author of the guidelines tells Endocrine News that the GDP set out to create a new clinical practical guideline for CPP with a focus on diagnostic evaluation and treatment considerations. “Our goal was to create a new clinical practical guideline for CPP with a focus on diagnostic evaluation and treatment considerations,” she says. “A multidisciplinary panel of clinical experts, along with experts in guideline methodology and systematic literature review were involved to answer 10 relevant clinical questions related to the diagnosis and treatment of CPP. Systematic reviews of health-related benefits and harms were conducted for each clinical question.”

Latronico goes on to say that clinical recommendations of the new guidelines were developed to address important uncertainties in the diagnosis and treatment of children with central precocious puberty. They were based on the best available scientific evidence regarding clinical outcomes judged to be most important to patients and families.

“In the current guideline, we suggest diagnostic and therapeutic strategies that will most likely provide net clinical benefits while simultaneously considering important contextual factors such as cost and feasibility,” Latronico says. “The guideline development process highlighted important knowledge gaps and the substantial need for additional research. Therefore, we expect that the new guideline will have an impact in the evaluation and management of children with precocious puberty as well as in the future research of human pubertal development.”

The Need for Shared Decision Making

Gonadotropin-releasing hormone (GnRH) agonists can effectively suppress premature activation of the hypothalamic–pituitary–gonadal (HPG) axis and have the potential to increase adult height as well as improve psychosocial and long-term health outcomes among patients with CPP. “However,” the authors write, “as secular trends have continued to shift toward earlier age of pubertal onset, some subpopulations of children with CPP as it is currently defined may not require the same extent of diagnostic evaluation and treatment.”

The guideline authors take care to point out that GnRH therapy is not some silver bullet to fix CPP. The authors do suggest that GnRH therapy is appropriate for many children with CPP, but they recognize that some patient subgroups might not benefit from the treatment (including girls ages seven to eight years who have slowly progressive puberty and those who at or beyond the peak of their pubertal growth spurt).

“The guideline development panel emphasized the importance of shared decision making for all patients with central precocious puberty, which should include a careful weighing of anticipated benefits and potential harms of medication use in the context of each patient’s clinical presentation and patient/caretaker values.” — Ana Claudia Latronico, MD, PhD, Sao Paulo Medical School, Sao Paulo University, Sao Paulo, Brazil

“In addition, the guideline suggested against the routine addition of growth hormone to gonadotropin-releasing hormone agonist therapy based on the potential benefits in the adult height demonstrated by previous retrospective studies,” Latronico says. “Given that GH therapy would likely have high costs and that it is not an approved indication for CPP worldwide, the guideline concluded that the intervention could exacerbate health inequities. The guideline development panel emphasized the importance of shared decision making for all patients with central precocious puberty, which should include a careful weighing of anticipated benefits and potential harms of medication use in the context of each patient’s clinical presentation and patient/caretaker values.”

Bagley is the senior editor of Endocrine News. In the May issue, he wrote about the ENDO 2026 session, “The Year in Bone” in “Boning Up.”