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

Abstract

Importance: 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.

Objectives: 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.

Data sources: A systematic literature search was performed in PubMed and Embase of all original peer-reviewed articles published in English before June 20, 2019.

Study selection: 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.

Data extraction and synthesis: 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.

Main outcomes and measures: Studies examining age at thelarche (development of Tanner breast stage 2) in healthy girls.

Results: 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).

Conclusions and relevance: 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community needs current and relevant data to redefine "precocious puberty," because the traditional definition may be outdated, at least in some regions of the world.

Figure 1.. PRISMA Flowchart Illustrating the Selection Process of the Included Records

B2 indicates Tanner breast stage 2. ^aA complete list of the excluded articles with reasons can be found in the eAppendix in the Supplement.

Figure 2.. Secular Changes in Age at Onset of Tanner Breast Stage 2 (B2) From 1977 to 2013 Around the World According to Year of Study

A statistically significant decrease in age at onset of B2 by 0.24 years per 10 years is observed (P = .02). The shaded area represents the 95% CI (−0.44 to −0.04) of the weighted regression analysis (black line). The size of the dots indicates the size of the SEM within the different studies. Two African study populations have been marked with upward facing arrows, indicating age at onset of B2 being above 11.5 years (larger dot, 13.2 years; and smaller dot, 12.1 years).