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Precocious puberty in girls and the risk of a central nervous system abnormality: the elusive search for diagnostic certainty.

The classic approach to the work-up of central precocious puberty (CPP) has been to recommend a brain imaging study to exclude an anatomic cause for the early onset of puberty, such as a tumor (most commonly a glioma or an astrocytoma), a hamartoma, or a subarachnoid cyst. Given the relative infrequency of CPP in boys and the relatively high reported incidence of abnormal findings,1 few would argue with ordering a magnetic resonance imaging (MRI) or a computed tomography scan as part of the evaluation for boys. The situation for early-maturing girls is much less clear. Many authors have advocated brain imaging for all girls meeting the criteria for CPP (age of onset 90%, depending on the study), the study would be normal.2 Others have recommended imaging in girls with CPP mainly “if there is a hint of intracranial pathology”.3 In practice, each clinician develops his or her own criteria for deciding when to order an MRI, so there is no consensus as to whether a healthy 6- to 8-year-old girl with breast development but no central nervous system (CNS) signs or symptoms needs brain imaging. In the past 2 decades, as clinicians have seen an increasing number of girls with onset of breast development before 8 years of age, this question takes on a greater urgency. The data of Herman-Giddens and the Pediatric Research in Office Settings (PROS) group, collected in 1992–1993 and published in 1997, indicate that by 8 years of age, close to 25% of black and 8% of white girls will have some breast tissue.4 The data from National Health and Nutrition Examination Survey III, collected between 1988 and 1994, give …