“My 6-year-old has started developing breasts and some pubic hair — isn’t she far too young?”

PRECOCIOUS PUBERTY is the onset of secondary sexual characteristics before about age 8 in GIRLS and 9 in BOYS, and warrants assessment and paediatric ENDOCRINOLOGY referral. Take a history (timing/progression, growth, family history, CNS symptoms such as headache/visual change, possible exogenous hormone exposure) including household testosterone gel (MHRA Drug Safety Update January 2023), and examine face to face (height and weight plotted on the RCPCH UK-WHO chart for growth velocity, Tanner staging with a parent present and never photographed, BP, fundi, visual fields, neurology, signs of a cause). Understand the framework: CENTRAL (gonadotrophin-dependent, "true") precocious puberty results from early activation of the hypothalamic-pituitary-gonadal axis — commoner in girls and often idiopathic, but CNS pathology (tumour, hydrocephalus) must be excluded, especially in boys or with atypical/neurological features — versus PERIPHERAL (gonadotrophin-independent) precocious puberty from ovarian/adrenal/testicular sources, congenital adrenal hyperplasia, McCune-Albright syndrome, or exogenous hormones. Recognise benign NORMAL VARIANTS — premature thelarche (isolated breast development) and premature adrenarche (isolated pubic/axillary hair, body odour) — which are usually benign but still warrant assessment to distinguish from progressive precocious puberty. Evaluation matters because of the psychosocial impact on a young child and family, the effect on final adult height (early bone maturation/premature epiphyseal fusion can reduce final height), and the need not to miss a serious underlying cause (CNS or hormone-secreting tumour, CAH). Refer to paediatric endocrinology for assessment — bone age, hormone testing (LH/FSH, oestradiol/testosterone, GnRH stimulation), and imaging (pelvic/adrenal imaging as indicated, and brain MRI where the specialist judges it indicated — the Endocrine Society 2026 guideline, international, suggests it need not be routine in girls aged 6–8 without neurological findings) — and treatment where indicated (e.g. GnRH analogues (BNFC) to halt central precocious puberty and preserve height/allow age-appropriate development); primary care’s role is recognition, initial assessment and referral, without delaying for GP blood tests. Support the worried parent and the child throughout. NICE NG12: consider a very urgent referral (within 48 hours) for a child with newly abnormal cerebellar or other central neurological function, with same-day assessment for signs of raised intracranial pressure. Vaginal bleeding without breast development, or signs of harm, need safeguarding consideration (Working Together to Safeguard Children 2023).