Are we treating a problem that doesn’t exist?

by Tara Haelle  

A smattering of studies here and there in the past decade or so have suggested that kids are hitting puberty earlier and earlier than they used to. The data certainly seem to support that possibility, even though there aren’t many answers as to why the trend is occurring.

But for at least one group of kids, the answer might be incredibly pedestrian: We’ve got their ages wrong.

That’s the argument Peter Hayes put forth in a recent Pediatrics editorial. He points out that the uncertainty about children’s ages during the international adoption process could be distorting what the actual rates of early puberty, or precocious puberty, are for kids adopted from overseas.

Finding out the extent to which mislabeled ages could be contributing to the trend is more than an exercise of academic or demographic curiosity. Kids who appear to be hitting puberty early are often treated with gonadotropin-releasing hormone agonists to slow down the puberty process. These drugs ultimately trigger a reduction in the hormones involved in producing sperm or eggs. But they have side effects, including hot flashes, headaches, reduced bone mineral density (a risk factor for osteoporosis), and potentially increased cardiovascular risks — though the cardio risks are small and so far limited only to patients receiving the hormones for advanced prostate cancer treatment.

As Hayes points out, there are good reasons to think that kids’ ages are frequently misrepresented, whether by accident or intentionally, during international adoptions. Often the children are adopted from countries that lack reliable (or any) bookkeeping or registries, and relatives may not remember or even know the child’s actual age. Abandoned children without relatives or a home may not know their age, which must then be estimated by local or state health officials or adoption workers.

Then, those estimates can miss the mark for a variety of reasons: “It may be suspected that underestimates are more likely than overestimates, either to facilitate placement with adoptive parents, who tend to favor younger children, or because neglected and malnourished children will be less advanced and smaller than the typical child of their age,” Hayes writes.

Although he notes that in studies on early puberty among international adoptees, researchers have acknowledged that inaccurate ages might play a role, Hayes doesn’t think those researchers give that explanation sufficient attention. He has a point when one considers the studies he cites showing that children are at higher risk for early puberty the older their recorded age is at adoption. The youngest adoptees “are at little or no increased risk of early puberty” in these investigations.

And think about it for a moment: Who is more likely to be mis-aged? An older child, for whom age estimates are more ambiguously based on height and perhaps maturity or developmental milestones, which will vary dramatically among orphans, or an infant or toddler, for whom the possible range of ages is much smaller? A 3-year-old is unlikely to pass for a 1-year-old or vice versa, but many a 6-year-old could pass for a 4-year-old. A child who cannot yet walk on his own would almost never be estimated to be any age over 2, but a 10-year-old might pass for as young as 6 if undernourished and immature.

It’s worth noting that this issue affects a shrinking number of children in the U.S., if only because international adoption rates have been plummeting for a variety of reasons. In fact, the number of kids adopted from overseas in 2011 is less than half the number in 2004; it’s dropped to fewer than 10,000 kids a year, and early puberty certainly does not occur among all these children.

Any child receiving treatment that can cause harm and no benefit, however, deserves to have researchers looking for the right answers and considering all the possible explanations for a problem that might not even exist.

Hayes describes three different studies that, taken together, support his argument that inaccurate ages upon adoption are a highly likely explanation for at least some of the high rates of early puberty among international adoptees.

The first was a Belgian study, which found that children who were slightly underweight or not at all underweight when they were adopted still went on to reach puberty earlier than average. The authors suggested that the reason was exposure of endocrine disruptors in pesticides, the same rationale that has been proposed to explain some of the early puberty rates among nonadopted children in the US.

But the second study, out of Denmark, threw a wrench in that idea by finding that migrant children were no more likely to hit puberty earlier than non-migrant children. In theory, the migrant children should be susceptible to the same pesticide exposure blamed for early puberty in the adopted kids of the Belgian study. The only difference is that the ages of the kids in the Danish study were likely accurate because the children remained with their parents.

The third study, from Spain, supported the findings of both of these reports. It also found that migrant children were not at higher risk for hitting puberty early but that appropriately nourished kids who were adopted were still at risk for early puberty – 18 times higher, actually, when compared to nonadopted children. The Spanish researchers suggested the stress of the adoption and life change might have been the reason the kids hit puberty earlier, but it doesn’t rule out the possibility that the kids’ ages were incorrectly recorded at adoption.

The only way, of course, to find out whether mislabeled ages is a key part of early puberty among adopted kids is to do a sufficiently large study of this population for whom accurate hospital records are available. Ruling out under-recorded ages as a “cause” of early puberty would keep the possibilities open for stress or malnourishment as causes.

The problem is that researchers do not seem interested in this kind of study. “The research to date has been largely driven by the effort to come to a better understanding of the onset of puberty rather than the context of adoption, with a notable absence of curiosity over how either adoption practices or social, cultural, and bureaucratic norms in different states of origin may impinge on the reliability of birth dates,” Hayes observes. “This reluctance to cross disciplines may help to explain why under-recorded age has received comparatively little attention despite the evidence in its favor and the questions that this raises over treatment.”

These questions about the treatment call into question why researchers are so uncurious about exploring this avenue. Adoptive parents may needlessly worry about a child’s “early” development and offer their children unnecessary and potentially harmful treatment when, in reality, it’s possible their child simply needs a few extra candles on their next birthday cake.