[Skip to Content]
[Skip to Content Landing]
Original Investigation
February 10, 2020

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

Author Affiliations
  • 1Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
  • 2The International Research and Research Training Centre in Endocrine Disruption of Male Reproduction and Child Health, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
  • 3Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
  • 4Division of Adolescent and Transition Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 5Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
  • 6Institute of Child Health, University College London Hospital, London, United Kingdom
JAMA Pediatr. 2020;174(4):e195881. doi:10.1001/jamapediatrics.2019.5881
Key Points

Questions  Has the age at onset of thelarche in girls changed within the past 4 decades?

Findings  This systematic review and meta-analysis found that age at pubertal onset, with thelarche assessed by physical or clinical examination of the breast, decreased by a mean of almost 3 months per decade from 1977 to 2013.

Meaning  In most textbooks, thelarche among girls younger than 8 years is considered pathologic and warrants further investigations; therefore, a younger age at thelarche in girls in the general population will change current diagnostic decision-making in girls suspected to have puberty disorders.


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.

Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words