Article Text

National survey of referrals for precocious puberty in Germany
  1. Sonja Baehr1,
  2. Dirk Schnabel2,
  3. Joachim Woelfle3,
  4. Felix Schreiner1,
  5. Bettina Gohlke4
  1. 1Pediatrics, University Hospital Bonn, Bonn, Germany
  2. 2Department of Paediatric Endocrinology and Diabetology, Charite Medical Faculty Berlin, Berlin, Germany
  3. 3Department of Paediatric Endocrinology and Diabetology, Erlangen University Hospital, Erlangen, Germany
  4. 4Dep. of Pediatric Endocrinology and Diabetology, University of Bonn, Bonn, Germany
  1. Correspondence to Dr Bettina Gohlke; bettina-gohlke{at}


An unusual high number of girls were referred to our paediatric endocrine clinic with suspected precocious puberty (PP) since the beginning of the COVID-19 pandemic. We analysed our data and initiated a survey among German paediatric endocrinologists.

At our centre, less than 10 patients were diagnosed of PP annually between 2015 and 2019. This increased to n=23 (2020) and n=30 (2021). A German survey confirmed this observation: Out of 44 centres which completed the questionnaire, 30/44 (68%) reported an increase of PP. Above this, 32/44 (72%) stated an increase in girls diagnosed with ‘early normal puberty’ since the beginning of the COVID-19 pandemic.

  • COVID-19
  • Adolescent Health
  • Endocrinology

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At the beginning of 2020, there was a rapid global expansion of the COVID-19; on 11 March 2020, the WHO declared a worldwide pandemic. To reduce transmission occurring through respiratory droplets, many countries have imposed regulations of social distancing and lockdowns. As in many other countries, this led to significant changes in daily life for children and adults living in Germany. Social contacts were reduced to a minimum, schools and day-care centres, gyms and playgrounds were closed. Meanwhile, it has frequently been shown that the changed social circumstances have led to an increase in obesity in the children.1 Loss of regular physical exercise and an increase in free time commonly used for sedentary activities2 was made responsible for the observed weight gain and increase of obesity in children. In addition, it has been shown that the changed social circumstances have led to an increased incidence of psychological disturbances.3 Obesity and increased psychosocial stress may increase the occurrence of precocious puberty.

Already in 2020, we noticed an unusual increase in girls presenting with precocious puberty at our centre for paediatric endocrinology. We; therefore, analysed our own data for 2020/2021 and compared it with the data from 2015 to 2019. Usually less than 10 patients/year were diagnosed of precocious puberty at our centre. In 2020, a significant increase was seen (n=23) with a further increase to n=30 in 2021 (figure 1). We then initiated a Germany-wide survey at all centres for paediatric endocrinology (questionnaire as online supplemental file 1).

Supplemental material

Figure 1

Numbers of girls diagnosed annually with central precocious puberty from 2015 to 2021 in one tertiary centre.

The mailing list of the German Society for Paediatric Endocrinology and Diabetology was used. Forty-four centres completed the questionnaire. Of these, n=30 (68%) confirmed an increase in the diagnosis of central precocious puberty since the beginning of the COVID-19 pandemic. Above this, n=32 (72%) stated that they had observed an additional increase in the number of girls diagnosed with ‘early normal puberty’ (Tanner breast stage ‘B2’ between the 8th and 9th year of life). Eighteen out of the 44 centres were able to quantify the numbers of referrals and, again, confirmed an increase of newly diagnosed girls with precocious puberty (figure 2).

Figure 2

Numbers of girls diagnosed with central precocious puberty in 2019, 2020 and 2021 in 18 German centres of paediatric endocrinology.

In accordance with reports out of many other countries (including Italy, Spain, USA, India, China), there was an increase in girls presenting with precocious puberty in 2020/2021 in comparison to previous years in Germany. Various mechanisms have been suspected of being causative.4 5 The change in lifestyle (decreased activity, increase in sedentary lifestyle, changed sleeping pattern, increase of digital devices) as well as increased mental stress, change in nutrition followed by gain of weight are suspected to be the cause. However, in addition, it must be taken into account that a worldwide trend for secular changes in age of onset of Tanner breast stage 2 (B2) has been reported for the last 20 years.6 In conclusion, it is recommended to increase the diagnostic criteria for precocious puberty.

Ethics statements

Patient consent for publication

Ethics approval

The Ethic committee of the University Hospital, Bonn approved to the study (approval number 25/21).


We thank all colleagues who have provided information about their numbers of patients.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Contributors SB collected data, carried out the initial analyses and reviewed and revised the manuscript. DS and JW coordinated and supervised data collection, and critically reviewed the manuscript. FS designed the data collection instruments, collected data, carried out the final analyses, and reviewed and revised the manuscript. BG conceptualised and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests No, there are no competing interests.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.