A stinky preschooler

The Pediatric Insider

© 2016 Roy Benaroch, MD

Erika wrote in: “Is it normal for a 4 year old to have musty armpits? Only I can smell it because I jam my nose in her pits, but otherwise no odor emanates. But still, age 4?!?! Do I do nothing? I definitely don’t want to start deodorant or antiperspirants.”

After almost 20 years of seeing (and smelling) dozens of shirtless kids a day, I can promise you, yes, some of them do have their own odor. I suspect all of them, do, really – and in the mists of time, years ago, those odors were probably unique to each child and a way for moms to keep track of their little ones. These days, we expect cleanliness, anti-bacterial toothpastes, and children to smell vaguely of star anise, essential oils, and gluten-free pizza. But it wasn’t always that way.

If your kiddo is especially stinky (and it sounds like she isn’t – honestly, if you have to get your nose into her pits to find the odor, I think you need a new hobby) you can bathe her more, or insist she use a washcloth, or use a deodorant soap. It’s not really likely that an antiperspirant will help much at this age, because before puberty sweat is of the less-stinksome variety.

Speaking of puberty – I’ve been asked before of stinky young children, is this a sign of early puberty? Probably not, unless it’s accompanied by other things. Real puberty begins with breast development or increased testicle size (not, presumably, at the same time.)  There will also be a jump in height. Other things like pubic hair, body odor, and acne often begin around the same time, but actually aren’t caused by hormones from the gonads, and aren’t reliable signs of puberty. If you’ve got questions about your specific child regarding puberty, ask your doc, in person, during an exam. (Not over the phone. Honestly, I can’t tell without examining your child. And, please, don’t email photos. Someone could get arrested.)

Bottom line:  file this under “something else not to worry about,” and enjoy your little one, musty armpits and all.

Is his penis too small?

The Pediatric Insider

© 2013 Roy Benaroch, MD

A question popped up on a bulletin board over on WebMD where I’m a “featured expert”: Could an 8 year old boy have a penis that’s too small? A parent thought that one son’s looked much smaller than that of her other boys.

Penises start out small, and stay fairly small until hormones at puberty cause growth starting around age 10-14. At birth, an average penis is 1.5 inches long, and anything over ¾ of an inch is considered normal. An average 8 year old (and, really, an average any-year-old prior to puberty) has a penis size of about 2 inches—that’s gently stretched, while pushing back the pubic fat pad that can sometimes “bury” the base of the penis. A more detailed table of normal and abnormal penis sizes by age can be found here.

A penis that appears much smaller than expected is sometimes the result of obesity or a thick body type that makes the penis look “pushed in.” This is called a “hidden penis.” If the penis can’t be pushed back out (by pressing back on the fat pad), it may be a truly “buried penis,” which may require surgery. Sometimes, the scrotal skin is attached up high on a “webbed penis,” which can also be corrected surgically.

Parents who have concerns about penis size should bring this up with their doctor—don’t expect that a pediatrician is going to measure Junior’s penis at his well check, or that we’ll more-than-eyeball that part of the exam. If it’s really small, we’ll probably notice, but if you’re worried, bring it up and discuss it to make sure that that part of the exam is done carefully and recorded. Along with penis size, a careful exam should also include a complete genital look-see, checking to make sure testicles are where they’re expected to be and that there are no other signs of unusual genital development.

A truly too-small penis is called a micropenis. This can be treated initially with testosterone injections, which usually enhance growth. If that fails, the family of a boy with a very small penis may have to consider the difficult and ethically challenging issues of whether gender reassignment is appropriate. Anyone facing that kind of situation should certainly be working with university specialists in endocrinology and urology to learn about and explore every option.

When is the right time for deodorant?

The Pediatric Insider

© 2011 Roy Benaroch, MD

Jennifer asked, “What is the right age for deodorant? My husband is thinking that our second grade girl needs to start wearing it. I am not sold on the idea. Any good rules of thumb to keep in mind?”

Kids should start wearing deodorant when they get stinky.

Often (but not always!), that coincides with the onset of puberty—but actually, a strong body odor itself isn’t actually caused by the same hormones that cause puberty. If an adult-type body odor is the only change going on in your daughter, I wouldn’t worry about that being part of true puberty. I’d just work on hygeine (shower every day! Use soap!) and pick out a deodorant if you’d like.

Real puberty in girls starts with breast budding, and real puberty in boys begins with the growth of the testicles. If these are starting too early (before age 9 in a boy, or before age 8 in a girl), further evaluation is needed. Further evaluation is also always needed if height growth is accelerating too early. Many other things tend to occur at the same time, though they’re not truly signs of puberty. These include armpit hair, pubic hair, acne, and a, let’s say, more-robust body odor. If multiple “other things” are going on, it’s worth a discussion with your pediatrician. But if it’s really only the stinky, there will probably not be anything to worry about.

Oy! Soy! Will it girlify your boy?

The Pediatric Insider

© 2010 Roy Benaroch, MD

From LeeAnn: “Are soybeans (edamame) safe for my 11 year old daughter to eat? I have heard that they can ‘mess with’ her hormones?”

You want to see a freakshow? Try googling this topic. I found one essay, on a “news” site, that blamed soy products for everything from stroke to vision loss to homosexuality. On the other hand, other authors love soy: it will apparently prevent heart attacks, improve the symptoms of menopause, and help flush the toxins out of your body while improving your sex drive (women) and fracture healing (men.) On one site, in two adjacent paragraphs, I found a breathless author worrying that soy could cause breast cancer, followed by a second paragraph extolling its virtues in preventing breast cancer.

Please.

Soybeans contain a group of chemicals called “phytoestrogens” (sometimes called “isoflavones”) that are chemically somewhat similar to human estrogen hormones. In the 1970’s and 1980’s, some research showed that in the laboratory, these compounds could activate human estrogen receptors, presumably causing estrogen-like effects. So that’s the germ of truth.

But these phytoestrogens activate human estrogen receptors very, very weakly. They’re also easily broken down by cooking and processing, and by enzymes in the human body. It would take a tremendous amount of soy, eaten every day, to have anything close to a genuine hormonal effect. No human study has shown anything close to a measurable effect of consuming soy, at least not in ordinary amounts.

So: enjoy your edamame, tofu, and soy burgers. Dip your sushi in a little soy sauce, and try this tasty recipe from Alton Brown. If you want to be super-careful, just don’t do all of this on the same day.

G-d has a sense of humor

The Pediatric Insider

© 2010 Roy Benaroch, MD

He was terrified.

A 13 y/o boy sat on an exam table, shirtless. He twitched a little, as people do when they’re acting cool. I learned to see through that a long time ago.

His forehead glistened.

“I know it’s nothing,” he said.

What he meant was, “I have cancer. I know it. Or even worse, I’m going to have breasts. Either way, life is over.”

“You don’t need to worry about it. Many boys have a little swelling under their nipples during puberty. It’s called ‘gynecomastia,’ and it’s completely normal. What happens is that your body has such high concentrations of male sex hormone that it’s starting to stimulate the receptor of the female hormones. So you get just a little swelling.”

I didn’t say that.

Instead, I said, “You know, G-d has a sense of humor. Really, he does.”

I let that sink in dramatically before continuing. “He knows that at your age, hormones are surging through you, turning you from a boy into a man. You’ve noticed that, too– you’re growing taller, and your voice is deeper sometimes, and you’re getting hairy all over the place. G-d knows all you boys are dealing with the huge changes, and he thinks it’s funny to just give you a little taste of what the girls are living through.”

He started to smile.

“Look, it turns out that at super-high concentrations, all of that manly testosterone hormone starts to make your breast tissue grow. Just a little, and just for a short time. That swelling will go down, and I promise you won’t grow boobs. It isn’t going to happen. But guess what– G-d likes to play his joke on the girls, too.”

He looked up, eyes wide.

“You know the girls have tons of their girly hormones, just sloshing around. It makes them grow womanly, with boobs and hips, and those other mysterious girl things. But did you ever notice that a few of the girls are growing just a teeny bit of a dark mustache?”

He laughed. Tension streamed away.

“That’s it! That’s G-d’s joke on the girls! Just when they’re really turning into women, their high estrogen levels tweak their androgen receptors, just a little, and just enough to give some of them a little mustache. But I have to tell you something….”

Here I paused, and spoke quietly.

“Don’t you ever go up to a girl and say, ‘Ooo you have a teeny mustache, because G-d has a sense of humor.’ If you do, she’ll slap you silly, and you’ll deserve it!”

Early puberty in boys

The Pediatric Insider

© 2010 Roy Benaroch, MD

Allison posted, “I’ve got a friend whose (just turned) 8 year old son is showing signs of puberty ‘down there.’ I told her that was VERY early and that I’d get it checked out. Thoughts?”

Although it’s actually considered normal for girls to begin puberty at age 8, true pubertal changes in an eight year old boy are abnormal and ought to be evaluated.

But first: is he really experiencing puberty? The first sign of true puberty in a boy is enlarging testicles, followed by growth of the penis. These changes are driven by hormones produced in the pituitary glands and testicles. Although pubic hair, body odor, and acne often appear at about the same time, these changes are related to hormones from the adrenal glands, and are not really part of true puberty. A boy with only the appearance of hair, without testicle and penis growth, may not be entering puberty. He can be watched for signs of further development without further immediate workup. But a boy who’s truly entering puberty at age 8 needs a thorough evaluation.

Evaluating early puberty starts with careful measurement of height– puberty will coincide with an increased growth rate, so if a boy is suddenly becoming taller, that’s a definite sign of puberty. A careful physical exam by an experienced physician is essential. Sometimes, a bone age x-ray is useful, or blood tests of hormone status are needed. Some of these boys will also need an MRI scan of their pituitary glands, or other radiology exams.

Though early puberty in a girl is rarely caused by a serious underlying health condition, at least half of boys with true early puberty are going to have an underlying cause that needs to be found and addressed. Boys with true early puberty are much more concerning than girls. Allison ought to tell her friend to get her son to the pediatrician for an exam and further workup.

Boys with breast tissue

Carolyn H posted, “I have a 16 yr son who has been complaining of a lump/knot under his nipple. He says is it tender and I am concerned. I have heard about gynecomastia in teen boys, but what I have read indicated that is a condition where they actually grow breasts. He does not have enlarged breasts. His nipple has become inverted and the whole area is hard. Is this something to be concerned about ?”

Gynecomastia refers to excessive development of breast tissue in males, though it doesn’t necessarily mean that full breasts grow. More usually, it’s a knot of firm tissue underneath one or both nipples in a teenaged boy. There are a few medications that can cause gynecomastia, though they’re rarely used in children. Still, if your son is on any regular medications you ought to check with the doctor who prescribed them if they’re a possible trigger.

She’s too young! Is puberty starting early?

The Pediatric Insider

© 2008 Roy Benaroch, MD

I saw a ten year old girl in fifth grade for a check up this week. Her mom mentioned that she had started to develop breasts about a year ago. When I started talking about the girl’s first period, mom’s jaw dropped open. Mom had been 13 when she started—could her daughter be about to have her first period in elementary school? Why?

Puberty is the process through which boys and girls develop into women and men capable of reproduction. It includes the development of sexual characteristics (pubic hair and breasts), other physical changes (a deeper voice, acne, and body hair) and marked increases in both height and weight (the “pubertal growth spurt”.)

A girl’s puberty starts with breast development, which historically was thought to be normal from age 9 to 14. About 2 years after the beginnings of breast development, a girl can expect her first menstrual period. Two years after that, she’ll have reached her adult height and will stop growing taller. This signals the end of puberty.

Boys begin puberty about a year or two after girls, with a normal range of 10-17 years. Boy puberty begins with an increased testicle size. Boys continue to grow for about 6 years after the beginning of puberty—meaning for two years longer than girls. This accounts for most of the height difference between adult men and women.

There are some very normal minor variations in puberty. During the prepubertal years, many girls will develop a small amount of pubic hair, which does not progress. As long as other findings of puberty don’t occur, the appearance of pubic hair in a young girl is not a cause for alarm. Likewise, many boys going through normal puberty will have a small amount of breast tissue develop. This can occur on one or both sides, and though embarrassing for some boys it does not progress and doesn’t mean anything is going on. I tell the boys not to worry, they are not going to grow breasts. Boy who are self-conscious should choose to play for the shirts, not the skins.

What about early puberty? Many studies have documented that in the developed world, girls are indeed starting earlier. Also, we now appreciate that there are differences in normal puberty among girls from different races. Health authorities now recommend that for Caucasian girls, puberty should be considered early only if it begins before age 8, while African-American girls may begin at age 7. Some authors consider even ages 6 or 7 to be normal. No similar decrease in the age of starting puberty has occurred in boys.

Why has puberty become earlier in girls? The best studies show that the age that puberty begins is most closely correlated with improved nutrition and with body fat. Girls from societies with good nutrition begin puberty earlier. Also, as more girls become overweight, the increased total body fat affects the metabolism of female hormones, leading to a decreased age of puberty. Conversely, girls who are very muscular and lean from sports participation tend to have a delayed puberty.

There are several other environmental exposures that parents sometimes wonder about. A lab-manufactured copy of a normal cow hormone, called BST, is injected into many dairy cows to increase their milk supply. Some people believe that this hormone in milk affects the age of puberty. However, milk produced by BST-treated cows does not contain more BST than milk from untreated cows. Most convincingly, developed countries that have restricted the use of BST (including Canada and countries in the European Union) have seen the same drop in the age of puberty as in the United States, where approximately one third of dairy cows are BST-treated. So whether or not they’re drinking milk from BST-treated cows, girls are starting puberty earlier.

Industrial pollutants including PCBs may act as “endocrine disrupters,” influencing the timing of puberty. Although buying organic produce may decrease your family’s exposures to insecticides, there really isn’t any evidence that it will decrease the exposures to industrial contaminants or allow your daughter’s puberty to begin later.

In 2007, cases were reported of boys developing breast tissue after regular application of skin creams containing lavender oil or tea tree oil. These products contain estrogen-like compounds that are absorbed through the skin. Though no cases of early puberty in girls have been linked to these herbal products, they do have a potent hormonal effect, and girls experiencing early puberty should tell their physicians about all medicines and herbal products that they use. In boys, early puberty has also been caused by inadvertent application of their father’s prescription testosterone creams. Fathers who use this cream need to wash their hands!

Why should we identify children with early puberty? Perhaps the most important consequence of early puberty is decreased adult height. Children who start early will end early, and may have fewer years in which to grow. Since pre-pubertal children grow about two inches a year, a girl who begins puberty four years early may end up eight inches shorter than she would have if she had waited. Also, at least in girls, early puberty can be associated with poor self-image, social isolation, and depression.

Though there is a wide range of normal ages at which puberty occurs, the normal age for girls to begin puberty has decreased. If your child is having physical changes of puberty early, a complete physical examination should be performed by your pediatrician. This should always include careful measurements of height and weight. An isolated finding of early pubic hair itself may not be worrisome, but a six year old girl who has breast development, pubic hair, and a big jump in her height is certainly going through full-fledged puberty early. True early puberty should be referred to a pediatric endocrine specialist for further evaluation.

updated for formatting 7/31/2017