Delayed Puberty / Delayed Sexual Development

  • It can be upsetting for a child to not be growing and developing physically as quickly as his or her peers. It’s usually nothing to be worried about, but having your child evaluated by a doctor can help set both of your minds at ease.

    Delayed puberty is defined differently for boys and girls:

    Here’s what you need to know about delayed puberty:

    • There’s a lot of variation in terms of what’s a “normal” time to start puberty.

    • A specialist, such as an endocrinologist, is often able to detect signs that puberty has started, even if it doesn’t look that way to you, your child or even your child’s pediatrician.

    • Delayed puberty can be caused by an underlying medical condition (e.g., celiac disease or a hormone deficiency).

    • There’s often a hereditary component to delayed puberty. If a parent was late in starting puberty, it’s more likely that his or her child might be, too.

    • In the overwhelming majority of cases, if treatment with hormones is required, it successfully jumpstarts puberty.

    Delayed puberty: Reviewed by Diane Stafford, MD
    © Children’s Hospital Boston; posted in 2012

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    Boston Children's Hospital
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    Boston Children's Hospital
    300 Longwood Avenue
    Boston MA 02115


  • What is delayed puberty?

    While there’s a wide range of what’s considered “normal” in terms of when boys and girls start to go through puberty, delayed puberty is defined simply as:

    • boys: lack of increase in testicle size by age 14

    • girls: lack of breast development by age 13

    Is it serious?

    Most likely not. If your child has delayed puberty but is otherwise healthy, he or she should be evaluated and possibly treated, but it’s not something that you should consider to be an emergency.

    Is delayed puberty equally common in girls and boys?

    That’s hard to know, since boys seem to be more likely to seek evaluation, perhaps because they (or their parents) may be more concerned with keeping up with peers in terms of height. 


    What causes delayed puberty?

    A few different things can cause delayed puberty.

    1. Constitutional growth delay (CGD)

    • CGD is a temporary delay in skeletal growth, which keeps a child from being as tall as his peers, at least for a while.

    • Among boys, around 60 percent of the time, delayed puberty is caused by constitutional growth delay.

    • It’s hard to say for sure, but CGD is thought to affect around twice as many boys as girls.

    • CGD is a normal variant of growth, but may still make a child feel distressed. 

    • As we grow up, our bones “mature.” If a child has CGD, a doctor can look at an x-ray of his hand and wrist, and see that his bones appear “younger” than expected for his chronological age.

    • CGD is often inherited. If one or both parents were “late-bloomers,” it’s likely that their child may be, too.

    • Kids with CGD go through puberty and reach an appropriate adult height, just not as quickly as their peers do.

    2. An underlying medical condition

    These might include:

    • cardiac conditions
    • celiac disease (which affects a child’s ability to gain weight, making it harder to grow at the same rate as his peers)
    • conditions that prevent the hypothalamus or pituitary gland from sending the “start puberty” signal
    • conditions that prevent the ovaries or testes from being able to respond to the “start puberty” signal
    • certain genetic conditions, such as Klinefelter’s syndrome in boys and Turner syndrome in girls

    3. Some psychiatric medications can contribute to delayed puberty, too.

    Signs and symptoms

    While delayed puberty is actually defined by signs (lack of increase in testicle size by age 14 or lack of breast development by age 13), we often see children who come in for an evaluation because they’re concerned that they’re not growing as quickly as their peers.

    My child has developed pubic hair and body odor, but still no breast development. Should I be concerned?

    Your child could have pubic hair and body odor but still meet the definition for delayed puberty, so she should be evaluated.

    This is because while they tend to happen around the same time, development of breasts and development of public hair/body odor are two separate processes, each triggered by their own hormones. The diagnosis of delayed puberty only takes into account the process and the hormones that lead to breast development. 


    Q: Should I be concerned about my child’s delayed puberty?

    A: In the overwhelming majority of cases, no. Kids with delayed puberty should definitely be evaluated by a specialist, but most often, it’s nothing to worry about. Even if your child has an underlying medical condition, puberty can almost always be started through hormone therapy. 

    Most often, it only requires brief treatment to “jump-start” puberty, but in some cases, doctors will recommend long-term hormone therapy.

    Q: Will delayed puberty affect my child’s ultimate growth and development?

    A: It’s possible. Kids with CGD tend to not grow as much during their growth spurts as other children, which may make them a little smaller as adults. 

    Q: Is delayed puberty harmful?

    A: No, delayed puberty isn’t harmful. Since there are medical causes, kids with delayed puberty should be evaluated, but most of the time it’s not a medical problem.

    Still, if your child feels as though he’s not keeping up with his peers in growth and physical development, it can be very upsetting. These feelings should be taken seriously.

    Q: When my child finally does go through puberty, will it happen faster than normal? 

    A: It could. Kids with CGD sometimes go through puberty at a slightly faster pace.

    Q: Will delayed puberty affect my child’s ability to have children?

    A:It depends on what’s causing the delay. If the delay is temporary, like in CGD, it typically doesn’t affect fertility. Certain medical conditions that affect hormones can cause problems with fertility, and researchers are working on how to improve fertility in these cases.

  • The first step in treating your child is forming an accurate and complete diagnosis. Your child’s doctor will most likely start by taking the child’s medical history, including questions about the family’s medical history, and performing a physical exam. Other tests might include:

    • bone age examination—a simple x-ray of the left hand and wrist that allows doctors to look at your child’s skeletal development, which changes over time.  If your child’s “bone age”–the age indicated by your child’s skeletal development–is lower than his chronological age, it could be a sign of constitutional growth delay (CGD), which is a variation of normal development.
    • blood tests–to measure hormone levels, including estrogen and testosterone, and screen for underlying disorders if appropriate

    It can sometimes be difficult to determine what’s causing a child’s delayed puberty. An extreme case of CGD might delay puberty so long that it appears that it might be caused by an underlying medication condition. 

    Sometimes doctors prescribe hormone replacement therapy to see whether they can trigger puberty. Whether this works or not often provides information about what caused the delayed puberty, but it’s far from foolproof—even CGD will sometimes fail to respond to an initial hormone trigger.

    After all tests are complete, we will meet with you and your family to discuss the results and outline the best treatment options.

  • At Boston Children's Hospital, we consider you and your child integral parts of the care team and not simply recipients of care. You and your care team will work together to customize a plan of care for your child.

    We can treat delayed puberty with hormone therapy. Even if your child has constitutional growth delay (CGD) and will progress through puberty at his body's own rate, having puberty “jump-started” through hormone treatment may contribute greatly to his overall well-being. You, your child's doctor and your child will discuss whether this is the right option for him.

    How will you follow up with my child?

    Each child is different, but depending on how old your child is and what's causing his delayed puberty, we might see him every four to six months throughout childhood to make sure that there are no problems or complications.

    Coping and support

    There's a lot of support available here at Boston Children's Hospital for you and your family, and here are some of the ways we can help:

    Patient education: Our nurses will be on hand to walk you through your child's treatment and help answer any questions you may have —They will also reach out to you by phone, continuing the care and support you received while at Children's.

    Parent to parent: Want to talk with someone whose child has been treated for delayed puberty?  We can often put you in touch with other families who have been through similar experiences and can share with you their experience at Children's.

    Faith-based support: If you are in need of spiritual support, we will help connect you with the Children's chaplaincy. Our program includes nearly a dozen clergy representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian and United Church of Christ traditions who will listen to you, pray with you and help you observe your own faith practices during your hospital experience.

    Visit our For Patients and Families page for all you need to know about:

    • getting to Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

  • At Children’s Hospital Boston, we’re known for our science-driven approach. In fact, we’re home to the world's most extensive pediatric hospital research enterprise; and we partner with elite health care and biotech organizations around the globe. But as specialists in innovative, family-centered care, our physicians never forget that your child is precious, and not just a patient.

    Our Division of Endocrinology operates one of the nation's most extensive research programs focused on pediatric endocrine disorders. With more than 50 basic science and clinical researchers, we are attempting to unravel the genetic and biochemical underpinnings of the endocrine system.

    Researcher Yee-Ming Chan, MD, PhD is studying kisspeptin, a hormone that’s thought to be involved in stimulating pubertal development. Understanding kisspeptin and the search for other factors that control the onset of puberty will allow doctors to answer basic questions about the control of puberty as well as develop better methods of diagnosis and treatment.
    Diane Stafford, MD, and several of her Children’s colleagues are currently working on a study to definitively diagnose who is in puberty and who isn’t by using something called leuprolide stimulation testing. Their research involves analyzing test data from patients they’ve followed over the years and comparing who has progressed into puberty and who has proven to be “a false positive” and did not progress into puberty. The results could provide much-needed insight into which patients require treatment for precocious puberty and which do not.

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