Puberty can sneak up on parents. One day your child seems little, and the next you’re wondering: Is this normal? When should puberty start? And how do I know if my child’s changes are happening too early — or too late?

There’s a lot for parents to keep up with, from growth spurts to body hair, periods, voice changes, acne and mood swings. And there’s a wide range of what’s considered normal; every child goes through puberty a little differently. Dr. Jayme Wood, a pediatrician with Novant Health Matthews Children's Clinic, explains what parents can expect, when it’s worth checking in with the pediatrician and how to discuss puberty changes with your child.

What do you want parents to understand about what puberty can be like for kids?

Puberty is tough. A lot of embarrassing things happen. Girls might bleed through their clothes at school. Boys may get unwanted erections. And that’s happening at a time kids are very sensitive to the judgments of their peers. Parents should approach puberty with sensitivity and work to normalize what their child is going through.

Are there common myths about puberty?

I think the biggest one revolves around the timing of it. Timing can vary widely, and a broad range is considered normal. Puberty follows a predictable pattern, but it can still look a little different for everyone.

When should parents seek medical attention if their child hasn’t started showing signs of puberty?

Genetics can play a role in the onset of puberty. If you, as a parent, were a late or early bloomer, your child may be, too.

For girls, the normal range is between 8 and 13. For boys, it's between 9 and 14. If signs of puberty appear before the low end of that range or haven’t appeared by the upper end of the range, we would want kids and their parent to come in, talk to us and share your concerns. That could prompt your doctor to order an evaluation.

What happens during that evaluation?

That evaluation can be done by a pediatrician or pediatric endocrinologist. It involves a detailed medical history, physical exam including a breast exam for girls, blood tests, maybe checking hormone levels. Often, we’ll determine “bone age” by getting an X-ray of the child’s hand. That determines if their skeletal age matches their actual age.

We would want to determine if a child is going through “precocious puberty.” There are two kinds: central and peripheral.

• Central precocious puberty is when the alarm went off too early, so to speak, and it's sending hormones down to your ovaries or testicles and kicking off true puberty. That can happen for no particular reason, or there could be something more serious going on. Some patients may require a brain scan to be fully evaluated.
• Peripheral precocious puberty is when the alarm hasn't gone off yet for true puberty, but something somewhere is pushing out those hormones and causing the changes. A pediatric endocrinologist can determine if treatment is needed.

What kind of treatment is used for early puberty?

There are medications for early puberty that slow it down.

What are typically the first signs of puberty?

In girls: Breast buds — that little bit of swelling underneath the nipples — are the first signs of puberty. They can be very tender, and they may grow asymmetrically. Both are normal. Around that time, they’ll start to develop pubic and underarm hair. Girls typically go through their growth spurt earlier than boys, and they usually have a first period two to three years after breast buds appeared. It’s normal for periods to be irregular for the first year or two.

To help prepare your daughter, you could create a little period bag. Around the time her period is due, she can take the bag in her backpack so she’s got pads, tampons and period underwear on hand.

In boys: Puberty starts with testicular enlargement, which may not be obvious to parents. Their voice deepens, and the growth spurt happens, but later than with girls.

It’s worth mentioning that boys become fertile earlier than parents think, and often before that growth spurt and voice deepening. So, while they’re still looking quite young, they can be fertile.

What concerns about puberty do parents frequently discuss with you?

Height is a concern for a lot of parents. Many of them worry that their child stops growing when puberty starts, and that’s not necessarily true.

If a patient or their parent is concerned, we can calculate their midparental height. We take Mom’s height and Dad’s height and arrive at the potential height the child could reach. If they are showing signs of not following along that curve, that would be a reason to see an endocrinologist.

Are there health risks associated with either early or late puberty?

With early puberty, the two main risks are not reaching your genetic height potential and the psychosocial stress from going through puberty early.

Are acne and mood swings inevitable during puberty?

Since hormonal changes lead to increased oil in the skin, some acne can be expected — although some teens don’t get acne at all or have just a mild case. What isn’t normal is severe acne, which can cause a lot of stress. It’s worth mentioning to your pediatrician and not just classifying it as a normal part of puberty.

I think the same holds true for mood swings, but I hold even more caution for that. Certainly, teenagers want more independence. They seek privacy, which can also read as moodiness. And mood swings are common. But parents should not assume moodiness is “just puberty.”

Mental health is a huge concern in our teenagers. So, any signs of depression or anxiety should not be written off. If you see persistent sadness and anxiety — especially if it’s interfering with school, sports or friendships — that should definitely be brought to your pediatrician's attention.

And parents: If something feels concerning, talk to your child’s pediatrician. Phases, of course, happen. But if something feels off to you as a parent, trust that instinct and seek guidance.

Do pediatricians treat depression?

We do. It's certainly within our wheelhouse to evaluate and treat mental health concerns. If it's something that feels more complex, we’ll make a referral to a mental health professional.

Parents should know that once your child hits those preteen years, confidentiality between the teenager and their doctor becomes part of their care. We ask parents to step out of the room so we can talk to the teenager alone. We want to ensure they're being safe and healthy, and we want them to feel a sense of autonomy over their body and their health. We give them a chance to ask us questions they might not want to ask in front of Mom or Dad.

That can sometimes catch parents off guard. But especially with mental health concerns, we want to give them space to be talk freely. There's nothing we’re trying to hide from parents. We just want to make sure your child has an opportunity to talk to their doctor confidentially.

I assure patients that what’s said between us is kept confidential unless there's ever a concern about their safety, at which point I do tell their parents.

How has social media affected kids’ experience with puberty?

Puberty is just as much psychosocial as it is physical. There's a lot of preoccupation at that age with questions like: Am I normal? How do I compare? Social media can make the transition even more difficult, especially for girls because their pubertal changes are more obvious.

Parents should have that on their radar and be aware of their child’s social media and how they’re using it.

Should parents discuss sexual development with their child before he or she reaches puberty?

Yes. I think all parents agree it’s best for this information to come from us and not from the kid on the school bus who may or may not know what they’re talking about.

And parents should start early — maybe earlier than they anticipate. Seven years old is not too early for most kids. What you don’t want are these changes to start happening to their bodies and for the child to feel unprepared, embarrassed or scared.

Conversations about puberty also offer a good opportunity to talk about bodily autonomy, privacy and consent. Explain to kids what their private areas are and that no one, except their doctor, is allowed to look or touch there. Every time I examine a child, I always ask the parent’s permission and then explain why I'm looking there.

A few tips for discussing sexual development with your child:

• It should be a continual, open conversation and not just one awkward talk.
• Use correct anatomical language for body parts.
• Talk about how the body changes.
• Be open, honest and available for questions.
• Keep the goal in mind: For your child to be body positive.
• Emphasize consent to both girls and boys: “No is a complete sentence.”