Julia,

 

I think you're right that if a child is diagnosed at birth---and always well-controlled---secondary precocious puberty, due to the CAH, should not really be an issue.  Because of that, I do think that many of the children on Lupron do tend to be the non-classical cases, i.e. those who are diagnosed late (usually, not until signs of precocious puberty have already set in.)  But, as you also suggested, even for those children diagnosed at birth, Lupron may be a necessity, if there are persistent problems with control, undersuppression, and advanced bone age. 

 

I think it's important, though, to realize that Lupron works on the pituitary gland, and not on the adrenal glands.  The necessity for using it depends on whether or not true central precocious puberty has started---meaning whether or not the pituitary gland has started to become active.  In boys, this is usually indicated by an increase in testicular size;  in girls, by the appearance of breast buds.  Secondary signs of puberty---such as body odor, pubic hair, and axillary hair---are more controlled by the adrenal glands.  So---in other words---you could have these symptoms, be undersuppressed, and still not need the Lupron, because the adrenals are what is out of control, rather than the pituitary.  In a nutshell, you have to target the right medication for the right problem (or gland.)

 

Even in cases where true central precocious puberty has begun, the decision to use Lupron, or not, can be  somewhat of a judgment call.  Much of it depends on the age of the child, and how far in advance of chronological age the bone age is.  The bigger the gap between the two, the clearer the indication to treat with the Lupron.  When the gap is not quite as wide, the indications for treatment become a bit more "gray."  As with anything, in my opinion,  good judgment usually involves a careful comparison of risks vs. benefits, so I think you really have to take each case, as it comes.