The increasing incidence of childhood obesity can complicate assessment of pubertal development in girls because adipose tissue over the pectoral area is often difficult to differentiate from glandular tissue in the early stage of breast development. A useful way to make the distinction is to palpate the breast. In obese prepubertal girls, palpation may may reveal an absence of tissue in the subareolar area (the doughnut sign). In true thelarche, by contrast, tissue is felt under the areola because glandular tissue appears first in the subareolar region and subsequently extends outward.
Sasigarn A. Bowden, MDColumbus, Ohio