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Background Several strategies have been proposed to determine onset of puberty without examination by a trained professional. This study sought to evaluate a novel approach to determine onset of puberty in girls. Methods This study utilized the Cincinnati cohort of the Breast Cancer and the Environment Research Program. Girls were recruited at 6-7 years of age and followed every six months in the initial six years, and annually thereafter. Breast maturation and foot length were performed at each visit by health professionals certified in t