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Sexual Precocity in a 16-Month-Old, f5 T8 U4 `/ T( i
Boy Induced by Indirect Topical0 b0 M3 e. d" p8 A) M: i; l" ]
Exposure to Testosterone
8 I' l* \! |, q% v/ U) wSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2' D; ^2 F- y- P4 V! G
and Kenneth R. Rettig, MD1) g; W6 h3 g, l. F9 ]0 o
Clinical Pediatrics
$ ~) d+ q. Q9 f" m+ AVolume 46 Number 6
" _2 v( x E3 PJuly 2007 540-5437 c; T& G1 L" k, s" U
© 2007 Sage Publications0 M& j. S1 r, c5 C% G
10.1177/0009922806296651
. ^8 J, L" o: E9 ~- phttp://clp.sagepub.com& }* k% J8 W5 b- k
hosted at
! ?6 m8 R$ G3 C. Ihttp://online.sagepub.com# j1 {4 @8 J" T8 |' a) p
Precocious puberty in boys, central or peripheral,/ \# c9 I, o( b# |0 L ^& V
is a significant concern for physicians. Central, X2 J k/ c$ G! g+ w
precocious puberty (CPP), which is mediated! N; r, a: v* @5 w3 a
through the hypothalamic pituitary gonadal axis, has
3 k/ r0 q$ y9 N$ ?a higher incidence of organic central nervous system s+ n6 z3 K0 w% l" J8 X
lesions in boys.1,2 Virilization in boys, as manifested: N4 e8 i+ o6 s( r& H* M
by enlargement of the penis, development of pubic
" b$ r" k+ n' X9 k; m/ T; @hair, and facial acne without enlargement of testi-
( ]! f: k0 e' x8 Zcles, suggests peripheral or pseudopuberty.1-3 We% a: i. D$ I. u! F& X9 L
report a 16-month-old boy who presented with the
, D$ c, l3 h" T @2 b9 c; \5 E, x2 ]" fenlargement of the phallus and pubic hair develop-3 L; n a. L8 \" s3 Z% I( a* p5 p
ment without testicular enlargement, which was due
+ h# j. r) s' v4 O, dto the unintentional exposure to androgen gel used by
4 Z5 n* N9 A& N. j. |, I+ z( \the father. The family initially concealed this infor-
3 o& X0 L/ B w, h$ vmation, resulting in an extensive work-up for this/ J$ M# k7 j1 g: M) a
child. Given the widespread and easy availability of& Z3 q, n+ K9 z6 G
testosterone gel and cream, we believe this is proba-, h( g' j. Q) U# \6 `: t
bly more common than the rare case report in the
* J% E1 w: @) Y8 E5 u$ S8 X* Aliterature.4. F0 Q, G4 o$ {# I
Patient Report2 Y8 o! \* M+ i1 R
A 16-month-old white child was referred to the4 }/ i$ o7 J. [: L2 }
endocrine clinic by his pediatrician with the concern2 G* S2 m b1 y4 x3 G
of early sexual development. His mother noticed
" f+ Z! E" N7 }; P- \light colored pubic hair development when he was
0 k7 h) Q8 f; L1 V" J- HFrom the 1Division of Pediatric Endocrinology, 2University of* `$ O1 z4 a" c6 C# P, w; }
South Alabama Medical Center, Mobile, Alabama.4 h$ ^1 ?0 k4 w7 |' T* X: a; j
Address correspondence to: Samar K. Bhowmick, MD, FACE,9 r+ \4 F9 I, g. R( _, e) w) Z
Professor of Pediatrics, University of South Alabama, College of
6 v' p, F- ]* x# f5 W$ VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 g: S) H7 ^: i
e-mail: [email protected].
0 Y5 _7 X* B' f% x2 y/ c- }& B" Uabout 6 to 7 months old, which progressively became+ g9 o( s$ m+ ^5 v* v" J2 g7 |
darker. She was also concerned about the enlarge-
8 e( F" E0 @+ D" C# c2 fment of his penis and frequent erections. The child
$ w' L, ?6 u2 B. C" `- Jwas the product of a full-term normal delivery, with
# E K2 \% z. W0 l' |8 s" b2 ^a birth weight of 7 lb 14 oz, and birth length of6 x% s, c* P2 W9 a) l5 E
20 inches. He was breast-fed throughout the first year
& o7 F- X1 b' E T* Wof life and was still receiving breast milk along with
6 M1 {2 F: r; {solid food. He had no hospitalizations or surgery,# n; p! P7 q- z' a. ?3 P! k( M! f* e/ ~% H
and his psychosocial and psychomotor development/ o6 _; E, t; D2 R+ b
was age appropriate.5 |2 O# ~7 J' V& }4 a3 |
The family history was remarkable for the father,
0 h+ J2 T# U" l( J/ |# I8 @9 B% D9 Lwho was diagnosed with hypothyroidism at age 16,
/ \' ]9 c: M" v7 }" ^0 {which was treated with thyroxine. The father’s5 D/ F+ W. L( X8 A
height was 6 feet, and he went through a somewhat5 X3 z0 ]; y6 W. A7 }% ~9 C9 p( ^6 H2 Q
early puberty and had stopped growing by age 14.
5 \4 Z5 t! A8 W2 A2 A* }* l9 e. ? kThe father denied taking any other medication. The; J. J! j7 T o% y8 J7 | H/ B
child’s mother was in good health. Her menarche
$ V3 k. s2 X5 w9 G* rwas at 11 years of age, and her height was at 5 feet" h: P6 C) ]2 |4 H; ]
5 inches. There was no other family history of pre-) V9 P8 K1 f' F8 R, I
cocious sexual development in the first-degree rela-
1 R v2 O! a# n+ jtives. There were no siblings.- f) K2 K C2 s! t2 x
Physical Examination6 E5 `3 w! f0 }5 K
The physical examination revealed a very active," m( R" P% `3 T- M ~& @2 Y
playful, and healthy boy. The vital signs documented
3 O+ ? B0 C2 U# Xa blood pressure of 85/50 mm Hg, his length was8 j5 n" ~, R5 c! ?
90 cm (>97th percentile), and his weight was 14.4 kg: S% V, d4 B! T4 W( e5 n
(also >97th percentile). The observed yearly growth
' Q/ [) Y, Y- D1 J9 ~9 Y7 w+ wvelocity was 30 cm (12 inches). The examination of
, M: m5 D) a; uthe neck revealed no thyroid enlargement.
8 S+ m- K9 p4 J7 u% q# s& KThe genitourinary examination was remarkable for4 r% @8 @: I* t- p* f" Z2 o2 i2 n8 o
enlargement of the penis, with a stretched length of
7 v) ]! ^2 @2 w: T# T) l# P8 K9 t8 cm and a width of 2 cm. The glans penis was very well
/ s# P- V% ^9 \4 {$ c& q$ Xdeveloped. The pubic hair was Tanner II, mostly around
! X% y; V, t6 g3 B" @540
# [3 @" K3 h1 s' m* p5 vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 x: |( a2 f! }/ K2 ^/ l' s
the base of the phallus and was dark and curled. The
( _9 B' p! r: z2 ]testicular volume was prepubertal at 2 mL each.) c* V) P& a" p5 N! _9 R
The skin was moist and smooth and somewhat+ q o6 O: U# B9 d2 L; I( ?9 g
oily. No axillary hair was noted. There were no4 R3 U8 E6 \( C* K8 a
abnormal skin pigmentations or café-au-lait spots.
% S+ P7 e* k' G+ }+ {Neurologic evaluation showed deep tendon reflex 2+, T! j( e5 ?$ L2 R# M0 u
bilateral and symmetrical. There was no suggestion
4 K, [2 p, C& ^. lof papilledema.6 P( H/ k# Q% l0 b C$ f2 E, q( ^" w
Laboratory Evaluation) [1 S, D" H+ R
The bone age was consistent with 28 months by9 M$ z% K7 ]( X6 f$ Z
using the standard of Greulich and Pyle at a chrono-$ E5 l% c" c: K0 C' L. B& m: y
logic age of 16 months (advanced).5 Chromosomal# [+ R* y; R& \- y9 A+ u3 t' P
karyotype was 46XY. The thyroid function test
z5 _ D9 v" v" p& z* Xshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 _, P, T" _4 M( ylating hormone level was 1.3 µIU/mL (both normal).
1 [3 u+ e: W6 B+ JThe concentrations of serum electrolytes, blood' s! l! `+ \+ g4 F
urea nitrogen, creatinine, and calcium all were6 c6 s+ B, z2 c' j) I5 I; g
within normal range for his age. The concentration
; g1 c, e( ` u% K; N- S9 [* Gof serum 17-hydroxyprogesterone was 16 ng/dL9 w& l4 a6 n% t7 V4 b0 I5 a
(normal, 3 to 90 ng/dL), androstenedione was 20
6 U4 C* O) d( yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 K( j4 g6 D' Jterone was 38 ng/dL (normal, 50 to 760 ng/dL),8 K% ~) |0 R- O W' Q
desoxycorticosterone was 4.3 ng/dL (normal, 7 to0 |7 ^2 ] c! S# d. R Q0 Y
49ng/dL), 11-desoxycortisol (specific compound S)+ w, k& Z1 {8 e: c+ h) T
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% I6 |" W+ n, V" o7 e- k
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 ]5 `# c* b8 ^( t/ n, {8 o
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),2 h$ r- }) G. ^/ O2 S9 Z
and β-human chorionic gonadotropin was less than
0 q1 S+ S+ ~ f+ p$ g5 mIU/mL (normal <5 mIU/mL). Serum follicular7 E. R" S- _; W
stimulating hormone and leuteinizing hormone
' a: x3 J1 Q# g+ J x& s# |& _concentrations were less than 0.05 mIU/mL
- ~8 H2 B6 x9 ?* H* N+ |5 r( R5 X9 [(prepubertal).+ J; ]8 S/ _8 ]! i8 @ I
The parents were notified about the laboratory
- [: n* z, ]" [ cresults and were informed that all of the tests were
$ M* ~" w1 P3 C0 c6 \3 qnormal except the testosterone level was high. The
* z; N! Z \ q5 I! f/ M' Sfollow-up visit was arranged within a few weeks to+ |/ J% h+ E9 ^4 `0 t2 r) k, R
obtain testicular and abdominal sonograms; how- z' w2 |9 P$ t9 {, s
ever, the family did not return for 4 months.
4 y l% I' c" H8 G; UPhysical examination at this time revealed that the% W1 Z9 g' v& l8 _* j' v
child had grown 2.5 cm in 4 months and had gained
* C% w4 Y' d8 @2 kg of weight. Physical examination remained' p5 b& a ]4 U/ i
unchanged. Surprisingly, the pubic hair almost com-4 f4 P" ?( A5 x. a0 B% W8 a6 F
pletely disappeared except for a few vellous hairs at; k; \* `" M* U+ `$ i
the base of the phallus. Testicular volume was still 25 Z5 {7 [: _/ T
mL, and the size of the penis remained unchanged.2 x, i3 J1 [& R
The mother also said that the boy was no longer hav-
6 e; |0 A- b4 M' Uing frequent erections.+ p7 ?* |- E2 Q
Both parents were again questioned about use of0 v! q+ @; w# b3 Z, a1 w6 Z. W
any ointment/creams that they may have applied to" T! B. A. J; {. }, q9 U7 h5 j
the child’s skin. This time the father admitted the
' q7 m* C3 p' b; S$ }/ B7 aTopical Testosterone Exposure / Bhowmick et al 541: s6 v) D r [4 l1 m2 n
use of testosterone gel twice daily that he was apply-
) o# E+ ]+ q# v5 ?' O! Ning over his own shoulders, chest, and back area for
5 b6 e+ K3 L' y6 ^a year. The father also revealed he was embarrassed/ H( L) y# I1 S# H4 } e. R
to disclose that he was using a testosterone gel pre-8 W; W4 o- R' [* P
scribed by his family physician for decreased libido
; D/ _! }3 V+ } o4 }+ S2 qsecondary to depression.
1 H' `& w* g M6 A) J* RThe child slept in the same bed with parents.
! Z5 n( i! F) J# u) SThe father would hug the baby and hold him on his
. N. N2 r2 ^3 [' _2 A$ x' }chest for a considerable period of time, causing sig-. d1 x/ s* n* \9 J# B) c6 m) P
nificant bare skin contact between baby and father.
9 x" O( U& }4 c5 `3 \- n7 ZThe father also admitted that after the phone call,3 h1 \# N% I$ d- ]6 D
when he learned the testosterone level in the baby
+ u8 Y9 o8 _7 v5 y2 D2 Zwas high, he then read the product information2 S: B$ } Y" b6 n
packet and concluded that it was most likely the rea-& f. H; t/ O ~
son for the child’s virilization. At that time, they' {% w, s8 F! s0 _; g' C5 m: _1 Z- C
decided to put the baby in a separate bed, and the# W' F& U. c/ E$ `
father was not hugging him with bare skin and had
. H) s$ }7 b; rbeen using protective clothing. A repeat testosterone
* a6 f$ m1 _5 P0 o% j# V! v R |test was ordered, but the family did not go to the
7 ~$ X* P2 }- @' S1 N' v; ~laboratory to obtain the test.
% L: Z& e5 n. Q$ }8 w- \3 D8 vDiscussion
% K- D3 I9 Q) Q' n3 V$ IPrecocious puberty in boys is defined as secondary
9 a( H. p: z0 n- v' o* U$ s2 Gsexual development before 9 years of age.1,4
1 z- L6 g! N! ?Precocious puberty is termed as central (true) when5 q, j; d5 e4 [6 p- a
it is caused by the premature activation of hypo-
1 U. V4 P" Z. K+ jthalamic pituitary gonadal axis. CPP is more com-3 f# _; X# B9 ~3 p( F
mon in girls than in boys.1,3 Most boys with CPP
# ?% a. D3 V1 a6 ]1 j+ amay have a central nervous system lesion that is7 n5 ~" d& d- j# @/ k
responsible for the early activation of the hypothal-: s0 S5 F+ ~8 [
amic pituitary gonadal axis.1-3 Thus, greater empha-
, C4 B1 g7 g5 g3 }: J4 G9 ^% M* l* jsis has been given to neuroradiologic imaging in$ c4 R8 x) W9 A% [' _* K
boys with precocious puberty. In addition to viril-
Z/ K# `6 {# ~) o# uization, the clinical hallmark of CPP is the symmet-
9 o% O; q! ?, i8 P4 H6 Srical testicular growth secondary to stimulation by: _% R% N, q t# H
gonadotropins.1,3 k& m: V) F! I$ X
Gonadotropin-independent peripheral preco-" L5 S: l5 P. e+ c7 W2 k
cious puberty in boys also results from inappropriate
3 @2 x+ x$ {; |8 V* t' zandrogenic stimulation from either endogenous or
+ P! n% Q1 v& J4 Y& v5 i& Dexogenous sources, nonpituitary gonadotropin stim-9 |; K. Z' }$ m3 B7 r; R& }, o
ulation, and rare activating mutations.3 Virilizing
. e. }& [4 R, w' Hcongenital adrenal hyperplasia producing excessive
2 ]" {2 Y, m" Q9 v) yadrenal androgens is a common cause of precocious
X; I* W0 Q) D3 Hpuberty in boys.3,4, `8 k1 g7 l6 u: L4 w: B% v+ _
The most common form of congenital adrenal/ D: ~% C6 S5 ^0 y0 q, U$ m
hyperplasia is the 21-hydroxylase enzyme deficiency.1 `% o+ t6 w A: I
The 11-β hydroxylase deficiency may also result in$ o8 d" s6 X! u0 S' H: J* F* {
excessive adrenal androgen production, and rarely,9 L! B) J. H( [$ e% C5 g- h8 Q: T
an adrenal tumor may also cause adrenal androgen
6 C; U4 t8 o$ U- Xexcess.1,3
( Z' K6 P6 ^. e* h( hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ Z% z, s. G# G' t6 g) S& J6 z) S542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' I2 C: I5 J/ P/ }8 _* V
A unique entity of male-limited gonadotropin-) j8 A: n, @/ n5 }
independent precocious puberty, which is also known% G, U$ e) t t4 |# e
as testotoxicosis, may cause precocious puberty at a
+ z2 Z9 o$ J2 V. ]$ g$ X7 _/ Bvery young age. The physical findings in these boys- r- i3 h1 I0 r& L0 n8 c
with this disorder are full pubertal development,) [# ^2 a7 V4 y$ h% g
including bilateral testicular growth, similar to boys
) r+ I- w2 T* H5 }8 Kwith CPP. The gonadotropin levels in this disorder( @0 R3 h; Q3 Z- t) j
are suppressed to prepubertal levels and do not show
1 p/ H# C( ?: Z- Kpubertal response of gonadotropin after gonadotropin-
7 _- S% x" k) e/ q5 |5 z7 i8 T" Wreleasing hormone stimulation. This is a sex-linked
" G3 G/ o6 ]. @3 X ^( W; [1 T. @1 aautosomal dominant disorder that affects only: e; { P0 }' u8 |7 b
males; therefore, other male members of the family
- x# h0 v+ Z7 ?& y! w( R0 \may have similar precocious puberty.3$ \8 B9 O. ^# C+ P
In our patient, physical examination was incon-
! E) V [/ g8 X7 c3 V2 |% vsistent with true precocious puberty since his testi-; e' y: P- P$ X# C* l: o
cles were prepubertal in size. However, testotoxicosis/ }3 l( v: ?- X6 z& i) G: a5 {" _
was in the differential diagnosis because his father
" e/ Z" D) d o" ~; y( g+ Xstarted puberty somewhat early, and occasionally,2 b1 D) v/ E8 |: d6 G
testicular enlargement is not that evident in the
! ^3 T8 d( Y& i% p2 i7 |5 G5 qbeginning of this process.1 In the absence of a neg-& q! K6 Y( j" P4 n- F5 q( w9 g
ative initial history of androgen exposure, our
; o3 `3 n9 E- m2 P( L8 E5 K! P8 mbiggest concern was virilizing adrenal hyperplasia,
6 e. k K4 \$ P. O% veither 21-hydroxylase deficiency or 11-β hydroxylase
" i' t: E4 ^& t: ~( z3 C; Tdeficiency. Those diagnoses were excluded by find-+ G. O1 r( \) Q! k5 ]
ing the normal level of adrenal steroids.3 D0 e" R" u) z; X" e
The diagnosis of exogenous androgens was strongly
. \% t l6 ~* X" Csuspected in a follow-up visit after 4 months because
: Z; \# j9 A1 k; T2 kthe physical examination revealed the complete disap-
. R* Z+ k, u* d2 B) v4 t) l* t. Wpearance of pubic hair, normal growth velocity, and. N! a: \; d/ D) E
decreased erections. The father admitted using a testos-
( _7 y( [8 O6 Cterone gel, which he concealed at first visit. He was( j) z7 |% j8 y% b/ _8 g* u
using it rather frequently, twice a day. The Physicians’
/ @9 T8 k* ]0 |2 _. q5 I6 v% Z8 ]Desk Reference, or package insert of this product, gel or# v. R2 x$ L) |4 g# l$ Z- h
cream, cautions about dermal testosterone transfer to
% W3 S& j& h3 q( v& M( |0 `& z$ dunprotected females through direct skin exposure.$ }3 `7 P2 Z6 j! Y" U
Serum testosterone level was found to be 2 times the
/ B5 o7 @- r8 H- bbaseline value in those females who were exposed to
. e1 Q, H: }* y0 Z; Peven 15 minutes of direct skin contact with their male; d) q6 k5 E$ q9 Z
partners.6 However, when a shirt covered the applica-' ^) ?* k$ }7 ]$ k
tion site, this testosterone transfer was prevented.$ i/ @7 v& j$ B, ^5 y
Our patient’s testosterone level was 60 ng/mL,8 R P9 l5 M5 ^0 V
which was clearly high. Some studies suggest that/ C8 n* k6 \1 C
dermal conversion of testosterone to dihydrotestos-: p+ E' R! p w1 R! y
terone, which is a more potent metabolite, is more& g. Y# @$ R% ?! K* A
active in young children exposed to testosterone
' \8 r7 {% B. ^exogenously7; however, we did not measure a dihy-- `8 \, k( u& }, p6 l& p
drotestosterone level in our patient. In addition to2 q9 a; d' e9 v0 r# n
virilization, exposure to exogenous testosterone in }( n! C7 p( i: l5 p) N
children results in an increase in growth velocity and
# G* ]/ |- U* ]1 W+ tadvanced bone age, as seen in our patient.
* T' z- W2 N6 c# }8 f" `* LThe long-term effect of androgen exposure during4 k" u1 v2 w: d5 L' |3 X4 z+ r2 R
early childhood on pubertal development and final# {9 x9 D7 l: _. s
adult height are not fully known and always remain' N i. L) g. \/ Y( b% s; S9 G
a concern. Children treated with short-term testos-, y0 |+ a$ F @
terone injection or topical androgen may exhibit some
4 G- h1 T6 Z2 c) h7 }acceleration of the skeletal maturation; however, after9 @% o3 j5 H; U+ p) V
cessation of treatment, the rate of bone maturation
, \- k [; F7 u9 w3 V- odecelerates and gradually returns to normal.8,9
; l& z5 A4 i( NThere are conflicting reports and controversy0 T4 b2 ?4 ^. P# h
over the effect of early androgen exposure on adult
$ v. A4 G' u7 T i2 y" _$ Openile length.10,11 Some reports suggest subnormal( u- [) m, c1 D
adult penile length, apparently because of downreg-
$ ?# F0 J5 c) x; [6 Gulation of androgen receptor number.10,12 However,$ W% I& h7 l) m8 O' Q$ P
Sutherland et al13 did not find a correlation between# v- W a v+ }% [/ z2 C
childhood testosterone exposure and reduced adult
& N9 \" _# W. U0 i# Xpenile length in clinical studies.4 Z* o6 t+ W, y- b$ u
Nonetheless, we do not believe our patient is! I3 k' l4 i8 ^' c
going to experience any of the untoward effects from/ {" l- ^/ F) ?
testosterone exposure as mentioned earlier because6 A$ N, j5 b- s0 B- J
the exposure was not for a prolonged period of time.
" x" T! O3 \2 q6 B) VAlthough the bone age was advanced at the time of
0 r0 N7 x$ F) F* G/ @. k" `; z0 q* c- ^diagnosis, the child had a normal growth velocity at* Z% I# c g& @4 C$ C! j
the follow-up visit. It is hoped that his final adult
' W9 t" k- h! ]: e4 P6 Oheight will not be affected.: R1 r9 n' F0 \+ g. D* U% z
Although rarely reported, the widespread avail-* B- q i" b; \/ |. F1 @
ability of androgen products in our society may Q) Y0 x. g7 t! o) g
indeed cause more virilization in male or female5 P* |9 X D0 V( z
children than one would realize. Exposure to andro-. s6 l1 r4 E: h( ]7 [# @$ D3 U! I
gen products must be considered and specific ques-9 e+ H# d2 ?" ?7 f5 F3 x
tioning about the use of a testosterone product or
& [; U. @# f+ c( a6 ygel should be asked of the family members during$ S' }2 o3 J2 k
the evaluation of any children who present with vir-
4 { n1 A$ q" t+ {) e. }ilization or peripheral precocious puberty. The diag-6 [* r S9 C. ^3 o$ E
nosis can be established by just a few tests and by) T( D: L+ a1 H
appropriate history. The inability to obtain such a
9 X$ D4 A. ]- w' S) l7 _ _history, or failure to ask the specific questions, may9 p! x3 j# n$ \; | J# ]
result in extensive, unnecessary, and expensive! J @/ G( t' i$ B
investigation. The primary care physician should be
/ D1 P. X* t0 S! v5 p1 qaware of this fact, because most of these children3 Z6 ?- l2 W7 @* U ]
may initially present in their practice. The Physicians’
. ^0 r% w0 S! w- t8 v. F$ ~3 c: P7 zDesk Reference and package insert should also put a
! g5 c; V: S0 ^2 A8 Z$ i, Mwarning about the virilizing effect on a male or+ J6 Z$ Q6 m m+ L# a) ~" l4 \
female child who might come in contact with some-
7 w6 U" Q% N0 G# c' @& T; Cone using any of these products.
) _/ ~( x% o2 E6 g$ j3 J7 i0 qReferences
: J+ G" t& m7 `: w8 F' D1. Styne DM. The testes: disorder of sexual differentiation$ z1 A/ x+ f3 e3 t3 ]
and puberty in the male. In: Sperling MA, ed. Pediatric
1 E n: _' E) T* K& u, s+ Y/ SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& i) c( E: B# W3 `0 i2002: 565-628.2 @& d- s2 Y ?* d A
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
. B3 _! X% G+ D& w! s/ K* r( N+ Fpuberty in children with tumours of the suprasellar pineal |
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