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Sexual Precocity in a 16-Month-Old/ r+ c" S8 G+ x/ u6 x
Boy Induced by Indirect Topical
4 j# K y8 f! ~2 u, |" u9 ?Exposure to Testosterone) m( R; V* J7 J, k
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. j b9 y# r9 A2 I0 hand Kenneth R. Rettig, MD1& t5 t( m( n8 b2 ^) C; s- o5 a
Clinical Pediatrics
5 {+ _# P; }9 o, D* f: sVolume 46 Number 6& c9 C( E# A/ R* W. V# a
July 2007 540-5433 H, M/ c% d! r7 h& ^
© 2007 Sage Publications
: v7 a# i! t: B' T1 F& \% d10.1177/00099228062966511 k& { e/ j: G/ C6 Q
http://clp.sagepub.com
+ w1 I- v7 Z9 V6 f/ E5 ]hosted at
$ Q3 @) |# B" j! h% k# chttp://online.sagepub.com! n% H* s5 d) r; I: |2 |, ~; o8 W
Precocious puberty in boys, central or peripheral,
c: M. h( G6 j; Y- His a significant concern for physicians. Central: q u; ^. i8 u3 A: p7 l
precocious puberty (CPP), which is mediated' y) B5 T$ r' _6 ]( _. T& n
through the hypothalamic pituitary gonadal axis, has
1 f+ E& P2 ^' J7 ?6 la higher incidence of organic central nervous system# z# R1 n6 R. w/ ~; X4 F; k: Y, y, i
lesions in boys.1,2 Virilization in boys, as manifested
' h) E) y7 v& x6 x. @by enlargement of the penis, development of pubic
0 y& Y) o* Q5 l+ j1 hhair, and facial acne without enlargement of testi-+ d; X+ ?" G( \" S: G/ b. U
cles, suggests peripheral or pseudopuberty.1-3 We0 |/ g: o4 ]- E( h5 H& M5 \
report a 16-month-old boy who presented with the: K2 k C; l. H$ b: {' d
enlargement of the phallus and pubic hair develop-& Y4 p2 U6 v* z/ a
ment without testicular enlargement, which was due, z& ?# K8 f/ T0 u9 \- {
to the unintentional exposure to androgen gel used by
1 s! b! C# t3 u' F5 |the father. The family initially concealed this infor-
7 @- v8 D8 ], X9 n( w0 I2 n# Y jmation, resulting in an extensive work-up for this
; U% I, z% B i! Z# c* achild. Given the widespread and easy availability of
3 S& X [7 Q @, L8 w' s/ T0 t5 Qtestosterone gel and cream, we believe this is proba-8 C) p3 l0 \7 B5 p
bly more common than the rare case report in the f+ T7 j: i7 j6 ?+ i, m
literature.4, E- h: E: [2 v6 u; J) l
Patient Report! ?+ l- C N& B; ~8 Z6 N
A 16-month-old white child was referred to the8 o+ I# a n k6 ^& H, z3 t
endocrine clinic by his pediatrician with the concern
$ E, q" s! i" s& O! X! T' Wof early sexual development. His mother noticed
. l6 A" S) Q! I4 {light colored pubic hair development when he was7 ]( n# n8 j4 J- g4 @: V$ ~1 G" p1 [
From the 1Division of Pediatric Endocrinology, 2University of2 ^7 Y: X$ [" Y9 U
South Alabama Medical Center, Mobile, Alabama.8 ?% Z; G1 |9 ?3 E$ S# s: y
Address correspondence to: Samar K. Bhowmick, MD, FACE,+ u: U3 F7 _' F+ G
Professor of Pediatrics, University of South Alabama, College of
/ w/ i: q! |5 @: O4 Z! ]Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 M$ p3 i3 l- f3 qe-mail: [email protected].
: d# Y$ `/ d0 _+ o, k: J1 Z4 gabout 6 to 7 months old, which progressively became+ a4 ~7 Y: [3 m6 Z0 {5 j
darker. She was also concerned about the enlarge-
2 [. T4 v5 u `; N& ?, _+ f$ ~& xment of his penis and frequent erections. The child6 I& c2 I) r. m [* x4 G
was the product of a full-term normal delivery, with, j! K7 D5 n5 _4 q5 H0 F+ a0 @
a birth weight of 7 lb 14 oz, and birth length of
7 X8 ?! ]$ T+ P) C20 inches. He was breast-fed throughout the first year
% ]# d, j3 g [9 W5 w" c% h# gof life and was still receiving breast milk along with+ V; ^! z/ M% s2 b7 t
solid food. He had no hospitalizations or surgery,9 q: c0 @( u f& p' @) p5 k
and his psychosocial and psychomotor development
# B# M f, K9 l0 X4 U8 awas age appropriate.
e, E9 X% h* G/ F: X$ \The family history was remarkable for the father,5 ~, S- d" X# c0 G: w
who was diagnosed with hypothyroidism at age 16,
, M1 k3 X V3 u; Cwhich was treated with thyroxine. The father’s2 j* O- J1 a# o( _1 H4 P
height was 6 feet, and he went through a somewhat
: ^. Z) Y# `6 Searly puberty and had stopped growing by age 14.
* |& s0 c5 h ^& M( SThe father denied taking any other medication. The0 T0 F, [! ?0 A U$ B+ }8 R6 m
child’s mother was in good health. Her menarche
; W; X: A' q* @4 {0 pwas at 11 years of age, and her height was at 5 feet
; W; ~0 u8 D& I1 s+ U, k; ~0 ]0 x5 inches. There was no other family history of pre-
) o$ q7 S8 s$ G+ U: Ecocious sexual development in the first-degree rela-- Y G1 x' s' D) ^
tives. There were no siblings.
! G4 r1 N: R" V- w7 E7 ZPhysical Examination6 p% V O/ F9 L0 Y |3 V6 s$ `
The physical examination revealed a very active,
O- S2 p$ _7 O! ^/ Vplayful, and healthy boy. The vital signs documented
4 A- ?% z7 P# R1 f% m9 Ga blood pressure of 85/50 mm Hg, his length was
* O) }: z @9 P) f; G( N7 Y90 cm (>97th percentile), and his weight was 14.4 kg( f9 ^* x; |# y" ?/ C- X! l
(also >97th percentile). The observed yearly growth
% g& I, K$ S! i [: E3 j! svelocity was 30 cm (12 inches). The examination of
4 t6 Z# Q6 W Q2 O- \5 _the neck revealed no thyroid enlargement.% L% Z# n7 A: n2 `& r$ f& Q# n
The genitourinary examination was remarkable for$ W6 b. @6 K) u. M% A- S9 M) I
enlargement of the penis, with a stretched length of
r `! y' w8 { ?% u( ~' z8 cm and a width of 2 cm. The glans penis was very well
F0 g& @ B% I) i# j( F$ R. Odeveloped. The pubic hair was Tanner II, mostly around3 [+ ]# Z+ K. s" T# K {8 T6 O
540: W6 N* r% V1 ]% F! P2 F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: T3 C m7 @0 [* j+ q
the base of the phallus and was dark and curled. The
7 k4 @ S2 B) R) W1 v( s5 h" Htesticular volume was prepubertal at 2 mL each.
; h$ q7 \$ s" Q h5 i3 F5 JThe skin was moist and smooth and somewhat
: ^$ S# t$ A1 C3 u* Foily. No axillary hair was noted. There were no
; U- J, O+ O4 f# S# m5 Q, l5 pabnormal skin pigmentations or café-au-lait spots.: ^0 x" p2 m% _/ ^
Neurologic evaluation showed deep tendon reflex 2+/ a1 h# y& A6 _. F* {5 O' K. _" K
bilateral and symmetrical. There was no suggestion
+ ?8 W# J& Z/ z$ y6 @' {of papilledema.( D! A* r4 g! }" P
Laboratory Evaluation
0 n/ i( \* _! r7 ~0 t, t& BThe bone age was consistent with 28 months by
# L& v6 O5 ?/ O ?- |using the standard of Greulich and Pyle at a chrono-
- H& o' w+ Y/ @0 ilogic age of 16 months (advanced).5 Chromosomal
% F5 O5 v1 T5 e% Q! m& j9 Ikaryotype was 46XY. The thyroid function test
2 s8 {# r* \, P/ P2 mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-" _; P8 i) D& o
lating hormone level was 1.3 µIU/mL (both normal).
, K0 q6 [$ K& X# d% SThe concentrations of serum electrolytes, blood
. e A# I* Q: O1 J7 hurea nitrogen, creatinine, and calcium all were
& U4 l9 s+ k; g4 Awithin normal range for his age. The concentration5 d4 s# P. r% [3 {
of serum 17-hydroxyprogesterone was 16 ng/dL1 Y' D8 t+ H1 E; e
(normal, 3 to 90 ng/dL), androstenedione was 20
# E9 p" Z! }% y2 Vng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, q* d0 ]3 Y9 P3 @terone was 38 ng/dL (normal, 50 to 760 ng/dL),
, j, _% z& y7 I; E3 jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
' V c) C( O! l. L/ G/ U# U49ng/dL), 11-desoxycortisol (specific compound S): ^) W; J) x6 a6 R
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% Y. G1 u" D0 y$ M( B" i2 V( r7 S
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total3 U* d( z, T8 P1 y# d8 P- G
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 i! g1 x& g5 {& i
and β-human chorionic gonadotropin was less than; E" `6 N7 J% o( K3 L& S: X! f
5 mIU/mL (normal <5 mIU/mL). Serum follicular2 P( K ^5 s5 n6 C
stimulating hormone and leuteinizing hormone
( |' I' N" O* P- C4 C/ ?concentrations were less than 0.05 mIU/mL0 p Y/ H E1 f2 O8 E
(prepubertal).
3 b- x4 w$ p2 l( b; {) i7 q" g vThe parents were notified about the laboratory- H# M5 S0 X' ^: u; H" l
results and were informed that all of the tests were
5 \/ e [; N' [# f$ C4 b4 Tnormal except the testosterone level was high. The) r. n* Q" \9 t) Y
follow-up visit was arranged within a few weeks to
0 L4 _. ]! P8 Y" b# L$ Mobtain testicular and abdominal sonograms; how-
3 _. p1 o: u) y4 ] ~ever, the family did not return for 4 months.5 k) s5 d1 z+ N0 x* q
Physical examination at this time revealed that the1 h( \. l, j; R( T
child had grown 2.5 cm in 4 months and had gained
9 L1 [* s7 R$ \' _8 a2 kg of weight. Physical examination remained
) b4 t6 t1 c7 H- S, ~ ^2 |: B9 F3 nunchanged. Surprisingly, the pubic hair almost com-5 ^0 B$ B6 w! e8 {( }
pletely disappeared except for a few vellous hairs at
1 Z9 v! a4 f9 R# O7 q- B, pthe base of the phallus. Testicular volume was still 2% A7 [% `; [$ }( j% \# v5 O
mL, and the size of the penis remained unchanged./ _- }8 l9 s3 z0 c' b3 G4 Y1 ]) i
The mother also said that the boy was no longer hav-1 l' W/ y/ h# p8 ]- A
ing frequent erections.
: H+ _9 P8 z E: YBoth parents were again questioned about use of
+ h% g* o& ?5 |# `any ointment/creams that they may have applied to
, X% G |" q+ I6 i' r! N4 E7 bthe child’s skin. This time the father admitted the
* F/ s' @ l$ NTopical Testosterone Exposure / Bhowmick et al 541
* Z! S$ c1 z3 x) W3 z6 d+ Uuse of testosterone gel twice daily that he was apply-
/ V- X0 Y1 L" N; Bing over his own shoulders, chest, and back area for
, h- A9 Z3 p+ n; l+ Wa year. The father also revealed he was embarrassed' O9 }5 T. }; n2 X+ \% W
to disclose that he was using a testosterone gel pre-/ p# ?" M) A) {
scribed by his family physician for decreased libido
' G3 @, p3 Z P7 z, Y" C* K* ssecondary to depression.
1 E# D$ c8 t; o- N. C. AThe child slept in the same bed with parents.2 O3 D! N3 o V$ r( B
The father would hug the baby and hold him on his) `0 @( ?# w- h! Z3 N& G0 Y
chest for a considerable period of time, causing sig-4 Z& y! v8 W w: r
nificant bare skin contact between baby and father./ d: Y- K$ ?0 [& c
The father also admitted that after the phone call,
+ \0 b8 U" C% lwhen he learned the testosterone level in the baby+ Q6 c- L' f/ I
was high, he then read the product information
, p% b" d0 E3 B! \) I5 upacket and concluded that it was most likely the rea-- o6 M0 \2 w5 `, X8 l
son for the child’s virilization. At that time, they
2 i6 U; _% S1 T6 `* ndecided to put the baby in a separate bed, and the
# R5 t3 o; A5 r* mfather was not hugging him with bare skin and had: w- w8 ]1 N* [) e0 Y( f
been using protective clothing. A repeat testosterone
; F0 r1 P) r$ |$ N+ d# Dtest was ordered, but the family did not go to the
$ o! y/ s, N; n5 slaboratory to obtain the test.
; a* E$ P, i% w( v* E& k! r4 MDiscussion
3 S i/ k1 b7 g$ \; O5 jPrecocious puberty in boys is defined as secondary
! D% \/ ?* n6 p" T3 H* ^# Esexual development before 9 years of age.1,4
! a0 n! h; {! M4 Q6 F4 q& [( S1 w: d& TPrecocious puberty is termed as central (true) when
! D; k: B0 T& L o. t, \it is caused by the premature activation of hypo-
8 K9 ]+ x! s! |0 w6 I9 w+ Bthalamic pituitary gonadal axis. CPP is more com-
, [, O2 l6 F- T% Z6 @. Qmon in girls than in boys.1,3 Most boys with CPP. R6 R8 @( d; J: {
may have a central nervous system lesion that is7 {# j( n/ r( [+ x: @$ `: w
responsible for the early activation of the hypothal-
' J9 H8 a0 ]4 }# s- h. o& _& o% m4 B' Jamic pituitary gonadal axis.1-3 Thus, greater empha-$ l% x) Y8 e, V: v9 l
sis has been given to neuroradiologic imaging in
4 {; G5 d4 f4 u0 Fboys with precocious puberty. In addition to viril-
$ p: b& f; P$ P2 V5 R; o/ Pization, the clinical hallmark of CPP is the symmet-
/ l# W; V3 l: ~* @4 {8 Rrical testicular growth secondary to stimulation by) @; K( c [% [2 A
gonadotropins.1,3
( m9 w$ a: L9 d, b0 l xGonadotropin-independent peripheral preco-" R: K1 Y/ ?0 [& O/ V
cious puberty in boys also results from inappropriate
% ^7 s. v" H8 w! landrogenic stimulation from either endogenous or
" N6 E: B* t: ?& D, ^exogenous sources, nonpituitary gonadotropin stim-
1 A$ \8 n7 h7 S7 j& \1 Wulation, and rare activating mutations.3 Virilizing0 x8 Q6 ?" p: ?: b) ^$ P
congenital adrenal hyperplasia producing excessive; ?6 `6 p) |7 S* u
adrenal androgens is a common cause of precocious
+ x6 a# \1 ]& k" I3 m R. ppuberty in boys.3,4
3 u. U2 a1 ?# U. _The most common form of congenital adrenal
( U& e8 H6 V2 X. P3 G* g xhyperplasia is the 21-hydroxylase enzyme deficiency.
; L$ v* e `* H# f; vThe 11-β hydroxylase deficiency may also result in
/ e9 ]5 T! i" H: N& qexcessive adrenal androgen production, and rarely,0 I) Z6 L- A$ P! i4 R8 c8 @
an adrenal tumor may also cause adrenal androgen
h2 F- w+ \' R7 ?( a2 Yexcess.1,3& @ |, j* M8 z9 N0 k& \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: O8 R) v! X, A, b* H0 S }7 F; g542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
. s5 t! i1 _* q9 e3 u1 fA unique entity of male-limited gonadotropin-" H! p+ j- z/ C
independent precocious puberty, which is also known& Z, K/ V3 `9 f0 J- S
as testotoxicosis, may cause precocious puberty at a! l& r! m. p' Y+ a9 h
very young age. The physical findings in these boys
" X/ g" k6 h# X# H$ H9 R9 |, lwith this disorder are full pubertal development,
) k8 ?) ~+ _4 a$ E( B5 c- B' Eincluding bilateral testicular growth, similar to boys3 Q4 ]0 s" ?2 T
with CPP. The gonadotropin levels in this disorder
8 N& G0 w- L2 U$ Yare suppressed to prepubertal levels and do not show) x7 _- S- ~7 b7 U" M( `' u+ i( |
pubertal response of gonadotropin after gonadotropin-# `. ~' R$ y f; d
releasing hormone stimulation. This is a sex-linked0 {# O; z2 h# c4 v4 p
autosomal dominant disorder that affects only
1 y, o) m+ x1 R \males; therefore, other male members of the family3 r; O" Y8 d+ R3 a; _
may have similar precocious puberty.3
+ T- h9 U+ ^9 N3 CIn our patient, physical examination was incon-. L3 c) O. p' S. S# D
sistent with true precocious puberty since his testi- E1 Q: q* v9 @2 P* q& Z1 f
cles were prepubertal in size. However, testotoxicosis
4 b) W6 z; A2 pwas in the differential diagnosis because his father
+ g& S* W# y+ U4 R: s4 [+ Estarted puberty somewhat early, and occasionally,
, \4 ?( e: N1 a) Q4 h, ]testicular enlargement is not that evident in the5 M; X; \! g7 b" g6 u
beginning of this process.1 In the absence of a neg-
1 N# D @2 [0 O8 B; c* Hative initial history of androgen exposure, our
7 D/ X8 j" A) P0 n" y; f- zbiggest concern was virilizing adrenal hyperplasia,
+ `, w1 O# b: Keither 21-hydroxylase deficiency or 11-β hydroxylase6 r# s2 {+ ]) K& a" b( @
deficiency. Those diagnoses were excluded by find-% z5 ^' s7 k9 ~5 u3 p7 X/ U
ing the normal level of adrenal steroids.
5 d, S( N% I {2 c% H6 bThe diagnosis of exogenous androgens was strongly2 N1 M9 c0 X- ]/ R7 z
suspected in a follow-up visit after 4 months because8 [. }) W2 ^+ s9 o
the physical examination revealed the complete disap-
- q) C4 `7 F, f4 y7 Wpearance of pubic hair, normal growth velocity, and( N% g8 g- t1 q7 R' P9 x3 |7 k
decreased erections. The father admitted using a testos-8 ~- s& p/ ?; N, `
terone gel, which he concealed at first visit. He was
& M) t1 i/ z" [8 l) I# t2 Vusing it rather frequently, twice a day. The Physicians’( ?, C& e7 }6 n9 x
Desk Reference, or package insert of this product, gel or5 K1 R' w& _9 b/ b! Y: E
cream, cautions about dermal testosterone transfer to
: R" G# [! _2 n/ x5 z1 T. [unprotected females through direct skin exposure.' R3 B) N1 v' s. j, ?0 T- D
Serum testosterone level was found to be 2 times the
* L, e; u) G: \# a1 ]. Mbaseline value in those females who were exposed to7 H8 i- r- U% M8 ~3 c
even 15 minutes of direct skin contact with their male
- v1 L# V& e* Tpartners.6 However, when a shirt covered the applica-3 _" i- i, M7 d0 e
tion site, this testosterone transfer was prevented.
$ U) ^4 Z; X1 o' o% Y% _+ b e5 NOur patient’s testosterone level was 60 ng/mL,( ?8 J8 M4 ?3 I7 W' J) J
which was clearly high. Some studies suggest that; i# o8 L) P9 o; w5 \! c. w
dermal conversion of testosterone to dihydrotestos-6 J% W$ k( J/ F2 B5 |6 z% P( p+ u
terone, which is a more potent metabolite, is more# E% {9 L7 U( J: g) b8 c: l
active in young children exposed to testosterone9 a8 _# N, H7 [$ v1 G* V2 e7 y$ q
exogenously7; however, we did not measure a dihy-8 {. p7 C' E4 y: w7 y
drotestosterone level in our patient. In addition to& H% C2 C, p/ _1 t8 t, _! m# Z
virilization, exposure to exogenous testosterone in* f* `& L* U O
children results in an increase in growth velocity and
8 l9 e# M% `! T2 R, H" Eadvanced bone age, as seen in our patient.
# V' F( N B. FThe long-term effect of androgen exposure during4 d% Z$ b% [9 r; j+ x' O
early childhood on pubertal development and final1 ^/ c7 }4 p( y" w/ U& Y; f6 N) ^8 I
adult height are not fully known and always remain" I* K7 h( Y" `" G: U
a concern. Children treated with short-term testos-/ k% P2 p4 h4 t R8 s R
terone injection or topical androgen may exhibit some
7 |) k& w( _" ^- E# W4 ]acceleration of the skeletal maturation; however, after/ h% Y4 M+ ]# c5 c- P" S5 C
cessation of treatment, the rate of bone maturation
- ?5 o# G3 l! k8 ]- ^) Sdecelerates and gradually returns to normal.8,9
7 N `1 I; ]0 R; F# k' aThere are conflicting reports and controversy
3 u% S8 ^$ j' L C- u+ Uover the effect of early androgen exposure on adult* G$ s1 M8 Z N* ]; c2 _: P
penile length.10,11 Some reports suggest subnormal$ q' N {! q7 t n4 a7 X- u
adult penile length, apparently because of downreg-
3 e+ l8 e' R$ L: ]. e5 I' culation of androgen receptor number.10,12 However,/ t M% x% w& J! B
Sutherland et al13 did not find a correlation between
1 U1 m8 c$ |- echildhood testosterone exposure and reduced adult
$ U: U- |: {! w$ Zpenile length in clinical studies.0 Q% U( i% u7 E5 ], S
Nonetheless, we do not believe our patient is
8 z( S: Z$ O& K1 U/ }' [: X) ^( [going to experience any of the untoward effects from4 ?$ u1 [3 R/ W0 k. x: B! m4 K
testosterone exposure as mentioned earlier because+ M$ v; [% G* s) F/ w$ }
the exposure was not for a prolonged period of time.& X* B5 d9 E3 k/ x
Although the bone age was advanced at the time of
! a- x* l% H) w( d: Y3 z2 tdiagnosis, the child had a normal growth velocity at5 ^, a i: k# g. Q, G
the follow-up visit. It is hoped that his final adult6 f ^; W) h" ]* I" Z6 l
height will not be affected.
/ }5 _, a5 L v) a# Q) sAlthough rarely reported, the widespread avail-& m2 W- {! a5 f+ Y3 M8 g" k
ability of androgen products in our society may# X, e: q, u8 x" N3 f' e# a
indeed cause more virilization in male or female
4 E! O: b0 g; |# l0 Vchildren than one would realize. Exposure to andro-
! Z7 f$ R! W& _% ~. Igen products must be considered and specific ques-4 r. [* D" t" c3 u+ Y
tioning about the use of a testosterone product or
. W+ h9 f& @+ K0 C/ tgel should be asked of the family members during2 M) a( l/ Z* \
the evaluation of any children who present with vir-& e" e9 f: F: a9 H$ A
ilization or peripheral precocious puberty. The diag-) z& S" G9 r0 w- y+ R
nosis can be established by just a few tests and by6 U6 k/ L* V6 U) a- t
appropriate history. The inability to obtain such a
8 ~2 _/ ]. e: Uhistory, or failure to ask the specific questions, may
2 Q$ K. }' v9 v+ Hresult in extensive, unnecessary, and expensive
& n$ p- R5 v- ]. Dinvestigation. The primary care physician should be5 p2 P4 T; v4 W- o+ ~7 O& z$ A7 g
aware of this fact, because most of these children1 D8 L7 N, k0 o& y. e& t' p1 _
may initially present in their practice. The Physicians’' b' \0 c: \8 Q6 B8 C/ d8 x
Desk Reference and package insert should also put a
/ g' D" I2 f# t+ R9 k5 C6 q( Uwarning about the virilizing effect on a male or
* n" W, d) ?, `% {female child who might come in contact with some-6 q: T" d( }: E1 S3 v- m* g. C
one using any of these products.
, M. f! @2 b$ A' y5 S C' ^References
9 x7 a2 p" O+ r- X6 q2 @1. Styne DM. The testes: disorder of sexual differentiation
# F, Z \7 n7 a) Land puberty in the male. In: Sperling MA, ed. Pediatric. P2 P+ K7 n6 X* V
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- l) K3 V8 ?2 |! z6 q( l
2002: 565-628.
1 e1 W" F* N* T7 J. t6 k1 s2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
; w% F+ p' E) E6 ?6 [/ I& [puberty in children with tumours of the suprasellar pineal |
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