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Sexual Precocity in a 16-Month-Old
; }( O3 l z! `: `+ |Boy Induced by Indirect Topical
) ]+ Q: q# i! |8 |3 r" PExposure to Testosterone
2 m5 i' I% U, K' qSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
7 \8 L* }, v8 M, P% B; eand Kenneth R. Rettig, MD1 a$ o4 B1 f- R) x3 N4 [/ L, b
Clinical Pediatrics+ Y' \. \ x5 h* z7 J: a
Volume 46 Number 6# H1 ]7 x' ?- [& w0 \- }! g
July 2007 540-543
& K" t6 o( v1 p" X/ W- N; m0 ~© 2007 Sage Publications% q1 J1 ~7 m! s1 N
10.1177/0009922806296651
9 }+ S: N1 d; H$ m' yhttp://clp.sagepub.com
9 ~% D0 e, @* jhosted at1 I' Z+ d4 a; A4 G/ v
http://online.sagepub.com |* |- f" n; Q! c0 W
Precocious puberty in boys, central or peripheral,4 I0 ?. C- j( q3 d) L
is a significant concern for physicians. Central
7 g- ^* g. Q' W3 ^2 gprecocious puberty (CPP), which is mediated( @9 f0 R" H& m4 n; b% C
through the hypothalamic pituitary gonadal axis, has
5 k: c2 I; ]+ i. d% G0 D" ua higher incidence of organic central nervous system
( y5 W4 V9 V ]4 C/ Tlesions in boys.1,2 Virilization in boys, as manifested+ W0 F8 [& ^& _6 `5 T& b' P
by enlargement of the penis, development of pubic5 m' l' U' R: }6 P+ @
hair, and facial acne without enlargement of testi-
+ C5 s+ D9 f# Z7 j& G0 l2 ^' s. vcles, suggests peripheral or pseudopuberty.1-3 We
. K! }5 g/ i0 g. q sreport a 16-month-old boy who presented with the
% \# ?2 P( m2 G( ?1 eenlargement of the phallus and pubic hair develop-
4 f. t$ o! L7 v9 _4 q. g5 F& [ment without testicular enlargement, which was due. k l: e7 N8 {* ^, c8 V8 b8 k0 N
to the unintentional exposure to androgen gel used by: S, X- r$ S' ^
the father. The family initially concealed this infor-& J' J8 N$ A( W, [
mation, resulting in an extensive work-up for this4 A. A* l9 b0 J, T) P) r
child. Given the widespread and easy availability of3 N0 e5 V/ \) _+ G. p0 l
testosterone gel and cream, we believe this is proba-9 {6 k. |* O ?4 h2 D, K0 u" y& b
bly more common than the rare case report in the |% Z; w" G: R6 m X6 c* k' f
literature.40 m0 ^) l2 D0 x/ v
Patient Report' J1 v7 M/ {& f* A
A 16-month-old white child was referred to the/ r% |4 i/ y# z& B
endocrine clinic by his pediatrician with the concern
% d* P0 ~$ t& }0 L) bof early sexual development. His mother noticed
% s7 |6 X! e$ I- G7 dlight colored pubic hair development when he was
: ?5 Z* t5 r" y' p: ~From the 1Division of Pediatric Endocrinology, 2University of
; G( A. j3 l) j% t8 _+ H% [* l) LSouth Alabama Medical Center, Mobile, Alabama.6 } c1 r9 C3 z f
Address correspondence to: Samar K. Bhowmick, MD, FACE,
N! j+ V( }- i" nProfessor of Pediatrics, University of South Alabama, College of
2 w% z; }$ \* iMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
* A0 W9 G) y# e2 ?: Ie-mail: [email protected].! M% \8 B5 T4 |# e: B! P, d0 N7 T
about 6 to 7 months old, which progressively became
' R* E' p. K& A, t9 l& Sdarker. She was also concerned about the enlarge-
+ \- J5 S# @& h- I: b8 g' E* iment of his penis and frequent erections. The child
6 `# W8 V9 T. X7 |3 x. T2 xwas the product of a full-term normal delivery, with% z0 X; c( }) {. V' Y5 {- Q
a birth weight of 7 lb 14 oz, and birth length of) s' B, |" E: I$ H! {" P* {
20 inches. He was breast-fed throughout the first year
% N2 l3 X7 s4 q' y5 F: ]( [- wof life and was still receiving breast milk along with9 @/ k0 {, {% T- ^
solid food. He had no hospitalizations or surgery,) T8 U) b, P: \9 D- s# ]
and his psychosocial and psychomotor development
. p, l8 ~+ A9 z4 ` ^( Jwas age appropriate.
7 L. W" _7 M% B* g; Q* n# WThe family history was remarkable for the father,: d$ [2 ^5 q5 F' h
who was diagnosed with hypothyroidism at age 16,
8 ?9 M9 D2 M1 W# k d; [which was treated with thyroxine. The father’s
6 w; O' Y, Y. }: Oheight was 6 feet, and he went through a somewhat8 w4 T) l9 ^9 |# b' k3 C' \
early puberty and had stopped growing by age 14.
- j0 h" k$ D) c: R9 y8 SThe father denied taking any other medication. The
}/ Y: a" }8 m1 u$ f, w& J: Mchild’s mother was in good health. Her menarche9 v( g( K3 w4 B
was at 11 years of age, and her height was at 5 feet+ t- }( ^; D7 S- H
5 inches. There was no other family history of pre-
! Z/ P$ P( E3 @3 ]) x$ d- H4 Fcocious sexual development in the first-degree rela-7 ^" I* [9 L1 }4 {1 X3 D) D$ P3 h
tives. There were no siblings.
6 X) {6 I5 L" i$ D* K P0 d8 KPhysical Examination
& \* P" q# F+ z2 nThe physical examination revealed a very active,- a4 ?+ F* c! q5 I# t% T8 |
playful, and healthy boy. The vital signs documented6 Q7 v( d+ s/ [
a blood pressure of 85/50 mm Hg, his length was
% y! M9 l8 y0 D9 i5 X% n: h90 cm (>97th percentile), and his weight was 14.4 kg: Q1 Q$ c* F8 O& |0 t k1 l
(also >97th percentile). The observed yearly growth5 b( z$ G7 ]0 o
velocity was 30 cm (12 inches). The examination of& D7 `7 F! ]- J& ]! w
the neck revealed no thyroid enlargement.
/ D8 U+ `: Z7 ]The genitourinary examination was remarkable for
2 f2 E1 M5 i6 ^# q+ Jenlargement of the penis, with a stretched length of
$ g& Z3 H8 d: V- F( w. \4 Q8 cm and a width of 2 cm. The glans penis was very well
# N W' J/ D( X$ h: Q7 ^1 qdeveloped. The pubic hair was Tanner II, mostly around E) Q7 _+ `6 d9 \3 I: v4 A8 [0 e
5403 L9 m: f: e2 A! D; ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( K$ Q% k) N/ l3 {the base of the phallus and was dark and curled. The( n% Q+ w+ W1 ~# j9 x/ G
testicular volume was prepubertal at 2 mL each.
4 d# Z4 R4 ~5 z" HThe skin was moist and smooth and somewhat
2 r: @ @( w" f# j1 U6 Foily. No axillary hair was noted. There were no2 W! C3 P9 [5 a u
abnormal skin pigmentations or café-au-lait spots.
3 W3 x& @4 A- D6 zNeurologic evaluation showed deep tendon reflex 2+: x& T1 }! s( l4 l# Z1 b U: n* `
bilateral and symmetrical. There was no suggestion
0 M& j. I3 C0 B4 S1 l# Vof papilledema.
+ B- C4 y! F( o3 ~( fLaboratory Evaluation) E! N" i' e) S7 O" E* ~/ A; L
The bone age was consistent with 28 months by6 O8 x. L! m; J9 [' q# k
using the standard of Greulich and Pyle at a chrono-
4 d1 M" A8 e" I( R6 I0 }logic age of 16 months (advanced).5 Chromosomal* L6 P' z/ H( }8 d5 O0 y4 X+ } Q
karyotype was 46XY. The thyroid function test
& q% I5 }& Y& I8 V; P( Y1 M* Fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
* F9 g& b* w1 j2 D: zlating hormone level was 1.3 µIU/mL (both normal).
4 M. a1 m* f+ t- J8 }& L- _The concentrations of serum electrolytes, blood6 t0 D6 y; n5 H" o; m; h
urea nitrogen, creatinine, and calcium all were
2 Z2 Y0 H. t" y- i# K& r$ F" Zwithin normal range for his age. The concentration
8 p- U; x! j3 H$ P) aof serum 17-hydroxyprogesterone was 16 ng/dL8 Z4 b; T. T/ h" b4 [3 X
(normal, 3 to 90 ng/dL), androstenedione was 205 _* T9 C* V& `
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros- l4 x% l4 _8 b4 C% ^$ E* D
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 o/ I6 Q$ F [5 [% v# o; v vdesoxycorticosterone was 4.3 ng/dL (normal, 7 to. y. b6 H/ m# x' K8 i, y
49ng/dL), 11-desoxycortisol (specific compound S)( G, l" h$ _) N- ]8 c% I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# _- e; e0 L5 c1 k5 k- n) f7 rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ }2 P( E6 J8 U% I
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ \* l! Q1 m m$ _) g. Sand β-human chorionic gonadotropin was less than
& y8 @0 i& N+ \9 g8 I+ g, n9 B5 mIU/mL (normal <5 mIU/mL). Serum follicular$ h- C( F* P. |2 C# H+ P. c& y$ T
stimulating hormone and leuteinizing hormone
/ q; f( G& `, Z0 M( @ yconcentrations were less than 0.05 mIU/mL/ W3 C9 I: P( ]8 u$ z, n$ }
(prepubertal).
q' c6 v8 w4 D. A- \: t3 S0 EThe parents were notified about the laboratory
+ y' @2 r$ W3 e, |2 S) _) Oresults and were informed that all of the tests were# n/ S+ k# V6 I/ V- d! M" J' M
normal except the testosterone level was high. The ]* ~# O7 M" j, ^. z, |; C: s
follow-up visit was arranged within a few weeks to; s2 z, O/ ?' M2 F! q2 a8 ]% j# v
obtain testicular and abdominal sonograms; how-* E6 K3 K: v9 t4 f# `; r0 x; |
ever, the family did not return for 4 months.
' ^& B1 E% t0 s4 y- |Physical examination at this time revealed that the, u0 m* U: \8 W/ A8 u2 T1 C, e
child had grown 2.5 cm in 4 months and had gained
- E ~7 f& Z: q& r2 kg of weight. Physical examination remained0 N) I& P2 A$ F
unchanged. Surprisingly, the pubic hair almost com-
' I$ G2 Y6 [9 s P2 c% D+ Y9 apletely disappeared except for a few vellous hairs at' Q K+ u! i, L& v
the base of the phallus. Testicular volume was still 20 P; O# ?1 v1 i w
mL, and the size of the penis remained unchanged.( Y+ Y' \( @$ P. w, x6 V/ R
The mother also said that the boy was no longer hav-
" S. g: L9 _3 |$ }8 i" m) ming frequent erections.# P% q) s2 q( \. }
Both parents were again questioned about use of
- G9 [; [% v( b8 Q7 ^9 Hany ointment/creams that they may have applied to
/ z" ~: K& W2 ^. Rthe child’s skin. This time the father admitted the
4 ]4 a/ u7 B3 W, v! @* M$ dTopical Testosterone Exposure / Bhowmick et al 541
# l, I+ K0 i/ q, H2 }use of testosterone gel twice daily that he was apply-
2 K; {! B3 _. V: Hing over his own shoulders, chest, and back area for4 j1 R8 [' C0 f% }5 c5 I3 k
a year. The father also revealed he was embarrassed! @+ a( Z2 J% }5 [# Z# ~8 L
to disclose that he was using a testosterone gel pre-) h6 ~- ~4 f$ o' W
scribed by his family physician for decreased libido) e9 L* r8 |/ K1 Z
secondary to depression.; C2 | ?3 ~' @4 |, S
The child slept in the same bed with parents. H6 d2 ^' M! m3 d0 M4 S
The father would hug the baby and hold him on his8 F j; Y. h6 n: {
chest for a considerable period of time, causing sig-
/ L: P H/ e2 o) d8 ]nificant bare skin contact between baby and father.
7 U6 u' z1 F1 y8 [0 g. t) Q+ ]The father also admitted that after the phone call,
- E0 }" q# a9 {when he learned the testosterone level in the baby% l/ P# k+ S# T' i
was high, he then read the product information
" ~& _% x! |. v' {! m! \packet and concluded that it was most likely the rea-
: z. v( W, M) M; p" m) o9 yson for the child’s virilization. At that time, they; X* `8 u2 N5 N9 o7 \ X4 T
decided to put the baby in a separate bed, and the
3 W5 W& B# x% s; \% J' t o& m% ?father was not hugging him with bare skin and had) a( J- b9 P: z
been using protective clothing. A repeat testosterone
q) |& J. z% g: w1 S8 Q3 ltest was ordered, but the family did not go to the5 J) t* e2 e* }& c a0 x- K
laboratory to obtain the test.- |% _1 a5 F5 m E" m3 q( I7 u
Discussion7 e; e' _: ~6 Y2 @; a7 e5 o9 r
Precocious puberty in boys is defined as secondary, @6 S) [# v7 |6 o9 r( L. O+ u
sexual development before 9 years of age.1,4, J; D- y/ G2 f5 a
Precocious puberty is termed as central (true) when
4 l7 n. }4 }4 H' Eit is caused by the premature activation of hypo-
3 ` ]. u3 e8 `/ y0 i$ R2 F) h5 } Z( G2 Pthalamic pituitary gonadal axis. CPP is more com-
1 b u& h: H( b( n9 V+ R/ _mon in girls than in boys.1,3 Most boys with CPP
6 P4 | m H1 A. l, i" dmay have a central nervous system lesion that is
, s7 a- E8 U0 N0 Sresponsible for the early activation of the hypothal-" g. X* n: e: y) T; s
amic pituitary gonadal axis.1-3 Thus, greater empha-
$ R/ M! S9 ?% Osis has been given to neuroradiologic imaging in
: E; Z" L, q: ~" n. ^boys with precocious puberty. In addition to viril-* P1 H: A( F6 h5 {2 p/ r
ization, the clinical hallmark of CPP is the symmet-& i& C `( h( e
rical testicular growth secondary to stimulation by
6 V7 Q: W/ `3 Kgonadotropins.1,3
! L& T2 Y+ ~% f; U( I& H4 hGonadotropin-independent peripheral preco-6 f/ u3 y, y; f" f# ?" B5 H
cious puberty in boys also results from inappropriate
/ r; H! j, ^7 ~% V1 v) Y& Kandrogenic stimulation from either endogenous or& Y+ i- ~% [5 v) d! f
exogenous sources, nonpituitary gonadotropin stim-6 i' X. f' \* ^3 Y9 ]
ulation, and rare activating mutations.3 Virilizing
) i" X/ a- X& E% G$ ?congenital adrenal hyperplasia producing excessive
$ M) E% q( h4 o1 cadrenal androgens is a common cause of precocious
[( }* Y, u1 p+ V# Opuberty in boys.3,4
3 Q- n. H" M5 Q! Z9 h0 N7 ]& m8 k2 F UThe most common form of congenital adrenal
+ p) }2 j0 ~3 {. m5 o O$ W$ phyperplasia is the 21-hydroxylase enzyme deficiency.
# [' E! A1 S& rThe 11-β hydroxylase deficiency may also result in' @3 Z+ d- `5 P v( H6 M
excessive adrenal androgen production, and rarely,/ \9 o# l+ s6 c2 }$ }' i! b3 M) K
an adrenal tumor may also cause adrenal androgen
; s+ ~, D9 D0 f5 Qexcess.1,3
7 v# q: q8 ^# C& xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 M* l% ]1 a' z' L: p2 l542 Clinical Pediatrics / Vol. 46, No. 6, July 20072 d9 e1 Z! T. \) E
A unique entity of male-limited gonadotropin-1 |8 l3 j7 Q' u. X. L2 S8 |
independent precocious puberty, which is also known
$ R, S7 b4 ?/ n! t" yas testotoxicosis, may cause precocious puberty at a
+ H3 l# d0 ]& u9 x. q+ p( t/ k+ Bvery young age. The physical findings in these boys5 k- L1 O4 c/ ?- h
with this disorder are full pubertal development,
7 m* e% F! d6 |4 n S3 g3 Tincluding bilateral testicular growth, similar to boys
, O( m6 K; c3 T3 Dwith CPP. The gonadotropin levels in this disorder
' k( m+ L. g! D g5 K) j7 C5 I( j* D8 aare suppressed to prepubertal levels and do not show
8 L! g6 V- P# ^3 G8 Tpubertal response of gonadotropin after gonadotropin-
& |, f2 Y2 @, @& l& d4 O) Lreleasing hormone stimulation. This is a sex-linked* s* @/ Y+ e) D# E3 W6 L5 C
autosomal dominant disorder that affects only; ^$ R# x9 E& k4 i2 a
males; therefore, other male members of the family+ _% X6 A; H% m$ l( E
may have similar precocious puberty.3% }3 ~4 c# `9 ~3 c1 R; l7 E
In our patient, physical examination was incon-
; n. K o0 m* ]# J; e' [8 hsistent with true precocious puberty since his testi-" r7 w" @' o! B9 T4 k+ n% _, [
cles were prepubertal in size. However, testotoxicosis+ J7 a9 x- ]: m' `/ U' ]
was in the differential diagnosis because his father _' [3 f1 q0 [2 n0 a
started puberty somewhat early, and occasionally,9 W1 s! A* n: c" j
testicular enlargement is not that evident in the8 ~) M0 [2 L; O7 W! i3 O
beginning of this process.1 In the absence of a neg-6 B% {9 R/ W( c' k) }1 Q
ative initial history of androgen exposure, our w- g2 C+ z R/ ?
biggest concern was virilizing adrenal hyperplasia,
& n& l! }" b b/ O8 d) l/ beither 21-hydroxylase deficiency or 11-β hydroxylase
2 {; g8 g7 b9 W& b' s5 Ddeficiency. Those diagnoses were excluded by find-! h4 B) i/ w: O* s( }: Y
ing the normal level of adrenal steroids.* U y" o. j/ M
The diagnosis of exogenous androgens was strongly F3 F4 |! e8 @7 m. n8 C
suspected in a follow-up visit after 4 months because
; F( V; R# ^+ B; {! B. s0 @the physical examination revealed the complete disap-$ {/ w+ B2 V' H# i& u/ `4 X) D
pearance of pubic hair, normal growth velocity, and9 m( n1 C6 B( c5 \ d
decreased erections. The father admitted using a testos-* _/ s$ m6 O3 {( N8 k
terone gel, which he concealed at first visit. He was8 E* e0 N) _! Q" f' s; _2 M
using it rather frequently, twice a day. The Physicians’
! h0 F# C. A _& R5 ?( ? i/ d6 y" h _Desk Reference, or package insert of this product, gel or
; M1 f0 v' U4 `+ U, ncream, cautions about dermal testosterone transfer to
7 l [1 Q, d" {% j3 dunprotected females through direct skin exposure.
: t: `' i6 {, U# ]* a% [, q0 fSerum testosterone level was found to be 2 times the: _% M( }: @! F) |5 c$ r( C/ G
baseline value in those females who were exposed to$ O, }* O, U2 q
even 15 minutes of direct skin contact with their male
8 F5 f& t7 x* [6 i, Vpartners.6 However, when a shirt covered the applica-& T% [* d" s' B0 p& m H! u1 o
tion site, this testosterone transfer was prevented.& W+ [ l* x* _$ ?( P$ S& P
Our patient’s testosterone level was 60 ng/mL,
/ U" G' q' D7 @" P2 ]3 W8 ewhich was clearly high. Some studies suggest that
4 `" R8 l5 R. t5 U$ S4 G, R. Xdermal conversion of testosterone to dihydrotestos-6 L1 T0 r+ S, ], {0 a4 `/ S9 c
terone, which is a more potent metabolite, is more r- J* H6 B0 x6 l& R' r! n
active in young children exposed to testosterone/ @" u$ h2 y4 ]0 K9 O/ O! k+ N4 I
exogenously7; however, we did not measure a dihy-/ T E( Z; \3 R4 ], W
drotestosterone level in our patient. In addition to- Q1 Z3 L' j3 s7 L
virilization, exposure to exogenous testosterone in
1 P+ n. }. F; X# Lchildren results in an increase in growth velocity and
7 k2 F$ i+ {4 R, }) N- R! Madvanced bone age, as seen in our patient., O& P- s" D5 i
The long-term effect of androgen exposure during
0 F5 }/ V) G, z/ Cearly childhood on pubertal development and final: ]9 i1 S5 t, t. p& g* P
adult height are not fully known and always remain
# c* ]! B) i* r8 @! D$ ]4 O$ Ha concern. Children treated with short-term testos-+ ^7 W7 ~# ]: m& T* D8 x* V' n# L- k
terone injection or topical androgen may exhibit some
3 N) C9 V1 \# b: c8 r% R0 h% Wacceleration of the skeletal maturation; however, after
2 d0 m7 r: k$ W. Y- B4 tcessation of treatment, the rate of bone maturation
% e' u: K6 m$ w5 ydecelerates and gradually returns to normal.8,9' C" V( y0 C o. t6 P
There are conflicting reports and controversy
+ `/ ?# K& b5 ] c2 b rover the effect of early androgen exposure on adult' G: j* x+ I- T( H2 |5 T: [
penile length.10,11 Some reports suggest subnormal
" i8 Q0 ?; x( g9 I( }adult penile length, apparently because of downreg-9 S: o6 z, ~% F9 D! R" X2 v$ [' N
ulation of androgen receptor number.10,12 However,
2 G M% ]" i" [$ G7 M! KSutherland et al13 did not find a correlation between" X% w; y( I: Q. W
childhood testosterone exposure and reduced adult
1 c' g5 l4 d# [* O5 B& [2 \penile length in clinical studies.+ i% ?0 x- v1 |) \
Nonetheless, we do not believe our patient is
7 d( R2 \6 N4 Sgoing to experience any of the untoward effects from6 b! n! R: w: N; @$ ]% o8 E8 @
testosterone exposure as mentioned earlier because
1 u) w/ m- C( D" }/ o0 G1 kthe exposure was not for a prolonged period of time.* |1 W* X* u/ `3 K5 J. _( z
Although the bone age was advanced at the time of
9 N$ U6 D# d q7 w c+ k2 q. D" pdiagnosis, the child had a normal growth velocity at
! D) w9 Q [% {$ ^3 X3 ~' Bthe follow-up visit. It is hoped that his final adult6 T3 p' x: k9 {8 n% Z5 b& c8 S
height will not be affected.' C# ]: m+ J. E1 Z$ b$ n) T
Although rarely reported, the widespread avail-
1 x) q$ \" U1 Mability of androgen products in our society may
- r" P2 y% x8 ?' k; Xindeed cause more virilization in male or female
; D& u: E( D9 H/ j$ o! r( n0 Qchildren than one would realize. Exposure to andro-+ I; Z5 |! t1 l5 Y2 M' e) I
gen products must be considered and specific ques-5 {8 U7 k! ^/ a3 a. F
tioning about the use of a testosterone product or) K1 H; f: {) L) M+ f
gel should be asked of the family members during4 D+ w- i/ A0 P9 w9 r# h# F
the evaluation of any children who present with vir-5 p9 Q- R6 w8 X* r' E) ?
ilization or peripheral precocious puberty. The diag-
8 v( O ?( t f/ [nosis can be established by just a few tests and by
$ q, f3 B8 c4 G, u6 d q8 ?; nappropriate history. The inability to obtain such a
% p0 `. E9 a/ [5 Jhistory, or failure to ask the specific questions, may
6 ?2 n9 r) x8 Q7 ~result in extensive, unnecessary, and expensive
/ N4 T) B* ~) ?) g, h( X9 l0 Ainvestigation. The primary care physician should be
4 |, F6 c' H8 u: ^" A" Xaware of this fact, because most of these children
$ q/ `& H& i- K3 C) Tmay initially present in their practice. The Physicians’$ x" m: d/ ^. v
Desk Reference and package insert should also put a! ~7 `7 p. O2 r4 [+ I* N
warning about the virilizing effect on a male or
- m/ V8 y# p. jfemale child who might come in contact with some-- a2 z4 Z: U6 z9 q- |1 K# @
one using any of these products.
. Q; W0 r7 o* p$ t9 |- R- U3 AReferences/ C; w3 n, w% {
1. Styne DM. The testes: disorder of sexual differentiation
3 W% T5 k5 a& Jand puberty in the male. In: Sperling MA, ed. Pediatric% g1 V" L: T ^: w
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- H! R0 D I4 k; v) ~2002: 565-628.7 Q, p2 O" h, d
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& P* W3 r: o( b" B: @1 J
puberty in children with tumours of the suprasellar pineal |
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