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Sexual Precocity in a 16-Month-Old- c! B( G6 g: q, f. t- w8 S
Boy Induced by Indirect Topical
! z6 R( y5 h1 U5 y9 I, zExposure to Testosterone
# D4 U0 P5 y; q0 C% ~Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) k" {/ d! B- ]+ e' x- V5 g4 {
and Kenneth R. Rettig, MD1
$ i2 ] k. C+ _5 h& q0 f8 FClinical Pediatrics' D) N1 M9 |0 F9 D- K- Q
Volume 46 Number 6
# l& k; F$ b+ ]1 m& }3 F2 HJuly 2007 540-543$ O4 p' C9 b* p$ d1 I
© 2007 Sage Publications5 v* V2 {) a. i$ g
10.1177/00099228062966516 |3 @+ Y' {: _4 b6 y
http://clp.sagepub.com
" j$ f# E' U) l1 T( {! ~2 thosted at
% B" i" V" ~# F& e# Ihttp://online.sagepub.com
* G$ K$ m6 X5 P0 c; KPrecocious puberty in boys, central or peripheral,0 E7 ]5 O P% |$ F, x& O( V$ ]
is a significant concern for physicians. Central9 w4 P+ c1 p8 h" t, ^ d
precocious puberty (CPP), which is mediated
0 ? _0 Q, F% k8 S# B4 S0 x: Ethrough the hypothalamic pituitary gonadal axis, has, f+ I: _& P# g$ K
a higher incidence of organic central nervous system
) F9 A) P! J6 Tlesions in boys.1,2 Virilization in boys, as manifested: n: ~6 m* Z& ]/ d3 R+ S6 O( g
by enlargement of the penis, development of pubic
# I7 R- A4 l ?8 z: _2 l S1 l$ f) shair, and facial acne without enlargement of testi-( ~9 K+ O" X3 t, Y& _5 W
cles, suggests peripheral or pseudopuberty.1-3 We6 l R7 n9 v3 A
report a 16-month-old boy who presented with the
! v3 ~) O* P; c3 E( L2 Menlargement of the phallus and pubic hair develop-
/ S. R% c8 O! t0 ?. Zment without testicular enlargement, which was due. m$ {5 P5 L ^3 A. h" Y8 ^& l
to the unintentional exposure to androgen gel used by% s. o9 t/ s- n# K. o4 U
the father. The family initially concealed this infor-! W) _" K8 f' `5 ?7 v+ s7 L
mation, resulting in an extensive work-up for this
4 a- N& [% J& M. g$ n4 p% w I7 K Zchild. Given the widespread and easy availability of
- v4 e- u/ s5 B# R$ r) }1 M+ htestosterone gel and cream, we believe this is proba-" p5 v/ A$ D7 f& w3 O
bly more common than the rare case report in the5 z; C" i4 i$ n/ C" R; O- m
literature.4
- ] x. j" f, I u- uPatient Report
7 X( W7 |) J gA 16-month-old white child was referred to the* O' X6 ^/ S5 C! _1 q
endocrine clinic by his pediatrician with the concern
! t+ U, y4 E: q3 W7 aof early sexual development. His mother noticed7 I" s4 \( r* y4 \: R6 `
light colored pubic hair development when he was
( p& a5 U! a |4 O# b, |7 A( zFrom the 1Division of Pediatric Endocrinology, 2University of( _: l0 P1 u G L# J- e7 z% ]
South Alabama Medical Center, Mobile, Alabama.1 _" K. y$ f* R( o. Z' x7 `
Address correspondence to: Samar K. Bhowmick, MD, FACE,) n P; }/ ]2 T6 |2 X7 H- z
Professor of Pediatrics, University of South Alabama, College of
7 ]% j5 F P2 _4 M/ {& n; rMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% l9 q( F1 C7 ^$ }; k' ye-mail: [email protected].$ O9 q: ^6 \# L- ?- V6 R- H9 Y
about 6 to 7 months old, which progressively became4 Q. N% j. E# R. g2 Y5 f# t
darker. She was also concerned about the enlarge-
6 D4 A* Y" k1 F3 C) Hment of his penis and frequent erections. The child
) X4 Q" c3 i( e- k. m. Z3 U( ~( ywas the product of a full-term normal delivery, with3 D1 U* b5 H f" X1 c" Z1 e5 j- |$ ]
a birth weight of 7 lb 14 oz, and birth length of
+ V$ d4 X+ n. Q" K' q20 inches. He was breast-fed throughout the first year) r" }2 ?) n( [: R& a% E8 }
of life and was still receiving breast milk along with0 |) u: [) x5 [( }% ]
solid food. He had no hospitalizations or surgery,
) `0 W2 x# C; `5 [and his psychosocial and psychomotor development' I$ X4 W" x: f3 p+ p6 o
was age appropriate.
) S" @4 u6 D+ _8 n' FThe family history was remarkable for the father,
# U3 v# x( _0 v/ L2 {who was diagnosed with hypothyroidism at age 16,) U# M$ {+ i3 o: V
which was treated with thyroxine. The father’s
6 H, x- R- f: x4 uheight was 6 feet, and he went through a somewhat
) T8 m0 w' w0 K- Q/ yearly puberty and had stopped growing by age 14.+ p, ~: |; i6 a% {9 M: G% [
The father denied taking any other medication. The: ]! w2 c% G6 D+ ~! p
child’s mother was in good health. Her menarche8 P5 o3 w7 A& q& x4 C- v
was at 11 years of age, and her height was at 5 feet( w0 V+ |) s+ Z* y. k4 `
5 inches. There was no other family history of pre-: Y3 M$ n' R H" W ?! K
cocious sexual development in the first-degree rela-. o& L n+ e& m' n+ @
tives. There were no siblings.
# k+ @! y% |: I) E% ^4 @Physical Examination9 r u$ [* Q$ K( U# V4 [/ \
The physical examination revealed a very active,
8 b5 B+ z# E, {7 W. iplayful, and healthy boy. The vital signs documented
# ~( g( h; b) f( e+ Q0 \1 ha blood pressure of 85/50 mm Hg, his length was q+ g; _2 I( H9 U) \/ H
90 cm (>97th percentile), and his weight was 14.4 kg: i6 |+ d& U6 P
(also >97th percentile). The observed yearly growth0 I' @5 Q8 r f0 {& V1 T3 u
velocity was 30 cm (12 inches). The examination of
5 {) d/ K: y9 y9 z$ @. a: o Ethe neck revealed no thyroid enlargement.9 t. D8 t9 b: J( s2 h* w
The genitourinary examination was remarkable for% B7 g0 O' v6 ~, [0 Q' @
enlargement of the penis, with a stretched length of- A3 v2 R3 S9 i4 F5 }' a
8 cm and a width of 2 cm. The glans penis was very well
- L. p( C! s& w0 [developed. The pubic hair was Tanner II, mostly around. J: B6 D( ^ L8 Y5 h) }: D
540
$ W' I3 O( _1 s, Q* S9 }9 Q: Sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ ^2 Z. P( J* n! f0 C; P
the base of the phallus and was dark and curled. The
/ a2 R" G& {" Q* ~; M+ u+ Wtesticular volume was prepubertal at 2 mL each.
1 N% ]2 |" I/ sThe skin was moist and smooth and somewhat
6 Q0 q# [4 C2 \& Y2 k3 Zoily. No axillary hair was noted. There were no: m4 O5 D8 V7 T/ A Z$ t
abnormal skin pigmentations or café-au-lait spots.0 R! H. v0 A! z' T( {0 X1 Q
Neurologic evaluation showed deep tendon reflex 2+' i4 C3 ^' j) M
bilateral and symmetrical. There was no suggestion* f# E" ^6 I& S9 ^4 t, |
of papilledema.3 p5 ?8 P, c7 d* X
Laboratory Evaluation
A* C0 A0 s# v* v! X1 ]. sThe bone age was consistent with 28 months by, F- I; T6 K. K* v" x' b( j0 p
using the standard of Greulich and Pyle at a chrono-
/ j% d" u. K7 @logic age of 16 months (advanced).5 Chromosomal2 N T: c: N5 s8 W1 }+ M
karyotype was 46XY. The thyroid function test
/ ? ^: ~% s3 |9 Bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-/ v& ?. Y: S3 u! g
lating hormone level was 1.3 µIU/mL (both normal).- r3 U! f# Q; D5 f
The concentrations of serum electrolytes, blood2 ^' K/ u# _" y7 n5 J& ~9 V% }
urea nitrogen, creatinine, and calcium all were8 Z7 V* v8 @) A8 m; V
within normal range for his age. The concentration, i" l2 O+ ? U$ V5 f# o) P4 w( B
of serum 17-hydroxyprogesterone was 16 ng/dL& b# b) g$ ]9 n; d7 Y
(normal, 3 to 90 ng/dL), androstenedione was 200 D* e: s* @6 ~0 H
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
R: l* d' f# L0 z9 F# i( n2 ~terone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 D6 Z7 ^1 D# l( @* mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 n8 ^5 I u3 x0 X3 b+ ]49ng/dL), 11-desoxycortisol (specific compound S)# J @' K; i8 D1 @; k/ m
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 D" `- \% g+ N
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
" s7 G/ U" ^) ^3 ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 E/ B' n7 r$ C
and β-human chorionic gonadotropin was less than
^/ P8 d' ~$ [/ F5 mIU/mL (normal <5 mIU/mL). Serum follicular
% s; \- t4 ?6 R: Y! ~stimulating hormone and leuteinizing hormone" o" @# f) e1 i
concentrations were less than 0.05 mIU/mL2 o8 c: R1 `, ~2 ^9 b
(prepubertal).
; D7 o5 F3 s# l4 B/ w& Y0 j0 s2 K& aThe parents were notified about the laboratory+ W+ N2 L3 e/ t' v( b
results and were informed that all of the tests were f& g! K& E0 c
normal except the testosterone level was high. The, [: l7 k- ]+ h) w& Y8 I6 A9 R) ^
follow-up visit was arranged within a few weeks to
* q+ V) s& H, T3 i* A r, xobtain testicular and abdominal sonograms; how-0 R% I2 O6 V& l" }0 g- S; a. ?
ever, the family did not return for 4 months.1 N: L! ]7 w- \) Y- m; Y9 @0 W
Physical examination at this time revealed that the( j; z& U( q0 ^; H
child had grown 2.5 cm in 4 months and had gained
+ c" O5 u& v1 s5 ?2 kg of weight. Physical examination remained9 J* F$ j- h# q; l8 f- u
unchanged. Surprisingly, the pubic hair almost com-& u) Y7 U p$ S4 p. {
pletely disappeared except for a few vellous hairs at1 h( K1 \ x t, {
the base of the phallus. Testicular volume was still 2' S9 R# o' g& j1 Z+ h' ^6 {( v
mL, and the size of the penis remained unchanged.
, t& x- k4 O' u) d \* X; NThe mother also said that the boy was no longer hav-
4 _6 G. L7 U- aing frequent erections.! b9 m! D4 E. c( k, d; x6 B1 g- n* D
Both parents were again questioned about use of3 f" w3 M' P( {& L6 I
any ointment/creams that they may have applied to
$ Y; Z) }. l H) r9 P. Ythe child’s skin. This time the father admitted the
) \1 B! f" S2 N- N( lTopical Testosterone Exposure / Bhowmick et al 5411 s9 y8 W" I% J& F# K& Y
use of testosterone gel twice daily that he was apply-
& S0 e9 i8 G# ]3 e5 f" uing over his own shoulders, chest, and back area for
2 l: E+ N& d9 j, F' d, La year. The father also revealed he was embarrassed
" r% o r: t/ L) Hto disclose that he was using a testosterone gel pre-
9 U ?+ o7 n& v3 T- v8 F/ I8 G$ Sscribed by his family physician for decreased libido
1 o6 x8 U( S' a) ~8 N$ tsecondary to depression.# n+ i& p- C' t P, m3 @
The child slept in the same bed with parents.
6 e: F( B$ Y; {! w9 U; jThe father would hug the baby and hold him on his
1 {3 Y/ z2 O( j. R: Zchest for a considerable period of time, causing sig-
; a# ^0 C* I5 z8 fnificant bare skin contact between baby and father.( m- p" B4 q; S
The father also admitted that after the phone call,2 T, J& L9 @$ ^, Q
when he learned the testosterone level in the baby
+ x- x! Z( R. }, M; fwas high, he then read the product information
7 M g' _* C/ j* z7 Wpacket and concluded that it was most likely the rea-
2 {% J8 ^6 k7 m5 M/ vson for the child’s virilization. At that time, they
# ~4 \# @- i5 {7 J9 x8 m4 Q6 m0 @decided to put the baby in a separate bed, and the5 v# J& O7 j! o* D4 E9 }
father was not hugging him with bare skin and had8 u: j7 c! u! A) S& O2 ^
been using protective clothing. A repeat testosterone* n; h5 D; b( g( Q7 F5 U+ N
test was ordered, but the family did not go to the" f; B9 J* i0 t0 a2 I9 H0 ~
laboratory to obtain the test.: |) M$ t0 V$ n" f' T. V
Discussion
8 S( Z$ h+ }9 C1 @( YPrecocious puberty in boys is defined as secondary
: W: P( L3 P" Ysexual development before 9 years of age.1,4
) }2 P" D5 j8 V0 L. EPrecocious puberty is termed as central (true) when5 V: X6 w$ o" L; d& Q
it is caused by the premature activation of hypo-
* G* s: a- J( s9 c+ X5 V8 Fthalamic pituitary gonadal axis. CPP is more com-* B$ n5 d3 n+ g4 M3 W9 f
mon in girls than in boys.1,3 Most boys with CPP
. I% a& C7 H& Q) c0 I7 H1 f5 smay have a central nervous system lesion that is) r7 x+ v: R. ]2 u9 m
responsible for the early activation of the hypothal-! t( h6 V, t& V$ H/ l1 N- Z: @
amic pituitary gonadal axis.1-3 Thus, greater empha-3 y* w7 Q0 E& y# w# J) i( u
sis has been given to neuroradiologic imaging in; U" w* j/ A i5 ?* ~% r
boys with precocious puberty. In addition to viril-* Q" S; w% C- Q% x* [. u
ization, the clinical hallmark of CPP is the symmet-2 v* a! A7 h2 r9 j4 P% R
rical testicular growth secondary to stimulation by0 t% R* \ Z0 Z8 r7 J9 ~5 Z
gonadotropins.1,3) n9 H! g7 J/ S
Gonadotropin-independent peripheral preco-
# v1 N5 g7 G9 T, ycious puberty in boys also results from inappropriate1 V9 G7 R& e( s* r% z' O$ @
androgenic stimulation from either endogenous or
& a3 d- f! H- y# o7 W* Texogenous sources, nonpituitary gonadotropin stim-1 q: d* X% H$ W$ V
ulation, and rare activating mutations.3 Virilizing6 G' k) d( y; l0 }5 Z7 o0 s
congenital adrenal hyperplasia producing excessive1 C9 }( g) F: {' z
adrenal androgens is a common cause of precocious
: ~# j) ]) p) {% tpuberty in boys.3,4
$ f7 P2 ?5 V0 UThe most common form of congenital adrenal
, x/ f3 ~! O, K- \hyperplasia is the 21-hydroxylase enzyme deficiency.
" W) y3 a- A U2 u! ]8 w, HThe 11-β hydroxylase deficiency may also result in' h! S/ Y+ U' c v; y& B- o4 f
excessive adrenal androgen production, and rarely,) S! X) H& r+ M2 n7 n% o* I
an adrenal tumor may also cause adrenal androgen
2 d2 m! \! H( ]% M* ]* N- G: E5 `: \excess.1,38 Y- u7 e6 q+ Z- ~) M% O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 Q' R+ B" X2 i! p542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& g2 ]3 s8 ]# Y1 E) U6 h
A unique entity of male-limited gonadotropin-
X) d: X( J- O6 \' E/ @; Dindependent precocious puberty, which is also known
: B: r6 z, f, T' z3 ^as testotoxicosis, may cause precocious puberty at a6 U, s8 e1 G2 P8 X8 |. X8 \- q8 g
very young age. The physical findings in these boys
0 @# z# b; h( P0 q# v/ lwith this disorder are full pubertal development,
; Z1 p- h3 h. n$ c+ T4 aincluding bilateral testicular growth, similar to boys2 J) Z# ~0 `! A/ K
with CPP. The gonadotropin levels in this disorder
1 `4 U- v; y9 o7 N0 Bare suppressed to prepubertal levels and do not show& w) L h0 {1 v3 `+ `8 z, ~
pubertal response of gonadotropin after gonadotropin-5 |/ n1 k6 {' H4 J9 H5 r6 V. s
releasing hormone stimulation. This is a sex-linked
+ E% P h* P: ?- L9 Qautosomal dominant disorder that affects only
# k t" P3 }2 v; s' I0 W' a' s3 L/ b9 S5 Dmales; therefore, other male members of the family1 t4 u' x) @# b7 l" e
may have similar precocious puberty.32 S- N' S2 ?0 O/ O& F4 \9 s
In our patient, physical examination was incon-
0 H i- J6 v; X) \" U5 Tsistent with true precocious puberty since his testi-
) \- H2 Z( H# `' Ccles were prepubertal in size. However, testotoxicosis
4 j J& h k1 T o' T6 U" |was in the differential diagnosis because his father
" h4 I( J" k" N% M! l! h( y: Mstarted puberty somewhat early, and occasionally,0 P- O) \7 R+ _" ^, N
testicular enlargement is not that evident in the% _& G0 d1 B- k4 h) q, f
beginning of this process.1 In the absence of a neg-
. ^0 I+ d8 b4 V! z: `1 D; g" qative initial history of androgen exposure, our
" T; R8 i4 h- b6 Kbiggest concern was virilizing adrenal hyperplasia,
% e, e i% _7 A3 G+ m3 n' xeither 21-hydroxylase deficiency or 11-β hydroxylase2 }% u% l' m! g, {5 S( L$ Z* Y
deficiency. Those diagnoses were excluded by find-8 H7 g, m9 @4 _% ^2 G
ing the normal level of adrenal steroids.
7 ]* D3 n% d# i# z) {! D. vThe diagnosis of exogenous androgens was strongly& u, e: i! u. O- f, T- ^. ~
suspected in a follow-up visit after 4 months because
! t3 y8 J% _6 ]the physical examination revealed the complete disap-$ R% Y/ e+ p# Q6 [, Y( V, C
pearance of pubic hair, normal growth velocity, and7 Y: ]9 T0 B2 l9 ?) w5 y, x
decreased erections. The father admitted using a testos-) O( {( V2 H+ {. k% H9 h
terone gel, which he concealed at first visit. He was
( U: L: g" J' P2 Jusing it rather frequently, twice a day. The Physicians’
( E3 q+ J+ f0 oDesk Reference, or package insert of this product, gel or
4 E4 w5 p7 j( t; C j- Zcream, cautions about dermal testosterone transfer to
! }8 r' ], \& d7 `( Sunprotected females through direct skin exposure.2 J5 B% t9 R! i2 t
Serum testosterone level was found to be 2 times the
; Z9 z# }3 t3 _4 N+ G5 j" R7 }baseline value in those females who were exposed to4 q' P/ J8 q, |) B% ?- d
even 15 minutes of direct skin contact with their male
8 P# f# {$ E0 L% a/ U( q4 _partners.6 However, when a shirt covered the applica-# K6 V% b, g$ a3 H2 t/ [; B
tion site, this testosterone transfer was prevented.
5 s9 K/ m& P6 d8 d7 R! tOur patient’s testosterone level was 60 ng/mL,0 ^, V% }- G' f. v$ P3 p
which was clearly high. Some studies suggest that
0 K7 ~ y' X. Z6 E) f; ]; N% Vdermal conversion of testosterone to dihydrotestos-( a* V8 z' T, T0 ^! U6 l4 ]: h0 Q
terone, which is a more potent metabolite, is more
* [- ]; o- M Hactive in young children exposed to testosterone q) t }5 M0 s+ Y/ l* D% F# x
exogenously7; however, we did not measure a dihy-2 e+ ]3 q+ T2 k0 @. @: h1 _( i+ d4 E
drotestosterone level in our patient. In addition to' K5 \/ X9 y, C& H
virilization, exposure to exogenous testosterone in6 a! Q3 H4 A6 R2 p# o& n
children results in an increase in growth velocity and
5 v, u( i8 k/ z4 `" Zadvanced bone age, as seen in our patient.; g( ^/ k- U- E" O
The long-term effect of androgen exposure during& | s @* j, l& h
early childhood on pubertal development and final
, W& w$ O4 [9 B6 s; r/ g; y# |adult height are not fully known and always remain
$ C; U6 r0 V( Da concern. Children treated with short-term testos-
% T* }; d7 ~2 B1 r' F* Z& V# Vterone injection or topical androgen may exhibit some) q( l6 V* R; S. T
acceleration of the skeletal maturation; however, after
% n- X% Q! X( p* Q# e/ dcessation of treatment, the rate of bone maturation7 v" X `0 a8 h; ?* ^
decelerates and gradually returns to normal.8,90 e( A8 V0 p5 w5 R
There are conflicting reports and controversy
, p+ ?! H: I% z: e9 n/ c' Kover the effect of early androgen exposure on adult$ F& u+ Z) @8 l2 A+ J
penile length.10,11 Some reports suggest subnormal
) n# D1 U" `: {5 ladult penile length, apparently because of downreg-: D( H; W% p4 @; a4 L
ulation of androgen receptor number.10,12 However,1 E9 Z1 }; l4 h# M3 _, f( s
Sutherland et al13 did not find a correlation between& P( g! t5 K6 U( L
childhood testosterone exposure and reduced adult
/ Z, P7 K: @0 d; j7 R2 }1 c0 K% |6 s, k/ ?penile length in clinical studies.9 V4 Q( s& v: D
Nonetheless, we do not believe our patient is" z u/ A5 ]% i: w Y
going to experience any of the untoward effects from
- H. Q1 ^& p, m) G2 Qtestosterone exposure as mentioned earlier because
! Z0 J u8 b; O; N2 n$ a! cthe exposure was not for a prolonged period of time.+ g( R( _' U5 @$ C
Although the bone age was advanced at the time of/ V+ W0 Y8 m. e) b# x% p+ n
diagnosis, the child had a normal growth velocity at& D* }. L9 o G$ ~
the follow-up visit. It is hoped that his final adult5 b. R& |2 ]7 `5 n6 k
height will not be affected.7 p9 ^$ [' e& u2 D2 z! |
Although rarely reported, the widespread avail-8 ~1 Z9 d8 |) {( T# J
ability of androgen products in our society may( y4 f& v" _9 ~. r( x! N) d
indeed cause more virilization in male or female2 \( k( |) D4 z( A
children than one would realize. Exposure to andro-
8 a% {. a" n7 vgen products must be considered and specific ques-
4 V7 S/ m+ [ I: gtioning about the use of a testosterone product or
8 k% r: ^; P' Y7 F Jgel should be asked of the family members during: j! S) C4 l3 ]) \, l' S& K0 G
the evaluation of any children who present with vir-+ V* E, g% L8 {2 {/ t
ilization or peripheral precocious puberty. The diag-
4 x+ u+ N; | nnosis can be established by just a few tests and by# o# P. s# t% X" J8 O, Z) D8 X
appropriate history. The inability to obtain such a
0 V- q3 |, s: A, thistory, or failure to ask the specific questions, may
: G6 }; ~) \5 c2 Y! \6 h' Nresult in extensive, unnecessary, and expensive
4 \% N; f9 j% \( z5 c- m J/ Xinvestigation. The primary care physician should be' z& }* U l8 W1 ?( `6 j) {7 D
aware of this fact, because most of these children1 ?6 r& N& }# a$ B( F' U
may initially present in their practice. The Physicians’, p2 p4 w; o9 X6 H& ]) _. z
Desk Reference and package insert should also put a
! ?, p" p/ H" }1 v4 [# E& Pwarning about the virilizing effect on a male or
& V# p- {7 K. k! |$ efemale child who might come in contact with some-
' E$ Y6 N, F- N2 D. k1 _2 r0 Gone using any of these products. m. V3 }& D" v& ^. z1 t8 k
References- q8 u9 Y; V$ |" h
1. Styne DM. The testes: disorder of sexual differentiation. Y b9 W' K$ m# p6 _1 T
and puberty in the male. In: Sperling MA, ed. Pediatric
" D9 m( y- c- HEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;# P5 R( a, m' n% P' g& A
2002: 565-628.5 c; C2 f' h' A8 l3 X2 u2 ~
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; x# }: F! G) w% r4 C5 l
puberty in children with tumours of the suprasellar pineal |
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