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Sexual Precocity in a 16-Month-Old% H- F, q2 ?' Z# C
Boy Induced by Indirect Topical
- u2 s+ ]0 g) o2 ^ H6 TExposure to Testosterone
# |( G0 k/ u: H7 r I z, ]Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& g m( _& S5 p1 P/ B8 f- wand Kenneth R. Rettig, MD1& p/ H; _! h$ b* f) O$ [- g
Clinical Pediatrics
2 p. }. X- l/ Z* a1 K9 U7 ZVolume 46 Number 67 v* e5 ]0 G( J$ H" d% f; n
July 2007 540-543) R `" B( G X
© 2007 Sage Publications6 {% m8 u1 f6 w* P" Y7 W
10.1177/0009922806296651( {8 _1 ^! r; h/ o5 i; i
http://clp.sagepub.com
3 I, ]6 U5 n% m0 f5 R4 uhosted at
) u1 s! i4 S7 Y2 ?http://online.sagepub.com
$ @9 w1 Z# h$ J" G" U3 b' B) `Precocious puberty in boys, central or peripheral,' }! ~. D, h; W% \0 b G; N
is a significant concern for physicians. Central
5 }9 p' f, j. @) M2 eprecocious puberty (CPP), which is mediated+ }" n0 Y; S( R# n' k
through the hypothalamic pituitary gonadal axis, has- S6 D R, u, }
a higher incidence of organic central nervous system
: I. Z7 }- {% K! Tlesions in boys.1,2 Virilization in boys, as manifested
5 J' I Q, A. k/ W. `by enlargement of the penis, development of pubic
9 j' k5 [2 d! h; A# Y0 Bhair, and facial acne without enlargement of testi-
; d' q1 p. C! X) g2 Gcles, suggests peripheral or pseudopuberty.1-3 We
4 D) B! C- F4 z; [0 h( e$ creport a 16-month-old boy who presented with the) k2 y5 X: P6 A- k* I
enlargement of the phallus and pubic hair develop-* a+ N1 ]# a7 c
ment without testicular enlargement, which was due
0 k ~+ h2 ?% y1 t2 ito the unintentional exposure to androgen gel used by
, y; v3 E1 o% y( s- }! Qthe father. The family initially concealed this infor-/ ?/ G3 F7 V0 [0 l" j& }0 R& g
mation, resulting in an extensive work-up for this
1 b- D4 v) o, q( q+ p' M/ j; e/ r3 Echild. Given the widespread and easy availability of# q# X9 Y$ n- z# b( P0 S
testosterone gel and cream, we believe this is proba-
1 y' A7 P4 M0 B+ l# {bly more common than the rare case report in the
5 v" O' o$ o+ V0 Y8 Z; _. Sliterature.4( Y+ N: H$ y7 i% b( J+ I5 C
Patient Report$ E) x9 ]7 q4 s; j: X9 e `
A 16-month-old white child was referred to the
7 j+ b, R5 m0 ?2 n# X) Lendocrine clinic by his pediatrician with the concern0 e' a W# P# X1 t6 P! C1 t
of early sexual development. His mother noticed
" B/ O7 f0 O' A! h3 k8 i, g% A# ~light colored pubic hair development when he was6 m5 g# j4 V1 k
From the 1Division of Pediatric Endocrinology, 2University of" ~/ {% y& ^4 T; z* c; {7 t' Y
South Alabama Medical Center, Mobile, Alabama.8 `. z3 D) b- f2 Z X1 o
Address correspondence to: Samar K. Bhowmick, MD, FACE,' Z$ O# j4 B, g8 }* M5 d, ~. X
Professor of Pediatrics, University of South Alabama, College of
$ P% @4 N# o# e/ o8 HMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 N2 X* P+ V2 h4 f e
e-mail: [email protected].5 H& Z4 u4 w3 s0 @7 U2 W
about 6 to 7 months old, which progressively became/ d' ]# c1 g N& F0 @) Z8 G( G
darker. She was also concerned about the enlarge-% [' e# C* C3 [. Z+ j( l9 b& v5 V
ment of his penis and frequent erections. The child3 e' ]0 G/ W$ \8 m" `, i
was the product of a full-term normal delivery, with
6 \& Z* |8 _2 ?, I$ X) v3 U9 T! x0 ja birth weight of 7 lb 14 oz, and birth length of
$ B! x T" V. o, v j20 inches. He was breast-fed throughout the first year
5 w1 T$ M) u9 Tof life and was still receiving breast milk along with
( j2 T; C8 ~8 U; `% }7 Zsolid food. He had no hospitalizations or surgery,! [% [. T- I9 C. _1 z8 Y, r
and his psychosocial and psychomotor development7 g6 {4 v. W) V. o
was age appropriate.* j( J$ i' L5 Q
The family history was remarkable for the father,$ t# K- K3 F9 g, u3 P# E: e5 a
who was diagnosed with hypothyroidism at age 16,
; a5 I* I: I" Z( Pwhich was treated with thyroxine. The father’s
. A8 e. _8 X3 I; w5 q/ I: pheight was 6 feet, and he went through a somewhat
6 s$ i" ~: k5 m1 W7 f) p3 I) aearly puberty and had stopped growing by age 14.
8 _& E& s4 N; m, ?0 rThe father denied taking any other medication. The
2 k/ X% v( q2 {3 y: m* Cchild’s mother was in good health. Her menarche
) D4 O/ c8 b$ B# o0 Jwas at 11 years of age, and her height was at 5 feet
2 f1 M7 o6 a6 y! h, m! q5 inches. There was no other family history of pre-& C9 Q0 O; r1 {0 d5 \
cocious sexual development in the first-degree rela-
4 g i( P8 l* J* w8 e/ Jtives. There were no siblings.# B" `7 C% V, R5 t! F
Physical Examination- K' C) d, ~* W6 n6 y
The physical examination revealed a very active,6 J- z3 v H4 p5 a7 C. w6 J/ G
playful, and healthy boy. The vital signs documented
9 L3 j$ W' `" Z8 va blood pressure of 85/50 mm Hg, his length was
9 | t: c$ d% H4 n4 e: C90 cm (>97th percentile), and his weight was 14.4 kg+ ?+ G( K: W% t9 v
(also >97th percentile). The observed yearly growth
) e% @2 g5 K: j. F# svelocity was 30 cm (12 inches). The examination of, [6 b. f' {6 i g! X
the neck revealed no thyroid enlargement.
/ E3 o9 d/ U Y/ }% EThe genitourinary examination was remarkable for% j. U. w/ J; U* s
enlargement of the penis, with a stretched length of7 p2 k6 i( T# G6 ?, z
8 cm and a width of 2 cm. The glans penis was very well
3 o2 ?# e3 t' z& ~developed. The pubic hair was Tanner II, mostly around
! r: ]7 _6 z8 l l0 J; L5403 h3 }6 `2 t* U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: B% x* M7 c V7 [
the base of the phallus and was dark and curled. The, x* m7 b0 @( F
testicular volume was prepubertal at 2 mL each.
5 @$ n, C: N5 B/ P8 |The skin was moist and smooth and somewhat
' L6 j( ?# I$ _: }oily. No axillary hair was noted. There were no3 W2 \- x8 X- r8 c
abnormal skin pigmentations or café-au-lait spots.
- t6 o$ w' t# R) N- J1 o( o) |Neurologic evaluation showed deep tendon reflex 2+
! p2 B, F% m4 ?+ X7 D" ebilateral and symmetrical. There was no suggestion& F1 _0 j( i; U
of papilledema.$ }: ]/ @5 d/ F& ^4 C
Laboratory Evaluation
. N. I3 y# x; v' ^: XThe bone age was consistent with 28 months by
& \& a/ ]6 {9 iusing the standard of Greulich and Pyle at a chrono-, M2 z# b8 l+ ?+ L, a5 a
logic age of 16 months (advanced).5 Chromosomal6 t2 P' \4 @+ i% V3 @6 f
karyotype was 46XY. The thyroid function test
2 N) Y' }" \1 \; t7 Nshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
! }0 `4 E4 P. j: g! N0 E5 X1 R% Mlating hormone level was 1.3 µIU/mL (both normal).
9 B' ~+ w5 {" l2 U6 |) iThe concentrations of serum electrolytes, blood0 j0 w8 [/ L8 C6 R' X
urea nitrogen, creatinine, and calcium all were9 ^9 G' A" T) j# f2 g* }
within normal range for his age. The concentration
- G! r, {1 d: ~3 Eof serum 17-hydroxyprogesterone was 16 ng/dL9 `+ r+ e# N0 L( B$ a
(normal, 3 to 90 ng/dL), androstenedione was 205 {* N0 m+ U% g2 @
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' [5 Y8 q* j0 R1 K4 |terone was 38 ng/dL (normal, 50 to 760 ng/dL),( O Z; i0 c7 b( x- @3 s' i
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ T# k i$ i7 P* w; w5 @- H; h49ng/dL), 11-desoxycortisol (specific compound S)
2 ^4 d& _( h: F4 A" e6 Swas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 A/ q. _$ `* F0 i Ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 k4 k, R1 g a: F+ ?* L( r+ @
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 r1 g8 Y, j; v! T5 H2 s
and β-human chorionic gonadotropin was less than* K+ p# O3 x: ~/ ^" x
5 mIU/mL (normal <5 mIU/mL). Serum follicular; p" @6 }9 d0 T, X
stimulating hormone and leuteinizing hormone
) p, X7 Y* y4 z x8 G7 Zconcentrations were less than 0.05 mIU/mL2 m9 o/ [" F7 f2 [& O" a2 E- ] U
(prepubertal).
8 ~2 t3 L0 F5 D' q1 iThe parents were notified about the laboratory
8 ]! ^9 o9 A8 s: F2 eresults and were informed that all of the tests were+ l! v6 o5 o. H2 I' G" Z
normal except the testosterone level was high. The
/ k b8 T. _; t/ J* p2 w' _' ifollow-up visit was arranged within a few weeks to7 s) o3 L! i, J% ]$ Q
obtain testicular and abdominal sonograms; how-( b$ X9 r4 u& b* _
ever, the family did not return for 4 months.
2 h7 O: r a& n2 C b7 }Physical examination at this time revealed that the
5 I5 Q1 @4 w' l g1 nchild had grown 2.5 cm in 4 months and had gained+ L% G' V' n6 i' b1 ?
2 kg of weight. Physical examination remained
) U& b) j2 H' M% zunchanged. Surprisingly, the pubic hair almost com-1 E2 w- @ v9 p' q
pletely disappeared except for a few vellous hairs at
6 I$ e3 f( O; P1 Fthe base of the phallus. Testicular volume was still 2* K, V+ B$ F6 x0 r( {* X
mL, and the size of the penis remained unchanged.
$ W( {: s3 C7 q. z! R% w a v+ FThe mother also said that the boy was no longer hav-
8 P2 h4 f1 J; H+ a+ g: Aing frequent erections.6 o* n; {: w, x6 Z. h" v
Both parents were again questioned about use of! A# q# J: E/ j3 R- y
any ointment/creams that they may have applied to
& l. K8 x) D% r- E1 m2 Ethe child’s skin. This time the father admitted the& U; X. f1 _1 `! Z+ e4 t
Topical Testosterone Exposure / Bhowmick et al 541+ X7 ]+ [0 k8 l; E* N3 l1 n3 E$ D, {. ]
use of testosterone gel twice daily that he was apply-
: C+ s9 P( a) u2 r9 U/ Aing over his own shoulders, chest, and back area for
8 |9 X- S X) ]. O+ }% \a year. The father also revealed he was embarrassed* }$ J8 A# M \; V' |
to disclose that he was using a testosterone gel pre-
# J3 z% D8 T9 _* A& zscribed by his family physician for decreased libido' X( ?0 C/ f+ ^% E% d, M' x8 H/ ]
secondary to depression.& \% h+ f3 F; W
The child slept in the same bed with parents.
/ _8 b+ K( x7 H$ tThe father would hug the baby and hold him on his; w$ _1 N/ u c& J& B( o
chest for a considerable period of time, causing sig-
* O1 g) H4 U$ U( l( D* Rnificant bare skin contact between baby and father.
1 Q5 V/ f7 i" ^0 g9 S& k3 @The father also admitted that after the phone call,
. g$ q @9 x' j$ n! Y5 Ewhen he learned the testosterone level in the baby2 _8 E' g0 X j+ i7 Y5 I
was high, he then read the product information
* ~! d3 v4 K; G+ P+ i1 [& k% Tpacket and concluded that it was most likely the rea-
$ j1 W5 h' Q* }0 F/ pson for the child’s virilization. At that time, they
% b/ ^5 I& \; k6 Q0 N+ Q zdecided to put the baby in a separate bed, and the
$ D: W: i8 Z* Cfather was not hugging him with bare skin and had
) o. ` I8 [7 hbeen using protective clothing. A repeat testosterone
' W2 x4 P* j9 `/ N# I! Q; Qtest was ordered, but the family did not go to the
3 ?& H1 ?# E$ j0 Z' llaboratory to obtain the test.
) V2 ^7 Q1 F% d! O2 _% G) ^5 qDiscussion
' g8 n( f: o8 l! lPrecocious puberty in boys is defined as secondary
5 K7 m1 {1 _ s/ _sexual development before 9 years of age.1,4
) n& m7 s p4 X3 h! d! uPrecocious puberty is termed as central (true) when/ c3 j" K2 R; [$ _5 h# ?6 A# b
it is caused by the premature activation of hypo-
7 a h/ n, J$ e d, h1 Lthalamic pituitary gonadal axis. CPP is more com-
) b9 X( N& D; P' z( q( d# Nmon in girls than in boys.1,3 Most boys with CPP, B$ e- t% U Y1 n
may have a central nervous system lesion that is
" Y D, P+ w3 M& n- Hresponsible for the early activation of the hypothal-" z# m- u; F; G2 m. K4 h
amic pituitary gonadal axis.1-3 Thus, greater empha-2 ~" j( S4 Z8 g& d: T8 C7 n
sis has been given to neuroradiologic imaging in
: T+ d# z) T& B; ]# {- \( q6 Oboys with precocious puberty. In addition to viril-/ y( U% C1 c2 Y5 W$ G
ization, the clinical hallmark of CPP is the symmet-
. S a3 ^* N' \" a! Z8 ~6 J/ A% [rical testicular growth secondary to stimulation by
9 `/ L- e; a& H1 W _+ Sgonadotropins.1,3
4 o i! z& Y* ?! K& e7 lGonadotropin-independent peripheral preco-+ W7 j& P, x, Z8 o+ r# D
cious puberty in boys also results from inappropriate
( D9 f% @5 F5 n7 _% F! iandrogenic stimulation from either endogenous or
0 ^) q+ J- a, w" i9 f& V+ \exogenous sources, nonpituitary gonadotropin stim-+ b# i0 d* e$ ]1 R( P1 N9 `
ulation, and rare activating mutations.3 Virilizing
2 e8 f6 v. E" n3 X: V4 g: n0 scongenital adrenal hyperplasia producing excessive* C; F* I' h' z: W! z7 x9 d0 `4 N
adrenal androgens is a common cause of precocious
' J" H! t5 q9 X; ~( c7 T7 Upuberty in boys.3,4
5 E n: @" E) e5 a, BThe most common form of congenital adrenal
' l9 y' G2 ^# v4 l6 n- r9 ~hyperplasia is the 21-hydroxylase enzyme deficiency.
- U: e2 M. ?- x$ x4 [) hThe 11-β hydroxylase deficiency may also result in
' U1 `2 @9 ^5 Z0 u4 `excessive adrenal androgen production, and rarely," V0 I1 R" _8 w
an adrenal tumor may also cause adrenal androgen
! S2 y9 s8 Y) K0 y5 _% l; Sexcess.1,3- m# V& T$ U+ U0 p) l
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! } ?; L1 o3 O* k {542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ u/ Z- G' h- c9 s; N/ o" u1 p; O
A unique entity of male-limited gonadotropin-
; ~, n, |1 W6 R3 Q6 `. Windependent precocious puberty, which is also known7 \& L6 |$ E2 C0 p. v/ ?; H; `" j
as testotoxicosis, may cause precocious puberty at a& n8 }' x+ L G$ L8 W5 h
very young age. The physical findings in these boys# |! U1 f `) n0 n
with this disorder are full pubertal development,
/ G7 J* _4 P$ Y p: d$ ?; E4 k; _( m0 Kincluding bilateral testicular growth, similar to boys
7 B, S: O' A4 M+ }$ i( V6 ywith CPP. The gonadotropin levels in this disorder" d0 i3 w+ H5 q2 _+ a
are suppressed to prepubertal levels and do not show- ]2 q, |& Q* M j
pubertal response of gonadotropin after gonadotropin-# k+ H( T' \+ V% o0 A( M G5 N m% v% ^
releasing hormone stimulation. This is a sex-linked4 G/ ]6 G0 q5 ^7 {5 y
autosomal dominant disorder that affects only+ k* H N+ G0 {8 Y- K6 {
males; therefore, other male members of the family0 K' Q9 [- |- f0 E
may have similar precocious puberty.35 L1 P5 H/ z. E. h; R3 X
In our patient, physical examination was incon-5 y5 H& f* F8 V& E. ~
sistent with true precocious puberty since his testi-
, S/ F; p# B4 N( \6 w- T$ `cles were prepubertal in size. However, testotoxicosis- T6 Q5 R6 p. M
was in the differential diagnosis because his father
2 m0 _# L. Q, Wstarted puberty somewhat early, and occasionally,- @2 A+ e3 V3 I8 A0 D
testicular enlargement is not that evident in the# `/ X N0 R$ P: U3 ]* v# U
beginning of this process.1 In the absence of a neg-% k$ @4 U7 w; ^% V) F
ative initial history of androgen exposure, our
8 h3 b" v1 v+ w9 L, r6 Q9 Vbiggest concern was virilizing adrenal hyperplasia,
# N! @& r/ u0 l3 [2 ceither 21-hydroxylase deficiency or 11-β hydroxylase
* n4 |! }2 e& ddeficiency. Those diagnoses were excluded by find-$ @' j, ^5 s' T/ F
ing the normal level of adrenal steroids.
( N; Q' S+ Y0 B9 Y/ f* I) |3 XThe diagnosis of exogenous androgens was strongly
9 }6 L- j4 ]) ^" ^3 M( n( Zsuspected in a follow-up visit after 4 months because$ z$ g5 F$ S/ v: J! [
the physical examination revealed the complete disap-
4 [" x. i1 ?9 ?) P, s6 e+ K e% `6 vpearance of pubic hair, normal growth velocity, and
9 k/ P; f- e" n2 Gdecreased erections. The father admitted using a testos-
7 x3 q+ @2 L! M; aterone gel, which he concealed at first visit. He was
# D ?4 E# Y! V7 l4 t, Xusing it rather frequently, twice a day. The Physicians’
) r: |3 u* f/ o; l% ]Desk Reference, or package insert of this product, gel or
* T) @! u% _* S$ Qcream, cautions about dermal testosterone transfer to/ g( V- g- Q! j3 I0 U9 K( I
unprotected females through direct skin exposure.
) N0 Q% F1 T$ \+ {* v3 VSerum testosterone level was found to be 2 times the
+ |3 `; l- t& W: H& l. ?5 l: ybaseline value in those females who were exposed to
0 _9 a) Z8 k6 m2 e deven 15 minutes of direct skin contact with their male
, K9 ~; n$ p1 F' X- ` q$ Ppartners.6 However, when a shirt covered the applica-
1 p* n; |- t( a) h7 Q, Rtion site, this testosterone transfer was prevented.
7 R: Y$ z' i% b* bOur patient’s testosterone level was 60 ng/mL,
3 z: ^& r! |& H, L1 vwhich was clearly high. Some studies suggest that: i: f3 k' u K4 _4 E) [2 b, L
dermal conversion of testosterone to dihydrotestos-2 c- f: T4 b0 k, A! F
terone, which is a more potent metabolite, is more
e6 l2 H; l1 _) x4 p( z( Factive in young children exposed to testosterone
+ i( ^6 K7 P5 o9 hexogenously7; however, we did not measure a dihy-
" S) v( B9 Q6 n) jdrotestosterone level in our patient. In addition to
( n# r" f7 I a) s4 r8 l# d: uvirilization, exposure to exogenous testosterone in
9 {8 O7 P$ p: Z3 J! Uchildren results in an increase in growth velocity and
5 i& P8 X$ x8 z& _advanced bone age, as seen in our patient.; j3 ?9 \: g$ S1 ~ e; J! j
The long-term effect of androgen exposure during ~8 V# l, D- E0 {) b
early childhood on pubertal development and final) o! Q, P. l2 B8 \4 n; \
adult height are not fully known and always remain
2 y7 p# F9 A! _) ^: Fa concern. Children treated with short-term testos-, s) E3 D$ q# D2 Q6 y: R
terone injection or topical androgen may exhibit some
: B8 S% w) O0 A0 z0 q$ Cacceleration of the skeletal maturation; however, after
0 N* o8 |. J& \ s, Ncessation of treatment, the rate of bone maturation8 x" N8 e2 D* U& {: W
decelerates and gradually returns to normal.8,9
. ~- F% n6 L# X6 r- _) H" E- f* RThere are conflicting reports and controversy
$ v9 U8 r- C2 _5 P9 x0 aover the effect of early androgen exposure on adult
" A* y9 U7 [7 X+ q4 v8 J% jpenile length.10,11 Some reports suggest subnormal9 B) x7 v! @" p% ^, Z0 h) `
adult penile length, apparently because of downreg-" w X! T& S; }* B
ulation of androgen receptor number.10,12 However,
; y) z8 W6 Q5 W; H( tSutherland et al13 did not find a correlation between
' U# q, q. C+ Q& [' R9 D8 |childhood testosterone exposure and reduced adult) z! M$ V, f. f; Z
penile length in clinical studies.4 I& ^6 y/ J% |# M8 P
Nonetheless, we do not believe our patient is& R& r7 C# n+ v
going to experience any of the untoward effects from
1 I- B3 u6 o. u0 k2 p8 O) Btestosterone exposure as mentioned earlier because" v `# A5 F' c+ t0 ~
the exposure was not for a prolonged period of time. F: B% n! k. h$ U
Although the bone age was advanced at the time of
0 w# M) ~5 J1 m9 x9 w# ldiagnosis, the child had a normal growth velocity at' i# B& y' R; t
the follow-up visit. It is hoped that his final adult* D$ v+ G4 P% x; L
height will not be affected.
# g8 m) y% h C1 Y- C& X5 ?% rAlthough rarely reported, the widespread avail- c$ `0 e3 V1 C# e6 ?2 V
ability of androgen products in our society may, R h, [3 v5 }2 ^0 {
indeed cause more virilization in male or female/ w0 F7 ?& }( ]1 S3 \5 L! y
children than one would realize. Exposure to andro-4 ?# I3 B8 v2 y/ c: `* L) R5 K% K
gen products must be considered and specific ques-) | c8 [; K* s: M3 A
tioning about the use of a testosterone product or8 y. V% S) f: j1 I' g' L+ r. |4 r
gel should be asked of the family members during6 h# }2 e1 p4 Z2 m
the evaluation of any children who present with vir-
3 w5 e, K7 W1 X: |ilization or peripheral precocious puberty. The diag-
7 F: q( u3 P, }8 gnosis can be established by just a few tests and by: l- R* l( f/ I7 ?, j
appropriate history. The inability to obtain such a
& t& O f) |1 ?, _history, or failure to ask the specific questions, may
2 f" {7 J7 v* n) H* F! Xresult in extensive, unnecessary, and expensive
* H7 c( i! V4 P0 ?5 q r& [/ N+ yinvestigation. The primary care physician should be4 r( N3 H# Z% S6 c4 S, Z$ u" V
aware of this fact, because most of these children
( y- m* v" j3 a- Ymay initially present in their practice. The Physicians’# q) N( v; ~ P
Desk Reference and package insert should also put a
" F. ?1 J$ ^) X, I4 f& b P* Bwarning about the virilizing effect on a male or7 Y# v' ^2 R4 X0 f$ _
female child who might come in contact with some-$ y! P" c' s R X- N
one using any of these products.
8 r& ]- r5 S" s2 I6 QReferences! \. B8 Z/ o/ [; ]- K. z
1. Styne DM. The testes: disorder of sexual differentiation
( w. K4 Y2 {( v6 y+ j% Aand puberty in the male. In: Sperling MA, ed. Pediatric( P# w- S1 a+ ~1 n5 T
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 ?4 U7 m+ e l9 f1 u# q: @2002: 565-628.
( F' h3 _! k9 d# y5 T+ i2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 o9 F- ?* l5 J: F
puberty in children with tumours of the suprasellar pineal |
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