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Sexual Precocity in a 16-Month-Old# c4 L/ @* q& j; q# u6 n
Boy Induced by Indirect Topical: |: Y r# G# a' ^! g+ s
Exposure to Testosterone
! A+ w- g/ Z! @$ s, _. q7 t' U) v8 gSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# f7 Y' I. Y5 j2 q+ M1 E
and Kenneth R. Rettig, MD1. f5 ^6 w, S9 b/ b' l) W* m
Clinical Pediatrics; d( |' W9 S4 {) x" X
Volume 46 Number 6
1 H: u1 p3 k( _July 2007 540-543" e* G' w" _1 ~
© 2007 Sage Publications+ I" v# o8 X: W/ g/ o! l) Z
10.1177/00099228062966518 A# d, e& Q. c3 N* O7 H+ a+ E
http://clp.sagepub.com1 o1 K3 s" Z. k
hosted at* |( }& C+ Q6 d; t! G. B
http://online.sagepub.com' B4 F) v# z) z" T0 i# A
Precocious puberty in boys, central or peripheral,
* ^' o) m+ v2 k% tis a significant concern for physicians. Central
+ ]+ k+ T. c/ ]) s0 o) Y$ Kprecocious puberty (CPP), which is mediated2 h% `+ K# i# B6 W$ I5 m( p3 I
through the hypothalamic pituitary gonadal axis, has, Y. s+ B4 j2 F$ |) h9 j
a higher incidence of organic central nervous system
1 S3 Z2 `' K2 e6 E# |1 a5 Llesions in boys.1,2 Virilization in boys, as manifested& J/ |+ h3 \) a. s! T' O% q
by enlargement of the penis, development of pubic
6 J- T* Z! F: |$ w, |' V2 T* I( Uhair, and facial acne without enlargement of testi-
* {, B2 x+ H5 j2 h7 s/ M3 ]cles, suggests peripheral or pseudopuberty.1-3 We
" y4 E& f2 d' _) ] [report a 16-month-old boy who presented with the, M! i4 [0 f3 v, v
enlargement of the phallus and pubic hair develop-
% X* S$ o' n' Ement without testicular enlargement, which was due
$ S$ _& h/ L0 r% `to the unintentional exposure to androgen gel used by3 Z; G7 S; \6 y. E
the father. The family initially concealed this infor-% c6 G; F1 {, o2 ?4 ^% G0 J& [" T
mation, resulting in an extensive work-up for this, Y6 x% b: T1 K) s' U% W* b
child. Given the widespread and easy availability of
& _# P7 ~/ I6 S: ctestosterone gel and cream, we believe this is proba-% U( i/ u; D) @9 ~% q
bly more common than the rare case report in the2 f. T4 p( B5 E& q: `6 c5 I0 M$ I
literature.4* |( @7 M4 {; B: E( J- M- T q
Patient Report
& C6 Y/ K; r& U5 C d+ ~A 16-month-old white child was referred to the
$ P+ R3 u4 @) O) E A2 ^/ vendocrine clinic by his pediatrician with the concern
( T! E% x# T n. p( [* dof early sexual development. His mother noticed
2 g5 d) s) e7 \3 j8 glight colored pubic hair development when he was
' W7 {- h. d( HFrom the 1Division of Pediatric Endocrinology, 2University of
$ G# f9 G' Y1 A9 @7 [% ]5 TSouth Alabama Medical Center, Mobile, Alabama." N% h# _8 f( g, R$ Y6 ^
Address correspondence to: Samar K. Bhowmick, MD, FACE,
- h6 b0 T' c: Z7 U# }Professor of Pediatrics, University of South Alabama, College of
- [+ L( ]! {, _Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 G9 A' A ?& z: l/ ]$ i1 a3 Oe-mail: [email protected].1 _+ _: |. ~" R
about 6 to 7 months old, which progressively became
! a, y7 s: s0 m( K' E; cdarker. She was also concerned about the enlarge-
; K7 f% ~9 U. Q$ Q+ a! }ment of his penis and frequent erections. The child
: w8 t/ s$ _& n# Y Mwas the product of a full-term normal delivery, with. B" Z! B& d0 @& Q Q
a birth weight of 7 lb 14 oz, and birth length of: @3 m6 q/ z/ w5 j! z
20 inches. He was breast-fed throughout the first year
6 r% I- [6 h3 E. s! t* L3 J4 Hof life and was still receiving breast milk along with
; L" r' e$ q$ M% Asolid food. He had no hospitalizations or surgery,! W8 J2 _2 e' R$ _( ]$ N* i; H
and his psychosocial and psychomotor development
' R; ~( o/ [3 X$ P8 k+ x) kwas age appropriate.; D( Y2 H8 `+ ` {' `2 `
The family history was remarkable for the father,
I( {4 V% P. @. H# swho was diagnosed with hypothyroidism at age 16,0 Y& z% u2 W0 l. M" Y
which was treated with thyroxine. The father’s
5 C, X2 Z1 r; Y9 [. lheight was 6 feet, and he went through a somewhat
$ y2 R/ r( g# G% E1 ?early puberty and had stopped growing by age 14.% `; E4 U _; y# c5 x" w( \7 \
The father denied taking any other medication. The; p4 t) Z8 e% r. \
child’s mother was in good health. Her menarche2 v" D1 O4 H1 i% Y% |& @' J
was at 11 years of age, and her height was at 5 feet, g3 B9 v0 W7 V
5 inches. There was no other family history of pre-$ B) Y" {: ]; ~! R2 E
cocious sexual development in the first-degree rela-% Y6 U& o% H! Y# r% ?# q
tives. There were no siblings.9 Z& R# V9 I% A& ?" _/ s# @* E/ d6 [9 E
Physical Examination
; \- j) ~% r# G9 KThe physical examination revealed a very active,4 y- k+ s, k: u; ^" Y: E' B
playful, and healthy boy. The vital signs documented( {- L. q; W9 Y7 z% w- d$ x7 T
a blood pressure of 85/50 mm Hg, his length was
1 g3 E# e0 H5 z9 U( z90 cm (>97th percentile), and his weight was 14.4 kg( e& u- t* R% }3 K" c8 `: H( s
(also >97th percentile). The observed yearly growth
$ l- F( T9 ~/ X3 ~' fvelocity was 30 cm (12 inches). The examination of
! U8 z$ ?, Q' O' Rthe neck revealed no thyroid enlargement.5 T, D+ ?* T: s. n$ f$ ?
The genitourinary examination was remarkable for, k$ |3 w3 F( ^2 Q2 z
enlargement of the penis, with a stretched length of
$ l' T# w0 U X) V8 cm and a width of 2 cm. The glans penis was very well: u) x2 a7 Z7 R
developed. The pubic hair was Tanner II, mostly around# z! r0 [2 m8 G
540& C3 V9 }# M! p8 H9 H4 ^! `& b
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* h! E, T5 o% O; f6 y* s; e( }
the base of the phallus and was dark and curled. The0 a& e; Q7 V x# n' ?! z8 ^! c# a! z
testicular volume was prepubertal at 2 mL each.
1 l/ p; `, N. N% R6 T7 |The skin was moist and smooth and somewhat" K. k+ E) c' n
oily. No axillary hair was noted. There were no
# C W$ w7 s9 _abnormal skin pigmentations or café-au-lait spots.6 G6 o& g5 V3 q
Neurologic evaluation showed deep tendon reflex 2+
+ X2 I; c2 f+ l* S% kbilateral and symmetrical. There was no suggestion
& P& B5 `! }$ a% o8 J/ hof papilledema.
: r, V% ^3 H6 f( U- V4 o) ~Laboratory Evaluation$ _' S, @1 W0 ?& i( F' e8 K
The bone age was consistent with 28 months by. m5 c. V3 i, N. n e
using the standard of Greulich and Pyle at a chrono-
1 \9 J5 y* S1 g* S: vlogic age of 16 months (advanced).5 Chromosomal7 ]# }% Y) r! u0 d0 Y$ @
karyotype was 46XY. The thyroid function test
0 k: |' N7 U# ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-
Y8 f& I5 \5 M& B3 J! ylating hormone level was 1.3 µIU/mL (both normal).
& B3 x9 ]5 c' w% j5 l, \The concentrations of serum electrolytes, blood
$ q4 d$ U% f% ^$ N4 hurea nitrogen, creatinine, and calcium all were
/ ^" J* X6 C6 m. v9 fwithin normal range for his age. The concentration$ D( R# S7 y3 H7 L+ s" o7 D
of serum 17-hydroxyprogesterone was 16 ng/dL2 h* i$ h6 }6 C) e' H# P, O8 t
(normal, 3 to 90 ng/dL), androstenedione was 20 _* \8 K& G! p: P# ]1 O% }
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
z" g- n: X& l# k" d- Dterone was 38 ng/dL (normal, 50 to 760 ng/dL),
3 C% X8 B7 W' z8 j, P% |: C8 tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to4 \- l! U! R6 j. e. @
49ng/dL), 11-desoxycortisol (specific compound S)- x4 d2 V; B* A7 {3 C- i* a
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) F! A; S% N- b* P) m
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 { b6 t* x/ J. v+ y9 ^; C, {
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),# s' y; j L K$ s; d7 B6 _; [% ?
and β-human chorionic gonadotropin was less than$ v/ D2 E& W7 z1 b6 i: {$ H. h6 F* v
5 mIU/mL (normal <5 mIU/mL). Serum follicular
m0 B) x& O% w% r' Lstimulating hormone and leuteinizing hormone
9 ^" s* j$ `: U, \4 W# Hconcentrations were less than 0.05 mIU/mL+ a$ `" N1 Z9 C
(prepubertal).1 n% s7 T2 {) {) h
The parents were notified about the laboratory
' K: G0 J) ]; Xresults and were informed that all of the tests were9 X( r' e: V3 J5 W+ L
normal except the testosterone level was high. The
+ ?/ I- H$ {, h' \ _6 Y1 G2 cfollow-up visit was arranged within a few weeks to
* J+ R7 f/ n4 j+ s8 m- Oobtain testicular and abdominal sonograms; how-
+ v. @$ ?3 X9 M8 O$ y# K* lever, the family did not return for 4 months.
' e- o- p- O7 b6 {- G3 rPhysical examination at this time revealed that the q+ ^- S: u' }
child had grown 2.5 cm in 4 months and had gained
+ b+ Z7 h, N" ?$ ~5 l' f& ^7 j2 kg of weight. Physical examination remained: ^) z' d2 x5 w/ L0 U; ~! b
unchanged. Surprisingly, the pubic hair almost com-
8 ?2 S# k. T3 g. q2 ^" zpletely disappeared except for a few vellous hairs at
+ O* A1 V' y) z$ I+ G: r# L! Zthe base of the phallus. Testicular volume was still 27 c4 y3 a' K) Q5 x
mL, and the size of the penis remained unchanged.
# W$ w8 s. S& m* j# aThe mother also said that the boy was no longer hav-
3 d! |6 Y1 \2 C% hing frequent erections.2 Y+ A2 `( x0 C3 m f
Both parents were again questioned about use of
5 p( G$ y2 {3 K0 M4 P" Y+ eany ointment/creams that they may have applied to9 g0 I# h) Z' A, [6 E
the child’s skin. This time the father admitted the- n9 u# f0 a% L9 O& q* G) L. T
Topical Testosterone Exposure / Bhowmick et al 5412 z6 C7 L5 l4 Q* i5 T
use of testosterone gel twice daily that he was apply-
8 r3 a- d- Q# X% a5 P/ `; Aing over his own shoulders, chest, and back area for5 t8 H: w; u* Y0 {" x1 L, K& t
a year. The father also revealed he was embarrassed! X4 b6 T7 t+ E- p, Z
to disclose that he was using a testosterone gel pre-
# ^3 b5 V# x! z" N# ^scribed by his family physician for decreased libido$ j4 U: ?- O9 p# o4 y c. j5 R1 T0 }
secondary to depression.. t& m' M% Z* e
The child slept in the same bed with parents. R5 |8 u6 w" i1 D" N7 t
The father would hug the baby and hold him on his; ~5 p7 P/ a+ t# b( g
chest for a considerable period of time, causing sig-2 W# ^1 A C* O- e6 f6 Y
nificant bare skin contact between baby and father.
9 s+ S# h, N: b/ wThe father also admitted that after the phone call,
$ ~, V* T3 I3 H) P V6 v* xwhen he learned the testosterone level in the baby
5 O2 ~3 `9 I( |& B0 I6 V l) |was high, he then read the product information8 V, I4 }, M# S; Q
packet and concluded that it was most likely the rea-& s7 \% t( n) V- p* ~( x6 ~9 ~; w
son for the child’s virilization. At that time, they. c C/ O2 X$ q: n2 b% y
decided to put the baby in a separate bed, and the2 Y. k- y& r% ?7 X6 r
father was not hugging him with bare skin and had5 k: _( S1 h0 K8 @! N
been using protective clothing. A repeat testosterone
! e4 {/ z/ K9 K% v2 o& Q2 xtest was ordered, but the family did not go to the
, S2 U u- `! {2 {" I( [laboratory to obtain the test.1 R, \8 \3 i$ E' k
Discussion
! E: W$ G( N: w; JPrecocious puberty in boys is defined as secondary
9 Q( Q* |( m" D$ msexual development before 9 years of age.1,42 D! k- R% O) F; ^, _4 L
Precocious puberty is termed as central (true) when
6 c u: l8 n1 w1 L# mit is caused by the premature activation of hypo-, N& h3 [+ y$ l$ h
thalamic pituitary gonadal axis. CPP is more com-' }/ f! \+ O+ d# Z( i- E$ [6 O
mon in girls than in boys.1,3 Most boys with CPP
+ M& m6 |" U# d, D, ~; q" j, a( r5 vmay have a central nervous system lesion that is
/ }' s/ L* i: A3 c; Y: D4 kresponsible for the early activation of the hypothal-; K- _' z! w) _" [: r
amic pituitary gonadal axis.1-3 Thus, greater empha-
9 D+ \# g: \ s K! ?sis has been given to neuroradiologic imaging in
, ?- a) e5 ^+ ]5 R. vboys with precocious puberty. In addition to viril-0 \8 o1 M* s8 M0 y( ~- s# ~2 U
ization, the clinical hallmark of CPP is the symmet-
# ^' S: w: P! U/ Zrical testicular growth secondary to stimulation by& g9 i7 Z' O" u7 L
gonadotropins.1,3
6 _& |" F1 G2 b! k( v0 J( I" YGonadotropin-independent peripheral preco-- [9 e+ U4 {) p$ e2 q
cious puberty in boys also results from inappropriate
( d& @9 f: p7 @androgenic stimulation from either endogenous or
! I: Q( h* ~8 h2 zexogenous sources, nonpituitary gonadotropin stim-9 o# v4 p. ^1 ]0 r3 Z# x! V) Z8 x
ulation, and rare activating mutations.3 Virilizing2 r* |- x# I! ?9 w* m- A9 Q% L
congenital adrenal hyperplasia producing excessive, y% W$ g: s K# d; d, B
adrenal androgens is a common cause of precocious
- c/ B0 G4 o' R7 D# ~' {& |3 g1 g* Bpuberty in boys.3,4
( G+ Z- F7 C7 G- f8 ]. L# _: B7 VThe most common form of congenital adrenal, V$ b8 C/ H3 ]- a0 K7 |$ ~ ^; W
hyperplasia is the 21-hydroxylase enzyme deficiency.* X: w0 f! W' ~* N& l6 g
The 11-β hydroxylase deficiency may also result in/ i% a$ \0 M/ }. e: E
excessive adrenal androgen production, and rarely,3 J5 B2 z2 ^! g4 W3 N! n, f* R
an adrenal tumor may also cause adrenal androgen
' W5 x( k- d: g! c& pexcess.1,37 \4 D; |7 @2 @4 B; U9 O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, T( p* T9 Q" S* }( i
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ P; I% ~- m6 M$ \A unique entity of male-limited gonadotropin-
9 F7 O" `4 X" Q5 c+ J9 i% {independent precocious puberty, which is also known
& c7 }* Y" u+ `6 I6 a5 ]as testotoxicosis, may cause precocious puberty at a9 U. A2 K, g+ w/ d( w( H* Y
very young age. The physical findings in these boys
) l) q+ {! ~' L" i1 K6 U+ gwith this disorder are full pubertal development,$ B. U$ T: l* ^
including bilateral testicular growth, similar to boys3 J% V4 i! @( Q5 A' O* E
with CPP. The gonadotropin levels in this disorder' c; M' B' P3 r% b) O9 U
are suppressed to prepubertal levels and do not show: Y8 q* I' W2 e' h; a/ Z1 C
pubertal response of gonadotropin after gonadotropin-5 ^! [" b- V! y9 `
releasing hormone stimulation. This is a sex-linked
) w; j' }/ ~/ Lautosomal dominant disorder that affects only3 F; Y, ?8 q) [& B# b3 o7 H2 L% x
males; therefore, other male members of the family
~7 l, I! M: u \" _% X1 v: cmay have similar precocious puberty.3: Z, u! P1 I6 [# c
In our patient, physical examination was incon-7 A4 I. _( T/ F( x8 A
sistent with true precocious puberty since his testi-
* I1 I& J; X8 y) Dcles were prepubertal in size. However, testotoxicosis1 g5 `7 P2 |+ H$ I
was in the differential diagnosis because his father+ p3 T: a/ c# H9 N
started puberty somewhat early, and occasionally,
2 @5 \$ V% A2 E* Stesticular enlargement is not that evident in the
- q3 t" T( }1 `/ n! xbeginning of this process.1 In the absence of a neg-# O# K c8 p0 h( c1 z2 i- |8 y
ative initial history of androgen exposure, our) h' b$ D9 C& ~8 Y4 P
biggest concern was virilizing adrenal hyperplasia,- Z" w; |$ J3 |4 U% n4 f* m
either 21-hydroxylase deficiency or 11-β hydroxylase- p' O* q# _& A2 a8 Z2 Q" O7 p2 m
deficiency. Those diagnoses were excluded by find-
. k" ?, q+ R% F5 [7 ring the normal level of adrenal steroids.% F3 o; f3 D7 V4 M$ E! S/ w" D6 q
The diagnosis of exogenous androgens was strongly& a4 c+ H& N8 V9 x# w* h/ w
suspected in a follow-up visit after 4 months because
) n9 P& o4 r3 R. G2 D4 i8 o. ^7 k1 Wthe physical examination revealed the complete disap-
$ |* F( d9 [$ {/ a; Npearance of pubic hair, normal growth velocity, and" f! K N% h4 I; u% ` @5 O
decreased erections. The father admitted using a testos-
" a1 w6 _5 V n: w' r- nterone gel, which he concealed at first visit. He was% z; R1 S0 B/ e+ h
using it rather frequently, twice a day. The Physicians’ e$ x0 P+ I7 B
Desk Reference, or package insert of this product, gel or
: D" L1 N0 f$ ~0 v3 x, b: Fcream, cautions about dermal testosterone transfer to# V# \; d( N( n n6 O
unprotected females through direct skin exposure.) i1 n1 F* T" h4 Z2 m" M
Serum testosterone level was found to be 2 times the
9 d% g, x, H lbaseline value in those females who were exposed to
6 K" t6 Z/ o* E) S9 Xeven 15 minutes of direct skin contact with their male
]- v4 o0 B0 e, b4 Epartners.6 However, when a shirt covered the applica-
. `* \, g9 X# L7 [0 ytion site, this testosterone transfer was prevented.& b( G6 B+ d Y7 t6 m. _# J1 |1 I
Our patient’s testosterone level was 60 ng/mL,8 R( z* Q! K5 L$ t& `% _
which was clearly high. Some studies suggest that8 {. `# J8 ^# v
dermal conversion of testosterone to dihydrotestos-
9 Q9 L0 j! a; l2 |4 tterone, which is a more potent metabolite, is more
9 j- B8 L2 n4 y# L" g% `active in young children exposed to testosterone: ?" p5 y. X7 c; h3 o% J/ k
exogenously7; however, we did not measure a dihy-' z7 w! V2 z: @, @1 C
drotestosterone level in our patient. In addition to) M/ D; M) H9 r9 J
virilization, exposure to exogenous testosterone in7 N# j0 |4 m2 T" v/ f' g; H. M) m% O
children results in an increase in growth velocity and8 D# o1 C% X2 \8 m/ C. _
advanced bone age, as seen in our patient.
% b) o6 J5 f: M4 R! o" m/ r5 @The long-term effect of androgen exposure during
0 z) t/ {/ P2 F& u, pearly childhood on pubertal development and final
4 ?- l& K! I, O; s# C& Radult height are not fully known and always remain
' Y5 g! {, z3 [& j$ X: t# M8 R9 ba concern. Children treated with short-term testos-
. {8 D* Z7 ^( wterone injection or topical androgen may exhibit some
) F" ~) `* |( J( A3 tacceleration of the skeletal maturation; however, after
& R, ~2 `6 h8 ?# ucessation of treatment, the rate of bone maturation
: A# J x" w/ L9 ?% V x$ adecelerates and gradually returns to normal.8,9: @" W0 h, _- X3 B( t
There are conflicting reports and controversy' N" L6 \ P/ p8 _8 x. {0 q2 n
over the effect of early androgen exposure on adult
+ O) x l5 x& d: F# A* W/ Y0 cpenile length.10,11 Some reports suggest subnormal
9 e+ |* H* X, ~! r. G1 c! D( Wadult penile length, apparently because of downreg-( U! s4 |3 q& l& O3 e
ulation of androgen receptor number.10,12 However,% |8 O7 I, d6 |2 \# W- J# C3 W) A
Sutherland et al13 did not find a correlation between
. L2 Q- j6 ?. H+ P! _* ^childhood testosterone exposure and reduced adult
# |" M$ M4 \/ V8 B( Z# ~6 tpenile length in clinical studies.
5 m$ Y; N0 ?% ?! W1 VNonetheless, we do not believe our patient is
4 R; f3 V# |* }# S, j' x7 V7 ~& `going to experience any of the untoward effects from( U5 z. Q+ F$ b' [# j
testosterone exposure as mentioned earlier because5 h8 K/ F' u" t
the exposure was not for a prolonged period of time.
3 F& Y5 M( A* w5 n+ Z( W ~Although the bone age was advanced at the time of5 D( }# A3 ~8 _( x" e2 F: ~7 C
diagnosis, the child had a normal growth velocity at
: j# C! F8 H+ U, A% Xthe follow-up visit. It is hoped that his final adult
& C; ~4 e5 |0 _9 A2 xheight will not be affected.) e9 ^" h0 ^+ p3 j W( `; {
Although rarely reported, the widespread avail-# E. X9 l7 J& ]4 c
ability of androgen products in our society may5 m1 o$ D! E* H0 G3 E7 N
indeed cause more virilization in male or female
3 @4 e" ^, \% h% [children than one would realize. Exposure to andro-9 q/ h6 _5 J4 b0 l
gen products must be considered and specific ques-
3 _: x/ n! A7 ytioning about the use of a testosterone product or; Q5 J7 {4 L& n2 x q
gel should be asked of the family members during
, f- |* C9 w4 E ?+ Tthe evaluation of any children who present with vir-1 V, k6 E6 @. S; d4 L
ilization or peripheral precocious puberty. The diag-4 X; ~& P0 g( t' L
nosis can be established by just a few tests and by
' L/ i9 k0 R6 M3 R9 ^appropriate history. The inability to obtain such a6 |4 b2 D2 k1 }& `' e
history, or failure to ask the specific questions, may
+ |7 i1 z$ T! N4 M" r3 ?. ^1 gresult in extensive, unnecessary, and expensive. T. t5 K$ j. w* D S2 c
investigation. The primary care physician should be
, k7 V% s, P4 X0 ^8 m) S: E# j4 taware of this fact, because most of these children
! y5 K' y, S. j; `may initially present in their practice. The Physicians’1 @0 ?( r- o2 w1 w. c+ U9 b
Desk Reference and package insert should also put a" o1 J0 }: U' P6 @/ }6 `
warning about the virilizing effect on a male or2 n2 f" E) K- }
female child who might come in contact with some-1 `$ V6 M' g7 G# y, @
one using any of these products.% f3 a# R9 I: n! y# i
References, U3 C) _* F, b+ v
1. Styne DM. The testes: disorder of sexual differentiation
# w3 E) V% b9 Dand puberty in the male. In: Sperling MA, ed. Pediatric
0 I2 B6 J/ h5 K3 R* f Z/ I0 Z& EEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;' K+ b! [, @" L
2002: 565-628.
. |6 b, n& f2 S1 f# _; e2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 T; ?4 v% s) W* F9 q; n! {+ Rpuberty in children with tumours of the suprasellar pineal |
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