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Sexual Precocity in a 16-Month-Old+ s, k0 Z# W4 Y+ S* U7 B, n
Boy Induced by Indirect Topical k( r5 Y7 \6 i
Exposure to Testosterone
+ V0 N3 T8 t: B& C7 R DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,21 R# H c' l; V( l
and Kenneth R. Rettig, MD1
; _ @9 K: p( d: y/ aClinical Pediatrics
+ ?' m+ R" d& K; WVolume 46 Number 6
+ X+ T1 d. c) C1 z# LJuly 2007 540-543. O' l; o; W2 R
© 2007 Sage Publications
0 h0 G) U+ B$ B5 J+ s# L( i' f- @# S- u3 P10.1177/00099228062966514 j% i, }4 L ]& B( d
http://clp.sagepub.com2 m5 M D9 c1 ?$ a
hosted at4 M' c% q( d4 m3 i# m
http://online.sagepub.com. n0 ^- M. L' A" _6 r
Precocious puberty in boys, central or peripheral,# l+ P$ u" E3 j; Z( i
is a significant concern for physicians. Central; K9 X. c# x3 a, q8 x& f9 F4 L
precocious puberty (CPP), which is mediated
. b8 @1 R! U( b# y* h* G' E2 L ythrough the hypothalamic pituitary gonadal axis, has
2 \9 I' B7 R0 q7 u7 H/ Oa higher incidence of organic central nervous system- y: `5 ~2 c$ B
lesions in boys.1,2 Virilization in boys, as manifested; c4 q: O6 a4 u; N: v+ p8 a
by enlargement of the penis, development of pubic/ V; ?2 I. X; T3 R
hair, and facial acne without enlargement of testi-
o" v1 q) x* Dcles, suggests peripheral or pseudopuberty.1-3 We
* _) R4 l* N9 R& d5 d# G/ ?. ^# p# greport a 16-month-old boy who presented with the
9 R; x3 R* W( ?& w: I4 henlargement of the phallus and pubic hair develop-
" s* c1 V: w$ z; T! Yment without testicular enlargement, which was due- D7 s* y; _3 c, T* M2 y$ Z
to the unintentional exposure to androgen gel used by
d. J& o3 ^& d8 O- \* Dthe father. The family initially concealed this infor-
# n; z: ` k7 C! r& k+ m! Hmation, resulting in an extensive work-up for this
6 f$ y# ?# h# k& w$ schild. Given the widespread and easy availability of
- c& X; s. Y7 ~, ?% `testosterone gel and cream, we believe this is proba-
' _3 H9 t" ?! ?4 x$ L/ }6 jbly more common than the rare case report in the
' t, f; k' ~ Qliterature.4
2 @ ~6 ` A9 Z, v) W; e3 u2 h. ~1 u- h" ?Patient Report+ o3 b2 ` K1 W, n$ C, X2 b
A 16-month-old white child was referred to the
8 f$ c1 @3 r5 {2 a1 q% f6 @7 ~1 Eendocrine clinic by his pediatrician with the concern
. {! t' s3 Q* Y4 r9 m2 D1 D3 z7 |of early sexual development. His mother noticed* G. M+ u7 h6 q) G4 ?# j4 e8 i
light colored pubic hair development when he was
# _/ f8 P1 Z. X$ QFrom the 1Division of Pediatric Endocrinology, 2University of
" U$ I/ ]( _. @/ t" L" T! rSouth Alabama Medical Center, Mobile, Alabama.
$ j, Y* j# k( x' E) i( QAddress correspondence to: Samar K. Bhowmick, MD, FACE,; H* Y a4 b/ [. |( v& @* @7 Q: L' T$ a! r
Professor of Pediatrics, University of South Alabama, College of* o* j% `0 z3 ~) n5 i0 c( x
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- q; j$ q/ T9 C+ H1 ze-mail: [email protected].
$ G) K6 L/ a: Fabout 6 to 7 months old, which progressively became
- u! X. [5 w3 ~8 N- w" o: pdarker. She was also concerned about the enlarge-2 n8 I0 y5 o7 F" z5 Y: K. }& u
ment of his penis and frequent erections. The child
% W1 u R; @; K8 [6 s2 D) zwas the product of a full-term normal delivery, with4 b2 X S3 P% L5 T' j
a birth weight of 7 lb 14 oz, and birth length of
# `# r0 s& C- t/ L20 inches. He was breast-fed throughout the first year; Z% N% B! Y7 Q/ {) @( P+ u7 b! L7 O
of life and was still receiving breast milk along with
0 H; Q3 \7 x- Z0 Q! n5 z1 D3 O9 @8 [solid food. He had no hospitalizations or surgery,
/ y% ?3 q2 `4 M" u; Y3 ^) Dand his psychosocial and psychomotor development
2 v$ T5 U o4 j9 z* b# F, a1 S8 gwas age appropriate.
6 G/ Q7 R- P8 u: S7 b7 VThe family history was remarkable for the father,! i# B6 u: s/ p4 ?& U
who was diagnosed with hypothyroidism at age 16,
# J# i. K d" i2 O ewhich was treated with thyroxine. The father’s
- L% H. b9 m! `height was 6 feet, and he went through a somewhat% {9 n5 P' F! @8 J9 r1 z4 q0 S
early puberty and had stopped growing by age 14.
7 e* z6 W, q* S1 [The father denied taking any other medication. The
7 Z" u3 b5 C! r2 e9 w0 Achild’s mother was in good health. Her menarche
" }4 ^7 w8 B$ ^) k8 lwas at 11 years of age, and her height was at 5 feet
* C) b& a! C5 a' o7 z" Q& R0 w5 inches. There was no other family history of pre-
8 J& D" p1 g1 ]. U2 bcocious sexual development in the first-degree rela-/ T8 U4 j- ~- E+ ], Y/ u
tives. There were no siblings.* ^9 w q& @0 s* P6 T
Physical Examination( ^% B( C- X( N+ G
The physical examination revealed a very active,! A0 n4 ^* `, m! I6 x6 `
playful, and healthy boy. The vital signs documented
% Z; X0 U4 v3 b& ga blood pressure of 85/50 mm Hg, his length was5 ^6 G' k* N8 ]- A
90 cm (>97th percentile), and his weight was 14.4 kg/ w$ @8 z! H+ k) \$ ]- ?8 t
(also >97th percentile). The observed yearly growth
. J7 \8 D. Y6 z( g- M3 W& Nvelocity was 30 cm (12 inches). The examination of
. C) T8 M+ H$ r3 \9 Fthe neck revealed no thyroid enlargement.
/ N+ B, [. Q* @' EThe genitourinary examination was remarkable for
9 g: z1 X- C. b& K, f$ S: benlargement of the penis, with a stretched length of% ]4 v3 Z' ^& ^$ S3 F: S4 [+ l
8 cm and a width of 2 cm. The glans penis was very well
: W, Q) h- g Z( y" D. |1 ndeveloped. The pubic hair was Tanner II, mostly around4 W" L; Q' J H) K: _( D
540: @$ c0 ]3 v* ^& V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 K$ G" M, f. i0 d3 R8 Y
the base of the phallus and was dark and curled. The/ {+ O5 }# s* `) S/ K4 Z' e- ]. C$ C
testicular volume was prepubertal at 2 mL each.* G# h" o8 |# v! y+ V
The skin was moist and smooth and somewhat
5 X# O8 B% ^( k! W# d. coily. No axillary hair was noted. There were no
' [' K5 g; ^# B2 Z5 Vabnormal skin pigmentations or café-au-lait spots.
) ?' K' B2 s G8 \2 O3 A |7 v( ]Neurologic evaluation showed deep tendon reflex 2+' K' L" {" s8 M! k
bilateral and symmetrical. There was no suggestion# L5 h% K$ v2 O. E. I: Y/ j9 P
of papilledema.3 j1 Z: N1 A9 y+ _$ j. \) E
Laboratory Evaluation3 Z2 o$ S. y7 J% _2 r6 O
The bone age was consistent with 28 months by8 V3 C2 u# {& F4 V% Y
using the standard of Greulich and Pyle at a chrono-
/ m Q+ \1 y( x4 n+ J: A! h( Tlogic age of 16 months (advanced).5 Chromosomal
6 J9 v5 j1 }2 w3 [% G W, jkaryotype was 46XY. The thyroid function test
$ ~: c7 j( j# T8 r1 Pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 f( k( I4 F3 ?, L3 Slating hormone level was 1.3 µIU/mL (both normal). Q0 F/ F z* f( I
The concentrations of serum electrolytes, blood
2 u% M$ o" t. {, e( F# K. c, Yurea nitrogen, creatinine, and calcium all were
4 m+ u, E0 m) Cwithin normal range for his age. The concentration& {0 ^* i! A0 G. N
of serum 17-hydroxyprogesterone was 16 ng/dL
1 B9 ~% d& i( l* r(normal, 3 to 90 ng/dL), androstenedione was 20
5 C* G/ T; |! O. q" m8 sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 _- m% W5 S% v4 D$ ^
terone was 38 ng/dL (normal, 50 to 760 ng/dL),) t6 J# X) d5 a' B
desoxycorticosterone was 4.3 ng/dL (normal, 7 to+ ?6 [# ]% G* y. k2 ^) h9 g; H
49ng/dL), 11-desoxycortisol (specific compound S)
( M) z' q9 N/ gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-* H& Q; O6 k1 o$ Z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* Y2 k9 A: e6 d1 U, u1 H) e
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% V$ l8 u) X$ d: dand β-human chorionic gonadotropin was less than; R9 Q8 l' E: \1 |3 X# W# B; W: B
5 mIU/mL (normal <5 mIU/mL). Serum follicular2 [" J8 P3 U0 O' J7 y
stimulating hormone and leuteinizing hormone
, p2 ~' u: H& j9 X. B5 }+ econcentrations were less than 0.05 mIU/mL. k( V8 X( l' `4 P _ {
(prepubertal).. I, f) B( h/ p+ e- Z- c
The parents were notified about the laboratory
" ^0 j/ S' V( S0 V& E& U" o2 gresults and were informed that all of the tests were5 x1 \3 f5 C. r- e' X
normal except the testosterone level was high. The' e( u/ G6 ?3 X! h6 }. E) |
follow-up visit was arranged within a few weeks to+ i1 N: E2 G! z- T6 H
obtain testicular and abdominal sonograms; how-$ z3 ]5 q$ D0 w7 f
ever, the family did not return for 4 months.9 b: f# M/ S! D% F$ W) a& s+ l; b2 ]
Physical examination at this time revealed that the
6 j7 _, {& F' y1 \8 p8 _# Jchild had grown 2.5 cm in 4 months and had gained
2 v5 ]0 M) I2 | f4 D2 kg of weight. Physical examination remained% J' `" P( m0 Y! T+ D6 M$ l
unchanged. Surprisingly, the pubic hair almost com-9 n2 k: v- g; p
pletely disappeared except for a few vellous hairs at) y6 t' B4 P0 b
the base of the phallus. Testicular volume was still 29 o7 t# S9 {0 u2 k
mL, and the size of the penis remained unchanged.
& u, B. d' z) C9 J1 |( @; L" q1 U& `The mother also said that the boy was no longer hav-# c8 U* a9 P2 M
ing frequent erections.
% ^7 f; V" X# M. z2 x' ^7 a& MBoth parents were again questioned about use of
% b2 N$ `5 R: z' lany ointment/creams that they may have applied to/ o9 ^2 Q1 ^0 f9 ?" a
the child’s skin. This time the father admitted the
& @, t5 o1 i4 ?0 y5 Y9 iTopical Testosterone Exposure / Bhowmick et al 541
* S7 V; ^/ j' |% @0 A9 |0 huse of testosterone gel twice daily that he was apply-, I) b9 S7 I9 d% w0 l, t
ing over his own shoulders, chest, and back area for
, I8 Z5 x& |8 _( |- pa year. The father also revealed he was embarrassed5 m9 f! H, w2 @* I
to disclose that he was using a testosterone gel pre-
: C1 K; w: G' }/ R* escribed by his family physician for decreased libido
; n |! O/ z; v6 ^! R* tsecondary to depression.7 |1 x$ Z0 a( z: u/ B8 T2 d# L
The child slept in the same bed with parents.
! t- ~1 r( b3 q$ o6 H. ^! oThe father would hug the baby and hold him on his
8 P# B% |2 _1 e6 O! A: w& L* C% rchest for a considerable period of time, causing sig-
8 T* D- B4 Y7 E) j4 g$ h/ Rnificant bare skin contact between baby and father.
9 h* y$ o9 c5 `) p9 W6 m! S% hThe father also admitted that after the phone call,
# _9 U4 s' t. R+ Dwhen he learned the testosterone level in the baby
' w1 {3 ~+ o. Q; }was high, he then read the product information* N) M3 ~) F0 o
packet and concluded that it was most likely the rea-
+ i! L" u1 G( S/ p" j) vson for the child’s virilization. At that time, they
4 Q4 \4 H2 J+ z, Q) x, Rdecided to put the baby in a separate bed, and the
, j1 ?, E& E% O2 ufather was not hugging him with bare skin and had
- \# r9 ?" n* C6 I+ P: ~2 ~been using protective clothing. A repeat testosterone
6 x: B* X9 m" k: Ttest was ordered, but the family did not go to the6 T0 f. x! ]; m; ~# c
laboratory to obtain the test.
9 C; L: y5 F& a; ^/ V9 g; cDiscussion2 f% q" `: j, o4 A# E
Precocious puberty in boys is defined as secondary0 K6 b+ \& Q3 S- D, L
sexual development before 9 years of age.1,45 H9 z& U# H- o0 i+ o
Precocious puberty is termed as central (true) when* g# _' E' P$ W ~* x
it is caused by the premature activation of hypo-
: Z4 p7 E" \& o/ Q, f2 Uthalamic pituitary gonadal axis. CPP is more com-
* l* K( ^3 K) E) O- Y( wmon in girls than in boys.1,3 Most boys with CPP) D( ~% N0 m2 Q( \7 F0 A" h
may have a central nervous system lesion that is1 ~$ j" S% J/ s! ?& b
responsible for the early activation of the hypothal-) b" J" M1 z4 B7 J3 i0 y: N5 T
amic pituitary gonadal axis.1-3 Thus, greater empha-4 @7 R; Z: j4 X( z! \& Z: F+ S% x
sis has been given to neuroradiologic imaging in
1 M! f) ?" S+ `boys with precocious puberty. In addition to viril-& \/ ]4 F8 w" |$ O8 d. b- |
ization, the clinical hallmark of CPP is the symmet- U. d' R# O" y, C7 m0 r
rical testicular growth secondary to stimulation by
. D% l& i% `3 b/ u! t, I8 F wgonadotropins.1,3% @3 c& Q! Q6 V4 x$ H7 Y5 z. r
Gonadotropin-independent peripheral preco-
; c1 T% I. r4 ~" zcious puberty in boys also results from inappropriate
3 t# y) G3 `: C; h n: m7 [androgenic stimulation from either endogenous or# e* P$ c& p4 n* U, \2 ~# a
exogenous sources, nonpituitary gonadotropin stim-
3 E1 t* c! `3 w+ `ulation, and rare activating mutations.3 Virilizing
1 j( T! a ^3 {congenital adrenal hyperplasia producing excessive D+ d6 S+ ]( G& R0 L/ q7 n* k
adrenal androgens is a common cause of precocious
$ c3 ]4 E7 z8 v# Hpuberty in boys.3,4( b1 j0 P0 j* l& V. _" F
The most common form of congenital adrenal
- w+ ]5 O* Y5 f) K* B, Xhyperplasia is the 21-hydroxylase enzyme deficiency.
6 f5 @. A2 J# r& a7 U9 CThe 11-β hydroxylase deficiency may also result in
" _7 Z- b- R: o' h% R7 Pexcessive adrenal androgen production, and rarely,2 t3 K8 P* b7 W0 i
an adrenal tumor may also cause adrenal androgen, w/ Z- I2 g& v4 z5 ?2 M
excess.1,3
& R9 E' k( {: g: h# G. {. ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, c8 Q& } {2 v, m: {
542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 U7 Y; y0 F+ ^7 {* t0 w6 B
A unique entity of male-limited gonadotropin-
7 v9 E+ l: J8 X5 L2 ~independent precocious puberty, which is also known
4 E% v9 X' h% f) fas testotoxicosis, may cause precocious puberty at a5 @, u& s, c; J! I
very young age. The physical findings in these boys
0 f6 D8 O$ \7 ^+ b( lwith this disorder are full pubertal development,
/ s& d6 c0 D' ` {' B' @2 X8 Dincluding bilateral testicular growth, similar to boys
3 ]8 _5 l8 C* c5 m1 E3 Qwith CPP. The gonadotropin levels in this disorder
7 ^6 L+ f4 ~3 `0 D. Q9 Bare suppressed to prepubertal levels and do not show
, g9 ~- s; M' t: ^+ ?+ opubertal response of gonadotropin after gonadotropin-
# e/ Q% Z0 m' a! N4 }$ `; Wreleasing hormone stimulation. This is a sex-linked# N+ `& o$ \" [$ {, x# q
autosomal dominant disorder that affects only
, C8 F& f5 i, @& s5 o- f8 fmales; therefore, other male members of the family2 [$ g) F7 }- y/ N5 b0 \! ^
may have similar precocious puberty.3
0 v+ t& B! f' r* w$ I6 \In our patient, physical examination was incon-9 {$ O; z; P6 y+ B
sistent with true precocious puberty since his testi- F- m$ G' O+ m Z+ Y7 M4 q1 T/ }
cles were prepubertal in size. However, testotoxicosis% t% I6 u8 e# ?" F' o7 c# Y/ K
was in the differential diagnosis because his father
( M2 q/ O3 n: P4 Mstarted puberty somewhat early, and occasionally,6 u5 C& g& J6 p/ r2 v3 U5 H) {# f x
testicular enlargement is not that evident in the' h, Q1 T4 p6 K$ S
beginning of this process.1 In the absence of a neg-
3 v) r$ n. Z, R; d' Zative initial history of androgen exposure, our4 h+ `8 O- W1 i; v4 N7 d
biggest concern was virilizing adrenal hyperplasia,
4 F" l0 E" Z7 B: Ceither 21-hydroxylase deficiency or 11-β hydroxylase) P' P/ s( @ J
deficiency. Those diagnoses were excluded by find-5 e( @; L a: ^5 d+ O" k3 T, v# L: P
ing the normal level of adrenal steroids.+ J' \% ]8 I, P. \
The diagnosis of exogenous androgens was strongly- f ^/ @+ X" I
suspected in a follow-up visit after 4 months because
8 F: J: v8 i! y$ C0 B& J* hthe physical examination revealed the complete disap-
# o w( l y5 t) P" _pearance of pubic hair, normal growth velocity, and
) W6 F! C& s( C4 m9 n7 Ndecreased erections. The father admitted using a testos-
. P2 O2 ^' @3 q+ ~! `# k# m5 U! hterone gel, which he concealed at first visit. He was W% U% ?4 ^9 }/ |
using it rather frequently, twice a day. The Physicians’
9 v5 J/ `3 _3 M; P; ?/ z" QDesk Reference, or package insert of this product, gel or
/ s* s: v' V8 I* [" d. icream, cautions about dermal testosterone transfer to
- D! ?; a) x0 ^% z2 s2 \# munprotected females through direct skin exposure.
0 J2 p/ z6 `5 c( W& A; S# ^8 Q$ aSerum testosterone level was found to be 2 times the
4 a* n. j! X5 x% Pbaseline value in those females who were exposed to0 s) l/ Z+ ^2 r' f b0 f: T
even 15 minutes of direct skin contact with their male% F Q# w, _! l! B
partners.6 However, when a shirt covered the applica-" d3 L) T3 x+ ?, V
tion site, this testosterone transfer was prevented.& U N. ]5 d7 s7 Q; |, P; ^" w
Our patient’s testosterone level was 60 ng/mL,
* P5 Y2 i$ N5 o0 |which was clearly high. Some studies suggest that
( Z2 T3 ^9 W7 Vdermal conversion of testosterone to dihydrotestos-
! f- F8 [, p) b3 w4 dterone, which is a more potent metabolite, is more3 ~2 c; Y" A0 _3 }
active in young children exposed to testosterone
9 j5 y- n3 P# I: G2 ^exogenously7; however, we did not measure a dihy-
( h7 I$ b( Y. J& b `- Cdrotestosterone level in our patient. In addition to( Z6 j& u: K6 l8 w
virilization, exposure to exogenous testosterone in, A2 n P- ?: y+ Z. L
children results in an increase in growth velocity and
/ ?; P. C! K& P+ |( s0 n5 radvanced bone age, as seen in our patient.* g6 A4 H! {0 F: @7 t2 ?& y
The long-term effect of androgen exposure during
$ m3 T/ @' G) Vearly childhood on pubertal development and final7 [3 Z0 R+ t, i2 r; R- ~; r4 J- N
adult height are not fully known and always remain
$ W. C/ J* @7 I9 e0 ~* t3 ?: fa concern. Children treated with short-term testos-
0 ~, I5 S0 ~6 E! o( ]; G8 Vterone injection or topical androgen may exhibit some+ o7 ~0 z8 d9 Z+ H
acceleration of the skeletal maturation; however, after- |' A0 a: A n2 l2 a3 E4 q
cessation of treatment, the rate of bone maturation4 I) A& L: v1 g' c' g
decelerates and gradually returns to normal.8,9
$ }7 i, c; k. I1 cThere are conflicting reports and controversy
: i* u% t" E9 l6 Mover the effect of early androgen exposure on adult
$ u3 O6 s5 t8 _4 l0 d' Ipenile length.10,11 Some reports suggest subnormal* E" X1 H/ p5 M- r5 u$ ?! {3 \
adult penile length, apparently because of downreg-
( K/ n. h" x2 K& A0 rulation of androgen receptor number.10,12 However,
/ v% Z* v- T/ t( G( B( FSutherland et al13 did not find a correlation between' U! a$ f8 }" j1 G. ~ b: A6 t+ l
childhood testosterone exposure and reduced adult& E' a# @, {, k m
penile length in clinical studies.
- }' _- z! Z' \2 d! NNonetheless, we do not believe our patient is
8 I: M3 @; E/ {5 t9 h3 mgoing to experience any of the untoward effects from9 ]" M; S q7 [) e5 H2 ?" G
testosterone exposure as mentioned earlier because
- O" @3 h" W; Qthe exposure was not for a prolonged period of time.
' r9 M9 T+ O( i" C5 S' EAlthough the bone age was advanced at the time of
% }5 z! r0 K5 d" w) Idiagnosis, the child had a normal growth velocity at
# Y8 c2 Z$ Q/ ?2 }( ]" D0 B, z. Z2 B5 _the follow-up visit. It is hoped that his final adult) p) U( y; K" C( c
height will not be affected.
3 u( j0 A8 k, u- V3 c" _Although rarely reported, the widespread avail-7 v' }: h% o# h$ D* ~
ability of androgen products in our society may% C. C1 m8 j4 V* ?! M" ?, c! U
indeed cause more virilization in male or female
- A4 i1 D- q4 }! ]children than one would realize. Exposure to andro-' t/ c) j2 E% `' r0 B6 n' y) U0 i9 i
gen products must be considered and specific ques-
7 e. W' W5 n2 Otioning about the use of a testosterone product or
4 X" r1 l) S {. V+ [" _) C; Qgel should be asked of the family members during3 e) V! b$ D) a! A6 i& G4 A9 s |
the evaluation of any children who present with vir-; ?9 h# a) R$ F
ilization or peripheral precocious puberty. The diag-, [* h1 _# g' [. ^
nosis can be established by just a few tests and by
/ _5 {! x! l! B+ ~# u) n/ ^appropriate history. The inability to obtain such a
% `% l' `# h3 H4 q [8 Vhistory, or failure to ask the specific questions, may0 y6 ]: } N; f- y8 }
result in extensive, unnecessary, and expensive) r9 d- X- r1 o5 {2 F2 q
investigation. The primary care physician should be: w4 H' [# g2 h/ g! a1 E' B
aware of this fact, because most of these children: r8 U' A8 ^" A
may initially present in their practice. The Physicians’
1 I+ z1 j: {2 d; lDesk Reference and package insert should also put a
, i- ~! J T) l7 ]* d3 `( bwarning about the virilizing effect on a male or
. ~5 S H: D, Q, Z9 v; Ffemale child who might come in contact with some-( q1 q% Y7 h* R7 D- [: k
one using any of these products.5 U$ v9 A e6 }& ~. D& p
References% H/ T' g1 U- I' T/ Q
1. Styne DM. The testes: disorder of sexual differentiation
6 ^" J" w2 T) Vand puberty in the male. In: Sperling MA, ed. Pediatric& j# f, H( A7 r5 @+ ?& @5 c
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;* m# Y/ j% v0 }+ s; [% {
2002: 565-628.- {; G6 J% A3 x2 Q5 V# N2 |1 W
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 f# Y. {. \ n4 V
puberty in children with tumours of the suprasellar pineal |
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