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Sexual Precocity in a 16-Month-Old& U0 G$ z) h" `' H) P% k
Boy Induced by Indirect Topical4 p" h7 h+ I. ~8 i
Exposure to Testosterone
7 H3 j+ ~: M9 DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 I7 T& r+ m: ]and Kenneth R. Rettig, MD1
: X0 u$ X: u5 D: E# C* @Clinical Pediatrics
d1 C! y9 J, z9 b9 u2 t) IVolume 46 Number 6
3 G' ~4 ?) }( D9 x$ \* t, H2 jJuly 2007 540-543- Q+ S+ U9 v, W; r2 L/ f
© 2007 Sage Publications
3 H2 E4 k. t8 J# I5 s. F+ w10.1177/0009922806296651
, H" `: y. @: [9 D1 Yhttp://clp.sagepub.com
5 n7 z$ F9 W3 Ihosted at
8 M. A4 L9 _, P& C% g$ g1 Ghttp://online.sagepub.com
0 W4 }, b: ~( ?4 ]2 FPrecocious puberty in boys, central or peripheral,# B, L( \" t6 k8 P1 ]8 u# v1 i
is a significant concern for physicians. Central
1 ] c; s! F! G$ m4 H& E6 E. g% V' ?precocious puberty (CPP), which is mediated0 B) D9 A# }' Z7 v
through the hypothalamic pituitary gonadal axis, has1 m3 L3 c( f! d* @6 a" L
a higher incidence of organic central nervous system
9 _. W1 B, Q# c- nlesions in boys.1,2 Virilization in boys, as manifested
2 W2 l/ U; V S3 eby enlargement of the penis, development of pubic
. Y! v3 B$ i, a/ V: _8 x- I4 Whair, and facial acne without enlargement of testi-6 u. W- w0 o' G% Z
cles, suggests peripheral or pseudopuberty.1-3 We
( M6 Q6 z" O. z \# hreport a 16-month-old boy who presented with the
2 W. i) S+ a# \' B) |enlargement of the phallus and pubic hair develop-
' \1 S$ r8 w/ m# L z: Fment without testicular enlargement, which was due
' ?2 W4 h: Z0 q6 ?# ^% G6 oto the unintentional exposure to androgen gel used by( J, L7 D2 b) [( R2 F* ^. _( P1 v
the father. The family initially concealed this infor-
2 I* r/ k; M p' V( I& {mation, resulting in an extensive work-up for this
& ?6 P5 ?2 H9 hchild. Given the widespread and easy availability of
1 u/ ^* H+ R+ Y* U- w, Wtestosterone gel and cream, we believe this is proba-! ~% s! H9 x& L$ T
bly more common than the rare case report in the7 [* i# W4 O& z2 W% F
literature.4, `& K8 }! I! K
Patient Report
$ u/ I) A3 X7 ^" a! jA 16-month-old white child was referred to the
* W" [ W9 e! V: T: k5 W5 Uendocrine clinic by his pediatrician with the concern
J7 J2 P3 D" R: |- \; F1 Zof early sexual development. His mother noticed
( @" M! O2 U Z, z0 h* z; {light colored pubic hair development when he was
# X6 Z$ v6 F. OFrom the 1Division of Pediatric Endocrinology, 2University of$ N' v8 ]9 ~7 [- s/ e, t- O
South Alabama Medical Center, Mobile, Alabama.0 h2 d; @3 R6 i. z `4 |
Address correspondence to: Samar K. Bhowmick, MD, FACE,7 y2 k1 i J2 S( R4 O$ \3 \0 y9 P6 i
Professor of Pediatrics, University of South Alabama, College of
* L! B# E w6 X+ b FMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' w) U! ] D8 O0 p7 U, P" ~; D
e-mail: [email protected].9 A- \( r. ~7 h
about 6 to 7 months old, which progressively became/ S# o/ `& L, D8 K& J+ f
darker. She was also concerned about the enlarge-' a/ G- H6 D' e
ment of his penis and frequent erections. The child
% g' F8 L2 w' P- g( ^3 qwas the product of a full-term normal delivery, with
, |, J) O1 J; N; b8 }a birth weight of 7 lb 14 oz, and birth length of
; }( b# [; v% ]9 v! k20 inches. He was breast-fed throughout the first year
% t" r: e7 d1 ]/ ?+ Aof life and was still receiving breast milk along with- P$ D1 Y2 U# \5 N" s3 J
solid food. He had no hospitalizations or surgery,0 _8 n9 _4 b/ @7 F
and his psychosocial and psychomotor development- `0 \7 [; s/ `' E' R- J
was age appropriate.# d& }7 H. |, U% @+ I. K
The family history was remarkable for the father,+ t8 c9 v0 h+ r7 ? x
who was diagnosed with hypothyroidism at age 16,
: w1 [! f4 t# \) }1 ~+ pwhich was treated with thyroxine. The father’s( m$ ^3 y7 e5 h. M2 U* `; T
height was 6 feet, and he went through a somewhat" Y1 a2 i# q/ l: W- {
early puberty and had stopped growing by age 14.* R! N6 t, `0 o) J+ u
The father denied taking any other medication. The. s5 i2 z- L' _8 k! r- X8 d
child’s mother was in good health. Her menarche
% }, V6 l- { v) Ewas at 11 years of age, and her height was at 5 feet
J% f2 o6 y+ i9 \5 inches. There was no other family history of pre-
* t2 n) V/ H6 ccocious sexual development in the first-degree rela-* A( J% z+ u) L( y9 {' c9 n; ?3 L
tives. There were no siblings.
, f$ I1 b' a |- v4 Q5 [7 [6 J/ uPhysical Examination
9 {! N( v2 Q7 r2 yThe physical examination revealed a very active,
4 H2 {" k. m0 eplayful, and healthy boy. The vital signs documented. m5 p6 W5 H8 P5 A6 g% [/ X
a blood pressure of 85/50 mm Hg, his length was
) B6 q0 e: f/ @4 D" ^90 cm (>97th percentile), and his weight was 14.4 kg+ {- J7 c, k- t* Y2 S; J7 _) |' {9 [6 y
(also >97th percentile). The observed yearly growth& u. h, X5 t4 a5 }7 V& ]
velocity was 30 cm (12 inches). The examination of
* R4 {; [# o2 N Athe neck revealed no thyroid enlargement.9 q2 `" r* a1 W
The genitourinary examination was remarkable for& J9 T' k5 f5 T4 _
enlargement of the penis, with a stretched length of* T1 ?1 @1 A3 d
8 cm and a width of 2 cm. The glans penis was very well7 Q/ [/ M' q; a* t$ n8 F; `; K" @
developed. The pubic hair was Tanner II, mostly around
) m K# [5 n8 b540
9 S1 M& P) {' ]0 z/ g& Z" e9 Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; `' B% f y3 c6 athe base of the phallus and was dark and curled. The& L* }" g# K2 Z& A! b
testicular volume was prepubertal at 2 mL each., ?2 f) e$ v! A4 C
The skin was moist and smooth and somewhat
2 O% v! K% h# O4 v8 o' U3 goily. No axillary hair was noted. There were no- e- J4 r5 K G1 e
abnormal skin pigmentations or café-au-lait spots.+ {1 Y5 F+ H5 B7 ~
Neurologic evaluation showed deep tendon reflex 2+( A" `7 I8 i2 H
bilateral and symmetrical. There was no suggestion
1 k! b4 [) H8 _% q# T) v0 Wof papilledema.
/ c" V$ I0 G( i- d& l0 X2 e) i( ULaboratory Evaluation
+ p' U L; G- Y3 j$ lThe bone age was consistent with 28 months by# `* f2 u6 O& h4 K# V
using the standard of Greulich and Pyle at a chrono-
$ Z7 ?0 |: ^; m) O( U) N' s* G' I6 Jlogic age of 16 months (advanced).5 Chromosomal( Z5 n4 @. H- q+ Q2 W; t; _! \- Y
karyotype was 46XY. The thyroid function test
+ G1 h& G$ T( g4 Dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-* T& c2 t) [3 V5 x) P5 v
lating hormone level was 1.3 µIU/mL (both normal).
5 k; Y3 h5 v* ^, D2 f: v4 @The concentrations of serum electrolytes, blood
6 }- ]0 x" `* n) g1 Y% |urea nitrogen, creatinine, and calcium all were! [9 g& @" C6 k& Q% [( X
within normal range for his age. The concentration/ F ~0 t1 p1 m3 J$ m9 M, u5 f
of serum 17-hydroxyprogesterone was 16 ng/dL$ f6 U. N' W% }
(normal, 3 to 90 ng/dL), androstenedione was 20# F7 r/ A4 s, ~9 S$ r
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 v1 y. C, s& g. a" fterone was 38 ng/dL (normal, 50 to 760 ng/dL),7 M$ N& A. P! g& L7 t4 m
desoxycorticosterone was 4.3 ng/dL (normal, 7 to' o, E2 r8 b' S; l2 C) L1 l
49ng/dL), 11-desoxycortisol (specific compound S)
1 G) A* @% L# W( @was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. C, H' G1 Y" {! D, Dtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
" V) k$ T. |8 E7 G) {# Mtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),, z+ P- f# ]5 h! ?, L8 f4 U& V
and β-human chorionic gonadotropin was less than
9 z8 a/ {" n) j7 x/ ^4 {& i5 mIU/mL (normal <5 mIU/mL). Serum follicular8 B1 t% E8 |8 I8 v3 }
stimulating hormone and leuteinizing hormone
* ?& }- v5 V% T) ~7 o2 Vconcentrations were less than 0.05 mIU/mL8 W' D* T3 k& K9 i0 C% M
(prepubertal)." \) x3 u9 Q: e/ G A4 n. s# J$ X
The parents were notified about the laboratory
: R [* {! ]/ D6 t1 u2 J0 Hresults and were informed that all of the tests were% J1 n- g0 h }3 L. K1 J# L; y
normal except the testosterone level was high. The
) Y# v0 }, R7 \$ O! X( cfollow-up visit was arranged within a few weeks to+ @% W+ u+ a7 [, \2 n% y
obtain testicular and abdominal sonograms; how-( R& \3 T2 C) I8 ^ [6 C9 U# p
ever, the family did not return for 4 months.% m8 f0 P4 H, ]3 Z+ x
Physical examination at this time revealed that the
5 o+ {! z( z' g- ]0 h+ \6 ochild had grown 2.5 cm in 4 months and had gained$ \/ \9 @6 B7 U4 Y6 @
2 kg of weight. Physical examination remained
4 L" ?# m. v+ a, b% q; Runchanged. Surprisingly, the pubic hair almost com-& c6 x S3 R' z. [9 z: c: r
pletely disappeared except for a few vellous hairs at- c, }( G$ }+ I# F) n
the base of the phallus. Testicular volume was still 25 e! f3 {2 a- S; h4 i
mL, and the size of the penis remained unchanged.
& K2 c, Y& Q% k8 CThe mother also said that the boy was no longer hav-& R% \& l5 X5 T7 D2 E- E4 @* K
ing frequent erections.
~$ N( h0 x1 G7 B! G8 xBoth parents were again questioned about use of
, f7 [1 `, @$ b* m! yany ointment/creams that they may have applied to
* a n5 I! e' P- A$ Q# C+ x+ Bthe child’s skin. This time the father admitted the. I3 L; b# u9 Y/ \# r
Topical Testosterone Exposure / Bhowmick et al 541
+ ~" m/ Y: {# |/ U# N% ^& m9 {8 fuse of testosterone gel twice daily that he was apply-# C4 Y5 `- T7 n
ing over his own shoulders, chest, and back area for' ^1 O; K6 C7 C- z# }
a year. The father also revealed he was embarrassed* @; C. L$ z& J \1 N
to disclose that he was using a testosterone gel pre-
5 E( O1 l. m/ i$ cscribed by his family physician for decreased libido% G/ B3 w2 q- M$ v' E
secondary to depression.
9 t& m6 U. {: @9 H4 Y" lThe child slept in the same bed with parents.
; r3 o9 w! D4 q m5 uThe father would hug the baby and hold him on his. f2 d2 o5 B$ Z$ j
chest for a considerable period of time, causing sig-
0 ?6 l1 n' H& o* ~$ h7 X5 F% ~" Tnificant bare skin contact between baby and father.. C/ Q' h. r l5 X6 o
The father also admitted that after the phone call,
1 L o4 H! Y! m8 J6 k9 H' Hwhen he learned the testosterone level in the baby! F8 a! l- [* e* L3 K) b
was high, he then read the product information
( d9 ^6 ?) S8 Cpacket and concluded that it was most likely the rea-7 L! @( g: n) ?, T }
son for the child’s virilization. At that time, they* m* [. e; m9 Z9 W( `) j
decided to put the baby in a separate bed, and the
0 @1 E) M. `2 p2 c4 nfather was not hugging him with bare skin and had1 c4 x7 ^3 P5 E, J7 J/ Q# C* g
been using protective clothing. A repeat testosterone
( Q& J% x9 s! s* ^1 V8 y. Jtest was ordered, but the family did not go to the
( Z3 |' I7 U4 d4 \laboratory to obtain the test.
8 d/ Q" U9 u6 R, E+ k3 M1 bDiscussion, @ U6 I, g; S7 B N7 ]
Precocious puberty in boys is defined as secondary5 i, V( S, m& G6 \. y& \- r
sexual development before 9 years of age.1,4# w8 Y: S3 }+ X0 r4 p* y. b
Precocious puberty is termed as central (true) when# R8 c+ R" k4 `7 S3 ^/ C
it is caused by the premature activation of hypo-/ i4 P @$ z! t7 ]
thalamic pituitary gonadal axis. CPP is more com-! i' v: ?9 C# [1 A5 \0 _
mon in girls than in boys.1,3 Most boys with CPP
( V& b8 ~8 U& ~3 u" k$ Ymay have a central nervous system lesion that is
6 b$ B2 W; Q) s$ sresponsible for the early activation of the hypothal-
- y# e* b0 L# `amic pituitary gonadal axis.1-3 Thus, greater empha-2 w' X' R [. [# R
sis has been given to neuroradiologic imaging in
/ D1 j0 Z, h8 E8 k' b0 ~boys with precocious puberty. In addition to viril-
( V) f4 D. j! u6 e, {, O3 Jization, the clinical hallmark of CPP is the symmet-
! x0 `6 T- }. e8 v' Z/ v; Wrical testicular growth secondary to stimulation by+ p p9 B# u) R* N; L( x
gonadotropins.1,3
7 O D. |/ |% c3 U' L3 ]Gonadotropin-independent peripheral preco-6 p. K6 {6 D3 m3 h9 g( x
cious puberty in boys also results from inappropriate2 f. }2 l( x- z: h" h
androgenic stimulation from either endogenous or
, f* y9 y$ F% S. V8 Qexogenous sources, nonpituitary gonadotropin stim-
% W& s4 Z7 K `( ]( oulation, and rare activating mutations.3 Virilizing0 r. ^: J; X) v+ Z. w6 e7 `" U, l4 v5 H
congenital adrenal hyperplasia producing excessive
5 z* o& K0 G' ^9 f* k/ I8 dadrenal androgens is a common cause of precocious
5 {/ g5 R5 x6 R) D% x" D, Y1 f7 ^puberty in boys.3,4
4 J' W7 ?( Z6 sThe most common form of congenital adrenal
3 U3 b: t8 v- p( L. l8 R8 n& D: vhyperplasia is the 21-hydroxylase enzyme deficiency.3 M- ~( p. Y$ t9 F( w
The 11-β hydroxylase deficiency may also result in
$ a E! n" A/ v, l; H! Zexcessive adrenal androgen production, and rarely,/ }& u. |+ E v% a8 R' \* K& [
an adrenal tumor may also cause adrenal androgen
8 U" {! o& }3 q! kexcess.1,3
y" k' \' O& t) N( Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
T9 N. ~3 Q9 N& A* Z2 S2 q542 Clinical Pediatrics / Vol. 46, No. 6, July 2007 x. r/ |; C5 s
A unique entity of male-limited gonadotropin-; Q! F4 E! e, `5 q5 M0 n, D
independent precocious puberty, which is also known+ g- o" B) o' I. K8 b3 ^( P( s
as testotoxicosis, may cause precocious puberty at a
7 S% y6 j+ t- y/ b, j6 ~very young age. The physical findings in these boys
7 c! T+ _) v* H2 y( w/ L6 l/ w! Ewith this disorder are full pubertal development,
% A' ]8 z Z2 d! j, ^including bilateral testicular growth, similar to boys/ G6 r* p! v8 U2 M9 D' k5 ?$ ^5 L
with CPP. The gonadotropin levels in this disorder
: c/ a& s3 x/ Aare suppressed to prepubertal levels and do not show5 \# Z# ~9 @/ o1 ^* x! w
pubertal response of gonadotropin after gonadotropin-
0 \: C9 B' G5 N* Z' H" Greleasing hormone stimulation. This is a sex-linked9 v) I8 e u; d+ A; _
autosomal dominant disorder that affects only% j' d' Z8 O+ F7 k
males; therefore, other male members of the family
: D _5 N" A' i! E6 Tmay have similar precocious puberty.3- [0 _+ ^& ?7 {& t. j+ L( S/ K) Q2 e
In our patient, physical examination was incon-
6 x$ o7 \6 W: ]sistent with true precocious puberty since his testi-
/ c# P7 u4 c5 e6 ]. U4 l- }: M" ccles were prepubertal in size. However, testotoxicosis1 f6 e6 e, P( d4 a* h
was in the differential diagnosis because his father
* P; a) j( H$ E8 ^. |started puberty somewhat early, and occasionally,
; m A7 W. S# ]) r7 Mtesticular enlargement is not that evident in the
8 n! E+ P6 o1 X8 |) j' |beginning of this process.1 In the absence of a neg-1 e1 I+ j- B0 u+ {$ Y
ative initial history of androgen exposure, our$ y" y& Q5 \- B# o
biggest concern was virilizing adrenal hyperplasia,
0 u5 _* a. r% q1 _either 21-hydroxylase deficiency or 11-β hydroxylase6 j- v; g3 l, E; o2 s. l# y/ m( s
deficiency. Those diagnoses were excluded by find-: F2 n D( w- b& r
ing the normal level of adrenal steroids.
4 S" B- z! v8 T+ @% `" O' ]The diagnosis of exogenous androgens was strongly
_- z i5 V" w, tsuspected in a follow-up visit after 4 months because0 V& Y# _- N* {. k' L8 Q' ~
the physical examination revealed the complete disap-! }+ [) P0 G7 |5 |1 J: E5 \1 ?, y
pearance of pubic hair, normal growth velocity, and6 l1 K8 r! k8 H* H3 E
decreased erections. The father admitted using a testos-' a( }: ~2 `: u! C6 u
terone gel, which he concealed at first visit. He was
& P& Y" l. o5 K: h; J3 Wusing it rather frequently, twice a day. The Physicians’
% Z( L; s* ~. u( w% [6 u) i( w Q. oDesk Reference, or package insert of this product, gel or
* O1 g" I+ ?) l( ^: xcream, cautions about dermal testosterone transfer to! e o7 r! L4 I7 ]
unprotected females through direct skin exposure.2 v% T3 _3 e2 K5 f/ v3 G
Serum testosterone level was found to be 2 times the# n7 K6 d' e/ t, |; P1 q) A/ {* U
baseline value in those females who were exposed to
. V4 w8 Q ~7 @6 Qeven 15 minutes of direct skin contact with their male3 D, d+ t0 L0 u& Y/ D9 T
partners.6 However, when a shirt covered the applica-
- T3 s; L% p5 H* Gtion site, this testosterone transfer was prevented.& @, _9 ?' M2 v" j* D! }
Our patient’s testosterone level was 60 ng/mL,
, k: T' o" r; p' }7 `$ ]& n7 Lwhich was clearly high. Some studies suggest that! Q% n: P7 @! H1 m S- ^! F
dermal conversion of testosterone to dihydrotestos-
' N( ?4 B* c8 D# P a) [terone, which is a more potent metabolite, is more
# f2 g* G7 ?4 F2 {& j2 p8 Lactive in young children exposed to testosterone
{5 y8 U( A/ d/ @ B$ W0 a+ Iexogenously7; however, we did not measure a dihy-
! M! Y, w: c8 |- z% Udrotestosterone level in our patient. In addition to: v; F+ N+ l3 E
virilization, exposure to exogenous testosterone in8 Z* g5 y1 Y+ f7 p3 K/ v5 h
children results in an increase in growth velocity and& R! ?7 F% }& Z- h' n2 W
advanced bone age, as seen in our patient.9 X8 K; b+ o8 y- Q, S# w/ t
The long-term effect of androgen exposure during0 q( Z" M1 A7 @7 U* V" ?
early childhood on pubertal development and final
' [. r& k6 z- C( y+ f3 |adult height are not fully known and always remain
8 |8 P2 @( W1 {" j: Qa concern. Children treated with short-term testos-
% ]3 r o. B& uterone injection or topical androgen may exhibit some
, L& E2 q5 {; ^; {; |; Racceleration of the skeletal maturation; however, after
. w6 C8 D, _& f! W. U5 e+ Ycessation of treatment, the rate of bone maturation
+ a# G, o2 L% k" adecelerates and gradually returns to normal.8,9$ j1 O6 y* ]+ T! K+ c
There are conflicting reports and controversy P) y7 m; G: B4 x9 W- _3 V* u% A ~
over the effect of early androgen exposure on adult) I/ j2 Y R4 D: u
penile length.10,11 Some reports suggest subnormal* S' X2 S* e! H& [/ k" k, d
adult penile length, apparently because of downreg-0 S! q. I7 M- `/ N! I: u
ulation of androgen receptor number.10,12 However," [+ y C& c% l+ a: |+ u
Sutherland et al13 did not find a correlation between
2 r8 L- ^8 Z7 q- f, tchildhood testosterone exposure and reduced adult F' Y( X7 j+ |6 n9 H
penile length in clinical studies.# r" |; l* S' [1 F# L+ Q
Nonetheless, we do not believe our patient is
0 ^" o! @7 G2 V& U! Z9 z2 ogoing to experience any of the untoward effects from/ B& V% P& k7 S* N$ L, Y8 I* d& L
testosterone exposure as mentioned earlier because
! M; B8 X$ H% [4 k/ X, P4 Gthe exposure was not for a prolonged period of time. d% M, T e4 r$ O( W+ g
Although the bone age was advanced at the time of
& x& } l2 @( M' B' H" Ndiagnosis, the child had a normal growth velocity at
9 B% D6 g9 a L O; C {the follow-up visit. It is hoped that his final adult
8 ?: X4 [! D5 z8 w* t; @8 }& Uheight will not be affected.
" N0 h0 ~" q, v+ oAlthough rarely reported, the widespread avail-. t4 Z% ]! Y, v, p
ability of androgen products in our society may
. E O2 Z0 }5 M, d* oindeed cause more virilization in male or female
( t$ `3 j9 O2 k1 f! K4 ~- R" M% kchildren than one would realize. Exposure to andro-" V7 E; b- A+ U) _8 O, m
gen products must be considered and specific ques-
& r" F! v0 E8 ~% Z' a' o5 k, Itioning about the use of a testosterone product or7 s* _' Y) T* M
gel should be asked of the family members during
6 c9 n/ D8 m: S# q. \. b, Ythe evaluation of any children who present with vir-0 r& z: B5 B# }6 {. A! c) d% ^
ilization or peripheral precocious puberty. The diag-
& Z( k2 _: q* u' c" a& K2 Y8 pnosis can be established by just a few tests and by6 i0 c/ x8 s c) [
appropriate history. The inability to obtain such a1 ]' y( i( b( t( F9 x5 F
history, or failure to ask the specific questions, may3 N* p4 k7 i4 S: D; K" p
result in extensive, unnecessary, and expensive8 l5 _; J) ?2 B! A. B T
investigation. The primary care physician should be
( T- B5 ^/ |& f. Q% |aware of this fact, because most of these children& B7 Q3 @/ ~( S
may initially present in their practice. The Physicians’5 _' z- ]: _2 N2 m
Desk Reference and package insert should also put a
- A, G4 x9 X4 o. V* y& ]warning about the virilizing effect on a male or
- r% i0 k8 h3 E* Zfemale child who might come in contact with some-
- A7 p) o! `: o& done using any of these products.# m3 N* n7 X' [: B7 i' C
References$ Z$ L0 @5 |' }) t# V. P
1. Styne DM. The testes: disorder of sexual differentiation
0 d, c* p$ U7 f/ tand puberty in the male. In: Sperling MA, ed. Pediatric0 P; C. @! e V; e4 r$ s
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 ?" h( F; |, L. Z% z7 z+ X2002: 565-628.
: ], F+ ]) J9 l, ?3 J2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 @. j! I3 R. ~7 O7 ppuberty in children with tumours of the suprasellar pineal |
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