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Sexual Precocity in a 16-Month-Old C V! P1 [, F
Boy Induced by Indirect Topical/ H' f, {7 H. o
Exposure to Testosterone
( p! z7 b, h$ t- k2 u: sSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
, b) X! R) s4 Kand Kenneth R. Rettig, MD1
1 g+ E7 W" S7 Q6 A6 L) lClinical Pediatrics3 {6 S0 [$ h* V l! z! s0 T
Volume 46 Number 65 A% W& R3 v+ M) r7 G% P
July 2007 540-543
2 u h7 q- A8 g! O1 U) j* [© 2007 Sage Publications2 `& q/ Y& f/ B% A
10.1177/0009922806296651
) o" V2 f6 f$ F$ T2 t( ]1 }1 m7 Chttp://clp.sagepub.com' L3 h8 p7 U3 m% G& E
hosted at0 [: n& S2 L- T- P
http://online.sagepub.com: }# c, O7 N( u6 b1 |4 h5 @
Precocious puberty in boys, central or peripheral,
# _& I1 u4 x& m" A( Fis a significant concern for physicians. Central
( S2 _: v8 Y. @9 L. @/ @5 cprecocious puberty (CPP), which is mediated
" j# {+ X2 M, Xthrough the hypothalamic pituitary gonadal axis, has
! h: X: m( }# Y) E0 na higher incidence of organic central nervous system3 T0 Y9 s! I; }9 ^7 R; A
lesions in boys.1,2 Virilization in boys, as manifested
- D( s2 o% e5 ~5 A4 s/ Wby enlargement of the penis, development of pubic1 U+ N4 q/ o# U+ O+ I7 L: o9 C
hair, and facial acne without enlargement of testi-' S! B; J# r4 v. v$ L1 f8 |0 i ~7 T
cles, suggests peripheral or pseudopuberty.1-3 We) I+ ~) J6 ^. K$ y7 K' ]7 h
report a 16-month-old boy who presented with the% g% M$ j2 w& c3 P
enlargement of the phallus and pubic hair develop-
% r8 v, N) f* G+ oment without testicular enlargement, which was due3 C. v8 K) M3 i ], H* ^
to the unintentional exposure to androgen gel used by
9 ]7 T# u! B! ^) qthe father. The family initially concealed this infor-+ V& r- e+ n& E
mation, resulting in an extensive work-up for this2 r5 Q/ X( U/ K2 l; H
child. Given the widespread and easy availability of
0 `- D# h, z/ o. [5 K; {testosterone gel and cream, we believe this is proba-
$ ~, m4 I; l# h" sbly more common than the rare case report in the4 F8 ]' \- d5 a2 S7 m
literature.4
' [. C: q/ L/ K, o# sPatient Report
) F# ]+ Q8 ]# k% U$ S3 J5 wA 16-month-old white child was referred to the
" K+ ^7 O' x) o/ }7 z c! sendocrine clinic by his pediatrician with the concern
. h) o0 ~2 T$ ?* s$ m2 k- Uof early sexual development. His mother noticed
7 f* Z) }% y7 alight colored pubic hair development when he was* v3 I0 {: Y8 ] h0 H* Y9 s
From the 1Division of Pediatric Endocrinology, 2University of
- X, q1 }; i" R0 ]/ z' j0 |; uSouth Alabama Medical Center, Mobile, Alabama.
$ h: v2 R& P% \+ P! JAddress correspondence to: Samar K. Bhowmick, MD, FACE,
9 k, d* v; @: T$ V% \8 R6 dProfessor of Pediatrics, University of South Alabama, College of
+ G3 G6 k9 ^+ VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
+ y3 U' Z! h, `3 q; I3 Je-mail: [email protected].
4 ~, O' [, a5 F( U7 Z: N3 nabout 6 to 7 months old, which progressively became
! D4 s# Z6 a# O7 \( Rdarker. She was also concerned about the enlarge-
0 n3 y1 O6 N# ?. \ment of his penis and frequent erections. The child
" j. D& w' d! V/ ? `- Awas the product of a full-term normal delivery, with
7 z# k5 ^( i# u9 ^a birth weight of 7 lb 14 oz, and birth length of# _8 Y/ A3 u( {% q4 {7 ^2 F
20 inches. He was breast-fed throughout the first year
5 O/ z1 _ U( o6 r8 c" [of life and was still receiving breast milk along with# j6 H" r) T. G4 T
solid food. He had no hospitalizations or surgery,
" O2 j* q6 q( e7 ^and his psychosocial and psychomotor development* Z- [& C9 {8 z8 s0 }
was age appropriate.$ I/ k c0 _1 ]
The family history was remarkable for the father,+ I @' q6 t0 J0 F
who was diagnosed with hypothyroidism at age 16,. e/ R( I; Y' L5 h
which was treated with thyroxine. The father’s2 r" B9 d! o7 G9 ]8 d4 z3 u
height was 6 feet, and he went through a somewhat
3 c0 R. M: h( t3 S% ^" j& o$ Oearly puberty and had stopped growing by age 14.
/ `, T% U1 q. N5 IThe father denied taking any other medication. The# ?$ Q* B5 h& G( }1 p# I9 G
child’s mother was in good health. Her menarche2 t" ?" w R+ ] B
was at 11 years of age, and her height was at 5 feet% _& E! q0 ]6 L/ W# c1 X2 M5 }: v
5 inches. There was no other family history of pre-
% B- h6 _$ T, {2 x! d* Ococious sexual development in the first-degree rela-
& E7 o/ S, a& V- l. |2 Ktives. There were no siblings./ F% O) V( W1 z8 N4 X5 m# j
Physical Examination
) r3 t7 ]0 G- N: a" @- tThe physical examination revealed a very active,
& n8 ?+ c7 V; P; B$ e. r: v; Eplayful, and healthy boy. The vital signs documented
( z7 Z2 ~- B R: g6 r/ P$ P: @! za blood pressure of 85/50 mm Hg, his length was1 N* O6 s5 V) z
90 cm (>97th percentile), and his weight was 14.4 kg$ ]% A. N4 g- j+ [1 C" ~
(also >97th percentile). The observed yearly growth
/ J; [3 x% `5 Y4 g% Uvelocity was 30 cm (12 inches). The examination of
! R7 c2 x1 l" T7 ethe neck revealed no thyroid enlargement.
0 z' P9 h1 d: o; n5 zThe genitourinary examination was remarkable for
2 e8 b0 K1 d% E. q. @2 F0 u; T9 {enlargement of the penis, with a stretched length of
/ G$ B2 p# Z5 z. ?! c8 cm and a width of 2 cm. The glans penis was very well
; ?3 N T+ p, Q* n9 u( X! M) ^0 k/ Tdeveloped. The pubic hair was Tanner II, mostly around, y! b8 c2 {9 ]# B9 Y
540" c( X: o5 {/ @+ z* Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 l9 Z) V4 x: s, D: Dthe base of the phallus and was dark and curled. The
* F* _; t( a# |/ {testicular volume was prepubertal at 2 mL each.& h2 H. {( i$ \6 T
The skin was moist and smooth and somewhat& H& v& a7 L$ d; o! D- o& M1 B
oily. No axillary hair was noted. There were no4 |1 \) E" |9 ^, K/ H9 F
abnormal skin pigmentations or café-au-lait spots.
$ r- c! F' Q7 w1 H9 gNeurologic evaluation showed deep tendon reflex 2+4 @: k6 z- Q) k" F; L3 E
bilateral and symmetrical. There was no suggestion5 x3 z# @' O. N: Q9 P: t) i* W
of papilledema.
6 [% L2 ]- n2 _. G3 d1 F7 h$ L$ N) CLaboratory Evaluation
) e: B0 p1 y- r+ U: `7 XThe bone age was consistent with 28 months by; b8 t$ C/ j) H5 a0 i
using the standard of Greulich and Pyle at a chrono-# U) O# n- G; j% f' K: J
logic age of 16 months (advanced).5 Chromosomal
3 N, D" `9 Y1 Y9 y( B5 }- x2 Kkaryotype was 46XY. The thyroid function test/ _2 e* d1 s- O3 h& X q; [
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
8 C8 T/ w! s z+ n" Tlating hormone level was 1.3 µIU/mL (both normal).
0 X, @7 d; w3 x' x& A7 ^The concentrations of serum electrolytes, blood" {; A! X0 a1 E6 ?
urea nitrogen, creatinine, and calcium all were& t w( Y6 _6 z. _& k% J3 n7 g" h
within normal range for his age. The concentration
( l: \* A5 K1 R0 \1 Aof serum 17-hydroxyprogesterone was 16 ng/dL/ M+ C1 F- c' q) j6 z
(normal, 3 to 90 ng/dL), androstenedione was 20
: P# s3 @/ y3 |& E2 S( i: kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, ]$ ?2 H" T. ~. X
terone was 38 ng/dL (normal, 50 to 760 ng/dL)," {* s& Z( ~8 ?& D; G! j
desoxycorticosterone was 4.3 ng/dL (normal, 7 to: h8 y# r: P: S% }- q
49ng/dL), 11-desoxycortisol (specific compound S)
9 a4 l" |, E+ f# G* x* @was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ d+ b; R& R& _. a; i4 G5 Atisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ p9 P' W, p0 `) R) \& N
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, t$ A& m; q3 Y6 z, ^and β-human chorionic gonadotropin was less than: v* u1 Y0 f$ o
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# k2 G! q; S" x6 istimulating hormone and leuteinizing hormone% Y, B" @& w [1 }4 S
concentrations were less than 0.05 mIU/mL7 t W# N+ H; u
(prepubertal).
1 _8 z* X) u. g) {, WThe parents were notified about the laboratory
5 |0 L2 K: A' ~" Jresults and were informed that all of the tests were3 f, ~9 a5 } U. K
normal except the testosterone level was high. The
) U+ D; P6 N( ?9 b7 m! b. c5 h3 qfollow-up visit was arranged within a few weeks to
& o# h4 g: s( I. }) b+ oobtain testicular and abdominal sonograms; how-: C0 W& v- x# ?$ t/ ?$ D1 Z/ J: \
ever, the family did not return for 4 months.
( a% k0 `( U/ n3 ]2 [( DPhysical examination at this time revealed that the, s! T' e' y( m8 C
child had grown 2.5 cm in 4 months and had gained
# t8 A7 [* y- a) x2 J3 N+ r2 kg of weight. Physical examination remained
. d3 M$ u V& o% `+ gunchanged. Surprisingly, the pubic hair almost com-: K& S4 A3 m, {. _+ c0 y8 r
pletely disappeared except for a few vellous hairs at1 O) N& j. b8 `0 F8 g% B; _& m
the base of the phallus. Testicular volume was still 2" O1 O$ z" Q( S; Y; i. r& h- [( M0 u' {
mL, and the size of the penis remained unchanged.) {$ H8 N9 C# O' c/ `" `' W
The mother also said that the boy was no longer hav-+ B; [0 d) j' V4 a5 d
ing frequent erections.
' r* l( S3 Q+ @/ nBoth parents were again questioned about use of0 a, }0 y, v; D9 B' o
any ointment/creams that they may have applied to7 C+ d* [0 X& `$ W, c; p% P
the child’s skin. This time the father admitted the2 v& S0 A5 J/ u% k
Topical Testosterone Exposure / Bhowmick et al 541) m- ?9 t" w2 @$ G T
use of testosterone gel twice daily that he was apply-9 s3 h* e% \) T4 ^8 j
ing over his own shoulders, chest, and back area for
- m7 N( B1 Y3 g. K0 O z9 `a year. The father also revealed he was embarrassed9 L1 D+ \) w3 V5 j; r
to disclose that he was using a testosterone gel pre-( \+ _3 W6 e7 Z4 y0 C3 P
scribed by his family physician for decreased libido
( C+ j4 U1 \3 C( k; X! t. H8 Hsecondary to depression.9 C* ~/ P! p0 |6 ~( L6 Y$ ?7 h8 f
The child slept in the same bed with parents.0 [$ N8 x1 k; z+ d" v1 [# J, c
The father would hug the baby and hold him on his; A3 n/ h/ W6 Z5 V3 c3 ?( c) j
chest for a considerable period of time, causing sig-
) s4 m- n1 p3 a2 `nificant bare skin contact between baby and father.- x4 [# ]- H& X2 S7 x* L' ]7 S/ t
The father also admitted that after the phone call,
/ ~* ]5 S8 h/ Ewhen he learned the testosterone level in the baby( x! a, t: f) V5 F' Q
was high, he then read the product information
B) {7 J3 b" e* ?( fpacket and concluded that it was most likely the rea-0 |2 p. h4 F. Y2 Y( f
son for the child’s virilization. At that time, they4 w" y' E% j* h S' d& n
decided to put the baby in a separate bed, and the( f u v, q4 }
father was not hugging him with bare skin and had
' o$ d7 ~* I9 r1 [$ P5 j, f. Xbeen using protective clothing. A repeat testosterone
. c# k/ X% B/ Rtest was ordered, but the family did not go to the! H1 i0 L: U; B8 Z! ~2 k
laboratory to obtain the test.! a2 s7 `+ Z3 n/ G
Discussion
! b5 v9 @( l; G% CPrecocious puberty in boys is defined as secondary
0 E% _3 Y* F/ V" n: wsexual development before 9 years of age.1,4. k# e2 p& _! {
Precocious puberty is termed as central (true) when( a, M8 {. w6 H
it is caused by the premature activation of hypo-
; \5 e- E N: nthalamic pituitary gonadal axis. CPP is more com-" @( q& [9 |# R
mon in girls than in boys.1,3 Most boys with CPP
3 O8 q4 g* s3 \& d( g/ Wmay have a central nervous system lesion that is
5 N5 A( ^, u$ Z, ~5 Z6 Uresponsible for the early activation of the hypothal-6 W0 r$ J# |. D: Y( S; _
amic pituitary gonadal axis.1-3 Thus, greater empha-+ U2 S% q: L3 p; P% @' ~" b% a
sis has been given to neuroradiologic imaging in
+ @3 i7 M- u& J* M4 B; b' Bboys with precocious puberty. In addition to viril-
: k2 w: G6 M: _4 Q Gization, the clinical hallmark of CPP is the symmet- L9 F$ i$ ?8 N2 a0 \
rical testicular growth secondary to stimulation by' u3 x9 d+ K$ @* j1 p5 f
gonadotropins.1,3+ {8 c- q( Q, f+ j# K2 v+ K
Gonadotropin-independent peripheral preco-
- G% t' L Z5 l& o( F0 G1 scious puberty in boys also results from inappropriate
8 o/ N2 J1 }* X9 oandrogenic stimulation from either endogenous or8 [: e9 h7 H2 ^7 ?
exogenous sources, nonpituitary gonadotropin stim-( d$ Z7 X: ~0 s" u
ulation, and rare activating mutations.3 Virilizing
3 z9 @3 L3 h1 l- Z4 Z- Xcongenital adrenal hyperplasia producing excessive# M2 P5 e3 p( [! n+ o' W5 N& u) y
adrenal androgens is a common cause of precocious
+ L9 ]9 C5 L/ F' ~puberty in boys.3,4
9 L6 G8 S6 Y& p) u- rThe most common form of congenital adrenal
# Q# P4 ~$ E5 z& o+ thyperplasia is the 21-hydroxylase enzyme deficiency.
7 t. t1 |8 |' r: ~% t' h/ GThe 11-β hydroxylase deficiency may also result in
* P4 t1 u9 \1 s& k8 y$ X+ v# qexcessive adrenal androgen production, and rarely,
3 G0 N8 H. ~8 Y5 u+ D- u* L7 z5 van adrenal tumor may also cause adrenal androgen( X5 b: Z! C1 f; X
excess.1,3
) x- s# v$ {1 `* B$ J- l9 l n/ iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 ?2 ]: V, }9 S3 T542 Clinical Pediatrics / Vol. 46, No. 6, July 20072 x j! S8 {7 g7 y) f
A unique entity of male-limited gonadotropin-4 E7 [3 o9 k4 y
independent precocious puberty, which is also known
1 F9 v k' s {2 O. j/ kas testotoxicosis, may cause precocious puberty at a% v G. w# u: A' w/ r! N0 ~
very young age. The physical findings in these boys$ g4 H2 d, p: u& x' P% X
with this disorder are full pubertal development," r% r; z. y% r3 P- X$ V) n2 E
including bilateral testicular growth, similar to boys, f- B2 H& S) J. D' Q
with CPP. The gonadotropin levels in this disorder1 b6 o8 T* f' }& O( Y& o
are suppressed to prepubertal levels and do not show
$ O: c( o% L+ G2 Jpubertal response of gonadotropin after gonadotropin-4 h0 b5 E* `, J% [, o; `
releasing hormone stimulation. This is a sex-linked1 e; a* j [! Z8 R3 J
autosomal dominant disorder that affects only/ B" ]$ g3 k3 l* s" x/ s
males; therefore, other male members of the family! ?6 H0 W2 T) N+ Q! B3 g: g* k
may have similar precocious puberty.37 X7 V% g Q ~( c
In our patient, physical examination was incon-0 f1 H8 e5 C9 Y( Q/ E
sistent with true precocious puberty since his testi-4 h' B' ~# S. o
cles were prepubertal in size. However, testotoxicosis& I& ~- t/ w% e6 f4 H' d
was in the differential diagnosis because his father6 x! W, p* I8 n y6 g4 W1 g! Y
started puberty somewhat early, and occasionally,* Y* a0 c* ?2 ^$ W, {1 \
testicular enlargement is not that evident in the3 ]; O( h6 ]9 k9 b3 H6 f/ D0 ]
beginning of this process.1 In the absence of a neg-) h7 k: I0 J& E
ative initial history of androgen exposure, our
% l% ~) s! T3 Zbiggest concern was virilizing adrenal hyperplasia,
( L# m+ ^. }+ o& ]9 ]- keither 21-hydroxylase deficiency or 11-β hydroxylase
9 ^' s* Y: e9 p) r; Odeficiency. Those diagnoses were excluded by find-- Y- X0 w3 o/ M
ing the normal level of adrenal steroids., [2 o- N7 G$ l2 J- b9 q* \/ h
The diagnosis of exogenous androgens was strongly
% ^# |3 o' Z3 osuspected in a follow-up visit after 4 months because
* b& O, Q. x. Y' H: }, L; xthe physical examination revealed the complete disap-1 t2 f* m9 o7 l, R5 }* q0 `
pearance of pubic hair, normal growth velocity, and6 D4 O" e, \0 m4 d! \; R9 K7 A& G
decreased erections. The father admitted using a testos-; K" c- h+ n. p" R* l
terone gel, which he concealed at first visit. He was
) K# ?& V0 e# jusing it rather frequently, twice a day. The Physicians’! h' o* c6 |( H' U! i) d
Desk Reference, or package insert of this product, gel or- V' I; D: ]: ]' O
cream, cautions about dermal testosterone transfer to
. i6 s G! Q+ ?; _# ^% Vunprotected females through direct skin exposure.' d" Q1 J6 T5 L6 m" ~
Serum testosterone level was found to be 2 times the0 j; R. s' m; {5 l$ r7 G4 O3 R
baseline value in those females who were exposed to3 q/ g1 U3 ]7 Y- O
even 15 minutes of direct skin contact with their male9 ?* A* I" q9 |! f9 ^. v& e/ t
partners.6 However, when a shirt covered the applica-& a' r* u4 k$ I; z# z* A5 P7 J
tion site, this testosterone transfer was prevented.) w2 n/ M6 ^! ]0 }
Our patient’s testosterone level was 60 ng/mL,. t$ H9 P+ {/ b" P' Q" _5 T' @
which was clearly high. Some studies suggest that2 ~) z* _) d3 Q8 x# A- K2 ^
dermal conversion of testosterone to dihydrotestos-% ]1 x+ q1 h, u S" Z8 k, h2 _7 m
terone, which is a more potent metabolite, is more
- j$ h. F3 c" Yactive in young children exposed to testosterone& k* K2 i9 l$ _$ R/ W) l
exogenously7; however, we did not measure a dihy-+ x2 g, O: |3 h2 v% a' {8 t7 r
drotestosterone level in our patient. In addition to
1 ^# n6 P. @. S& @) q8 c& X4 k. i* `virilization, exposure to exogenous testosterone in
( H+ Y, A# H1 y4 f M1 @; dchildren results in an increase in growth velocity and
/ q8 H. K8 \4 V) Wadvanced bone age, as seen in our patient.# P, v9 z0 K2 W8 G7 p& ^
The long-term effect of androgen exposure during
; c0 X0 Y8 u/ w( @" Fearly childhood on pubertal development and final# y8 c7 W/ c- ^& P3 ]
adult height are not fully known and always remain
# V$ A/ I+ @' F1 Ma concern. Children treated with short-term testos-# j( q2 ~" g2 ~" }& s; N( E& h
terone injection or topical androgen may exhibit some
0 k1 s& g3 Y1 @4 Aacceleration of the skeletal maturation; however, after& Y& |' P; @1 ?, r& o- J @
cessation of treatment, the rate of bone maturation0 @' e/ D& J0 W& a! J7 J2 J* U
decelerates and gradually returns to normal.8,9* q, I# m0 ^( \. M. l, {( y
There are conflicting reports and controversy; p/ A# i/ L* [: F( a" n; s% i, U8 ]
over the effect of early androgen exposure on adult! f% J$ w5 D8 w2 u9 |
penile length.10,11 Some reports suggest subnormal
" y2 @& C( n7 e, }/ Y" m1 Ladult penile length, apparently because of downreg-
1 F k. W5 N. |ulation of androgen receptor number.10,12 However,! X0 i3 w; D } ~, q
Sutherland et al13 did not find a correlation between1 q1 I$ A5 G' U, w. S. ]& W! k
childhood testosterone exposure and reduced adult
) N+ |& N+ @' g+ k: E/ b( Hpenile length in clinical studies.& z: N9 d5 P5 v i% I8 W7 K5 d
Nonetheless, we do not believe our patient is
5 e/ T4 W$ W6 T, P4 H% }going to experience any of the untoward effects from2 }# }) q! k6 |, k& k
testosterone exposure as mentioned earlier because" n. W2 g. o% |( |7 a2 V% w
the exposure was not for a prolonged period of time. d9 x# z2 R. k# ]) X/ X
Although the bone age was advanced at the time of
1 ^6 p/ ]+ h* g7 Sdiagnosis, the child had a normal growth velocity at
# |* X Q8 m; D, Nthe follow-up visit. It is hoped that his final adult
( }' V! [3 w/ f. }height will not be affected.
, G" t0 A* s8 Y# YAlthough rarely reported, the widespread avail-
' N( o. r/ ~% t; x5 }, wability of androgen products in our society may
1 B3 q8 ?7 ]* {indeed cause more virilization in male or female
5 M7 z! C$ f. e% \3 @children than one would realize. Exposure to andro-) P! C, o! M5 b- W5 r4 h9 f' g
gen products must be considered and specific ques-
" B* J3 V7 z) r1 z$ `# Mtioning about the use of a testosterone product or
& y' [) X( C! s; ^, S: w# Agel should be asked of the family members during
9 U0 |! b- _, G( E4 j' _the evaluation of any children who present with vir-
& |' B2 {$ v& o, S4 u( ]" m( q& kilization or peripheral precocious puberty. The diag-
5 h+ Y* ~, j; B5 s D( xnosis can be established by just a few tests and by2 |- {* X5 d/ Y( h F$ I4 a8 g
appropriate history. The inability to obtain such a
# R3 b' ?) ?/ M! z+ B' k6 R' O) Dhistory, or failure to ask the specific questions, may
" k8 ?% @' \$ }* E" q7 Aresult in extensive, unnecessary, and expensive
- E ]2 w3 |; l* f9 v- Qinvestigation. The primary care physician should be B5 D+ H# I* y9 \
aware of this fact, because most of these children# _9 g- @) j) J" Z% p1 y
may initially present in their practice. The Physicians’4 U6 A+ M# Z0 D# j& U7 T5 {
Desk Reference and package insert should also put a
9 S7 k0 n1 v; C1 }, Z4 C Jwarning about the virilizing effect on a male or. Q$ M6 D/ u, A, E3 ?! S
female child who might come in contact with some-
( b9 h3 }% f2 M6 H5 P- y9 jone using any of these products.3 d) K1 \+ k! E( q
References! B# g0 P. \# F) e4 p; j
1. Styne DM. The testes: disorder of sexual differentiation, V6 Z! d- T; p% t" |$ x
and puberty in the male. In: Sperling MA, ed. Pediatric% ?4 C+ x- ^& g; K9 Q& ]7 ?
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 L' E' V$ [, b$ V5 q
2002: 565-628.
5 { |, M+ A( o8 y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
?$ ?" ^6 r3 upuberty in children with tumours of the suprasellar pineal |
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