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Sexual Precocity in a 16-Month-Old
6 z! ^2 P3 \( R' A' M2 W( P oBoy Induced by Indirect Topical+ t* Q& b( S( z5 V4 E# q+ N
Exposure to Testosterone- T9 E4 K- }) X" ]- I4 I# h
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 h: Q+ t# Z0 z' @5 S/ Q
and Kenneth R. Rettig, MD1
7 w' @ {% j" a* w5 AClinical Pediatrics" [3 [1 Z8 a7 Q: C! ]. w, g
Volume 46 Number 6
5 S; i' o$ |0 \% P& \8 vJuly 2007 540-5431 Q, _# k+ u( S6 M; w
© 2007 Sage Publications
: O# Y8 J7 ^9 T4 U10.1177/0009922806296651& D3 ` u# M3 a4 e$ l m5 _
http://clp.sagepub.com
6 N! a" |: o. thosted at
6 P7 k& V4 m: Dhttp://online.sagepub.com! {' L; l& C l+ p& Q- T
Precocious puberty in boys, central or peripheral,7 Q, ~. ]% X* X) v' \9 t. e
is a significant concern for physicians. Central
, A& x( B! [& s' s0 ?5 `8 v2 Gprecocious puberty (CPP), which is mediated
( n; }: d3 A; W7 X) jthrough the hypothalamic pituitary gonadal axis, has
$ d) {# q! H% x/ S% `1 A) r" N7 qa higher incidence of organic central nervous system
: t7 C; m2 J$ W9 h' nlesions in boys.1,2 Virilization in boys, as manifested
! S8 f. y. n) w J R. Jby enlargement of the penis, development of pubic
" y5 S' Q- p- A, X; ^2 U6 s, Uhair, and facial acne without enlargement of testi-
7 m! @. T) x9 A$ w# }3 o& k& T( gcles, suggests peripheral or pseudopuberty.1-3 We
2 [* ~" j' X6 |report a 16-month-old boy who presented with the5 x! I# E, E7 j' n
enlargement of the phallus and pubic hair develop-! ^8 B, J! t' {! V
ment without testicular enlargement, which was due
! |4 h c5 O9 sto the unintentional exposure to androgen gel used by% q: d% ^9 ]0 `) C6 c4 s8 I: K
the father. The family initially concealed this infor-
# @, S! c; p# W9 X A( p+ c6 Xmation, resulting in an extensive work-up for this: j. u( }0 l0 e: {1 l& R% k, E" Q0 U
child. Given the widespread and easy availability of7 c, p% D9 J0 ]+ E6 h/ u- W j
testosterone gel and cream, we believe this is proba-4 ?4 o m+ h M9 G
bly more common than the rare case report in the9 Y1 v$ x1 W3 g+ b0 c" @# {$ ?
literature.4
P& P& t# u+ p1 h2 _Patient Report7 A/ [& V8 p. M
A 16-month-old white child was referred to the
: A5 d) q& y0 t+ uendocrine clinic by his pediatrician with the concern: S" Q2 W7 {9 f/ f% Y9 v
of early sexual development. His mother noticed- z! y6 Y& ^9 T8 J
light colored pubic hair development when he was& A1 k$ K3 n$ Z- b
From the 1Division of Pediatric Endocrinology, 2University of
( k% p7 ^& G* G( R5 H5 vSouth Alabama Medical Center, Mobile, Alabama.
$ ~3 v4 o4 F: o9 Z# E6 l+ Q3 c2 q6 oAddress correspondence to: Samar K. Bhowmick, MD, FACE,6 s) X# H5 t E7 M
Professor of Pediatrics, University of South Alabama, College of
4 c6 L& [8 H) ?! _" f5 EMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;0 U' Z, Y1 O: U5 J, U& {
e-mail: [email protected].
' ?+ Y W& e) t$ O- d0 Yabout 6 to 7 months old, which progressively became' G% T0 k' k$ Y X
darker. She was also concerned about the enlarge-& l7 w, @0 n( z! L7 s" a1 B& t z$ `
ment of his penis and frequent erections. The child
- f' G5 h' t2 n3 b* G+ m8 \was the product of a full-term normal delivery, with
& x) B9 y1 i2 T* g: sa birth weight of 7 lb 14 oz, and birth length of6 A0 d ^. b! W- G3 \
20 inches. He was breast-fed throughout the first year
3 E- [) S) Q" h$ G5 `6 F/ A' D, rof life and was still receiving breast milk along with
3 z* P. W% E# _( W1 L) |solid food. He had no hospitalizations or surgery,6 l1 {) N; Z0 j& n" d- e0 c6 l' w
and his psychosocial and psychomotor development
5 s. N) I# M5 j( Q. A zwas age appropriate.- N8 @' D. [9 |+ H! l3 ^
The family history was remarkable for the father,
! z* }9 j+ L k5 r/ r5 mwho was diagnosed with hypothyroidism at age 16,. g+ l0 |0 k9 I, u f% A J2 T+ B
which was treated with thyroxine. The father’s. e# R0 N# ~: X, k' {. f% I: @3 w, z5 o* k
height was 6 feet, and he went through a somewhat+ o. P! Z% k* K! U- _) _! }' U* V
early puberty and had stopped growing by age 14.$ }6 l" c' y# S% B
The father denied taking any other medication. The
# J& I) b. v3 X2 wchild’s mother was in good health. Her menarche3 |* s( V* E$ I1 {) X- e
was at 11 years of age, and her height was at 5 feet2 t( N' y6 s% o7 ~; p5 S
5 inches. There was no other family history of pre-" d$ K' K0 k4 g- Y# q3 W: l
cocious sexual development in the first-degree rela-( ^ `8 u) K, K# r) o& m2 Y/ p
tives. There were no siblings.( B r: B5 Z2 C$ B9 a" Y- Q
Physical Examination
: N* Z/ K% y$ o; jThe physical examination revealed a very active,
& t& W P& P0 p; xplayful, and healthy boy. The vital signs documented
/ c3 K, }& J& d) g" q# c' h/ X# Da blood pressure of 85/50 mm Hg, his length was6 s! C& Y! ]% q6 D N& R3 F- p
90 cm (>97th percentile), and his weight was 14.4 kg7 A5 ^# T: ^0 P: C; _1 ?! g
(also >97th percentile). The observed yearly growth
1 i4 Q6 B% m R. z/ y7 d! Zvelocity was 30 cm (12 inches). The examination of
4 m, f5 L; u; S5 p/ x/ Zthe neck revealed no thyroid enlargement.
! ~' a+ t, B% FThe genitourinary examination was remarkable for
- P/ ~' `6 L& |, g& c! g# penlargement of the penis, with a stretched length of
6 P& v/ `2 K8 ?1 X* `: @+ Z8 cm and a width of 2 cm. The glans penis was very well& _* ^$ h8 B e, R2 {' ^9 ]7 e
developed. The pubic hair was Tanner II, mostly around
3 d0 I5 M! S, P( ^$ j$ h! q) ?540( B3 g1 g% u" I6 ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" y0 G8 K" }9 c) I( Sthe base of the phallus and was dark and curled. The
5 [+ P+ Z0 u# h& }% Ttesticular volume was prepubertal at 2 mL each.
& E1 h: q$ [( X* O+ ~# g- T! WThe skin was moist and smooth and somewhat
1 q5 Y( |9 c1 D( e0 B$ r4 @oily. No axillary hair was noted. There were no; O v) s e* z* }: }3 O4 F5 p- |
abnormal skin pigmentations or café-au-lait spots.
4 [$ P1 K% y; S; }5 `Neurologic evaluation showed deep tendon reflex 2+! ~& G8 {3 s, C0 ~
bilateral and symmetrical. There was no suggestion
7 ~$ X3 l4 q4 y, D3 Y) nof papilledema.
4 B% }: e% _& Q' v; KLaboratory Evaluation
7 Z9 x8 r% R4 m& mThe bone age was consistent with 28 months by
( b/ }, U2 A, Rusing the standard of Greulich and Pyle at a chrono-
' g$ t# f; S' ~: \8 m+ |' w- f( d+ Nlogic age of 16 months (advanced).5 Chromosomal' a2 P0 N- y: D
karyotype was 46XY. The thyroid function test) P' [, k! Z' s( R
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 Z, T( s, H: t! C6 s" L# o0 H8 l% mlating hormone level was 1.3 µIU/mL (both normal).0 b' F! f) d' F8 G0 ^+ y6 w8 ]
The concentrations of serum electrolytes, blood
9 i: r3 i/ c( S$ m: X( g+ G% l. A' ?urea nitrogen, creatinine, and calcium all were
# F/ _& @4 I1 x; I: N, Uwithin normal range for his age. The concentration
x/ t' A# J/ [. V# }of serum 17-hydroxyprogesterone was 16 ng/dL2 u; |5 \2 b$ H% E6 @# u
(normal, 3 to 90 ng/dL), androstenedione was 20! D8 r K3 m1 o
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! |9 ~1 Y; W+ C$ v- U" ?, z/ Lterone was 38 ng/dL (normal, 50 to 760 ng/dL),
- m) \/ k5 `& Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to8 L L/ |2 m _; `
49ng/dL), 11-desoxycortisol (specific compound S)
- ~6 m! i& M7 t7 X! twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% Y+ X5 `% c+ L1 ^1 Ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 |: q; e x' T8 ]" m1 l8 btestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
1 m [9 u! o4 {, jand β-human chorionic gonadotropin was less than
; Q! v4 J! b N1 V5 mIU/mL (normal <5 mIU/mL). Serum follicular% |/ O H* y/ J) q
stimulating hormone and leuteinizing hormone
, [: x9 x' _& R' d& v$ s4 `- d+ t6 b1 Iconcentrations were less than 0.05 mIU/mL" l+ r! E S% K! J5 U
(prepubertal).: N2 e" x* |% M
The parents were notified about the laboratory
2 H6 X7 W1 g3 z" c5 p4 Lresults and were informed that all of the tests were8 I3 j+ |# e5 ]' K" B
normal except the testosterone level was high. The
5 q: o* }# R ^follow-up visit was arranged within a few weeks to
+ z8 S) Q M9 E) f0 Z7 Yobtain testicular and abdominal sonograms; how-! R3 Y" t3 U- F- m
ever, the family did not return for 4 months.& B; p) e5 J }) U, C. L z4 u
Physical examination at this time revealed that the
' Y7 }. s t) z8 Cchild had grown 2.5 cm in 4 months and had gained
% z# |7 d; P6 a, z* q; q/ R4 \9 E2 kg of weight. Physical examination remained p( X; r7 a$ k+ m3 L" }
unchanged. Surprisingly, the pubic hair almost com-! t3 U9 z0 K9 ~! A$ f( f- Q
pletely disappeared except for a few vellous hairs at
/ p8 Z% U+ f: ?, w! Wthe base of the phallus. Testicular volume was still 2
. f5 b, L6 Q- G! N1 h( d7 T |mL, and the size of the penis remained unchanged.
" I4 ]9 u3 s/ H, I K* IThe mother also said that the boy was no longer hav-1 g. i' y/ w" X" J! t# P; }* x
ing frequent erections.
* l+ J) ^' q$ P0 B! aBoth parents were again questioned about use of
: q/ }4 k, s' l! l& Y' I3 xany ointment/creams that they may have applied to
0 p" C/ y- r x2 L% k( `the child’s skin. This time the father admitted the, O* X* T$ r6 T
Topical Testosterone Exposure / Bhowmick et al 541
8 U# `6 l# `: Iuse of testosterone gel twice daily that he was apply-
3 C1 J! q9 X1 D& ring over his own shoulders, chest, and back area for/ z& h( M& m3 [1 u1 A" X, }; ?
a year. The father also revealed he was embarrassed8 S* y/ O& r' m6 O! [
to disclose that he was using a testosterone gel pre-8 Z7 W7 S2 }1 M+ k
scribed by his family physician for decreased libido0 C. T$ a) Y% f2 C4 V; T
secondary to depression.
- f: h- e/ @' U, r# E& XThe child slept in the same bed with parents.
/ w/ @) S/ ^; \+ ^2 j0 W4 r* [The father would hug the baby and hold him on his8 J* |; f) a1 [0 Y
chest for a considerable period of time, causing sig-
( X0 R5 y. q& knificant bare skin contact between baby and father., l$ Z$ p0 Q& {' B0 h6 W4 F
The father also admitted that after the phone call,' i, C# Y5 g0 l K& g( p
when he learned the testosterone level in the baby% e$ B0 @8 G u- z0 x3 u/ ~, ~' C
was high, he then read the product information
: H) U+ T: |; l1 z# e# Tpacket and concluded that it was most likely the rea-
+ O! r3 a+ f) C1 k5 B lson for the child’s virilization. At that time, they. J# H) m; t8 ~- X7 i4 x0 @+ h8 E
decided to put the baby in a separate bed, and the
: _2 B. e% Q) |& Yfather was not hugging him with bare skin and had
' v9 _, y) A8 ^been using protective clothing. A repeat testosterone
. \ R# v/ m- S" w8 ]4 k) v5 ntest was ordered, but the family did not go to the
* m$ l5 j& t) O2 r5 O* _: y3 _laboratory to obtain the test.
' ~8 h: y2 R E: v% u- z4 G, r' ~/ F; `/ xDiscussion
; H9 [; E# D$ rPrecocious puberty in boys is defined as secondary
2 }4 A* l, d) s; E' q& Hsexual development before 9 years of age.1,4
0 y( T8 u3 B7 a1 Q. n/ P8 S- Y+ L8 fPrecocious puberty is termed as central (true) when8 L- ~6 X5 j1 z0 C8 S; ~, ^5 Z! a% g: P
it is caused by the premature activation of hypo-; O- M- X9 B+ \' a6 S6 z& d
thalamic pituitary gonadal axis. CPP is more com-
* ^1 r/ x' u% W6 Rmon in girls than in boys.1,3 Most boys with CPP
5 i) a' m+ m) ?+ p8 S8 ?, amay have a central nervous system lesion that is$ ?% K( C6 W. f& w
responsible for the early activation of the hypothal-( C4 ?! I" x2 E3 z+ Q
amic pituitary gonadal axis.1-3 Thus, greater empha-
1 k3 v! }8 z0 Z6 \7 l1 z- Z. w# osis has been given to neuroradiologic imaging in/ C+ O, K. S5 S" o
boys with precocious puberty. In addition to viril-# k4 q3 o5 L, S$ v# t
ization, the clinical hallmark of CPP is the symmet-
2 p# n/ ?- Y, }$ M( srical testicular growth secondary to stimulation by
* O+ e) e, u+ {9 W: `/ b* a. w6 @; _gonadotropins.1,3
* K6 [, d+ O' B, p: h$ ~Gonadotropin-independent peripheral preco-2 G7 d* a% U: k. N2 A
cious puberty in boys also results from inappropriate
! n) b7 G) V2 a; T/ M1 Bandrogenic stimulation from either endogenous or
8 d. _0 W7 t7 v; Mexogenous sources, nonpituitary gonadotropin stim-
" p: L5 M; G4 H* M( x9 Rulation, and rare activating mutations.3 Virilizing
& G7 P' h4 Y% M4 icongenital adrenal hyperplasia producing excessive
7 i2 z: y. n# K6 ?. e' I& tadrenal androgens is a common cause of precocious) c |" B, [$ t ~, `! @# A$ o
puberty in boys.3,4
: A5 w! S7 k0 e0 q9 r# g* ^$ ~5 cThe most common form of congenital adrenal
9 e1 d7 Y( t0 u/ o6 Q" O* ^hyperplasia is the 21-hydroxylase enzyme deficiency.( a7 `( Z$ N1 {0 w! w/ d$ u+ G
The 11-β hydroxylase deficiency may also result in, w; }* \7 h2 \4 S
excessive adrenal androgen production, and rarely,1 Q3 B0 d8 u4 R
an adrenal tumor may also cause adrenal androgen
" f, |5 ^% y, L, r) `7 U3 Yexcess.1,3: w, ~9 J% ~/ A$ {- v# V( [/ s: J/ Z" ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ V3 {$ u( r! q5 H! b; b
542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 Y! ]+ ]" \! r' P! g0 z2 O, @: f
A unique entity of male-limited gonadotropin-
' u! c' \* m+ H6 windependent precocious puberty, which is also known' b4 W2 ^0 G. y: w2 }
as testotoxicosis, may cause precocious puberty at a
8 ~4 G3 u1 u3 \! N: vvery young age. The physical findings in these boys" |% K1 W/ L* T" W3 Q
with this disorder are full pubertal development,( g- }# g6 Z- P3 N
including bilateral testicular growth, similar to boys" e" U) y" u' I N( i
with CPP. The gonadotropin levels in this disorder" ^+ I/ f6 N6 L. f$ x
are suppressed to prepubertal levels and do not show
& b8 w7 l' u3 x0 Spubertal response of gonadotropin after gonadotropin-$ v. f" H8 ^8 `8 D6 V. ^0 O$ a% Z
releasing hormone stimulation. This is a sex-linked
- g! A a6 c1 T( M) A1 M5 qautosomal dominant disorder that affects only
- j. C. S% i& cmales; therefore, other male members of the family6 ?" f& u! x) c1 W. E% u* E
may have similar precocious puberty.3' I) r' f( M/ r
In our patient, physical examination was incon-" u* ]! f2 z6 _5 b& l# i' Z
sistent with true precocious puberty since his testi-
: S7 ?. b- J& K. B) `# icles were prepubertal in size. However, testotoxicosis7 o( S' e5 ^- ~" h/ w1 q
was in the differential diagnosis because his father9 }5 K( @6 h$ ?) h
started puberty somewhat early, and occasionally,
. H: E% z6 @9 W* \, |, t1 t; Ytesticular enlargement is not that evident in the, k1 n$ w4 k1 Y) c
beginning of this process.1 In the absence of a neg-
6 r& T& [ l- L5 M6 K# Uative initial history of androgen exposure, our
/ W- q+ ~! J" j, A: s! ]! Ybiggest concern was virilizing adrenal hyperplasia,
/ k# ]9 }/ x4 @either 21-hydroxylase deficiency or 11-β hydroxylase
0 m3 D3 B* T9 |! Q5 G0 G) e" vdeficiency. Those diagnoses were excluded by find-
" `) c: m, a# J! Ring the normal level of adrenal steroids., f3 b' |# R9 S: D
The diagnosis of exogenous androgens was strongly
* s1 z8 N/ ?- \$ ^( E) gsuspected in a follow-up visit after 4 months because
& c' v E6 m8 s" ^3 I$ athe physical examination revealed the complete disap-; Z6 m6 q$ `* T' A4 s
pearance of pubic hair, normal growth velocity, and
% j4 `2 z o& ^$ ^9 @decreased erections. The father admitted using a testos-0 x% S& m7 b1 u; ]- t" y- p+ K, J/ ^
terone gel, which he concealed at first visit. He was
5 u" k) }# B/ u0 J) @using it rather frequently, twice a day. The Physicians’% I# \9 B& z$ q- ^
Desk Reference, or package insert of this product, gel or
+ o. m, b' Q0 g5 A' M& Tcream, cautions about dermal testosterone transfer to
. F4 h+ L* z- K1 P' E4 ^) S! m# Q" bunprotected females through direct skin exposure.
+ Q* U( l1 [* |Serum testosterone level was found to be 2 times the
& r" @* o# x, X0 G( t, wbaseline value in those females who were exposed to& d( D0 R" t0 d1 j O- n
even 15 minutes of direct skin contact with their male# w6 V" F2 F* v! R; N# P
partners.6 However, when a shirt covered the applica-: h" G6 z& h B, c8 g
tion site, this testosterone transfer was prevented.
: z; ]1 ~5 Y5 m+ a1 NOur patient’s testosterone level was 60 ng/mL,# E6 G( I0 Y, ^
which was clearly high. Some studies suggest that5 ~, B" t' _2 \4 P8 y( c
dermal conversion of testosterone to dihydrotestos-
4 ^" e2 w/ {9 I' V6 {8 P7 T+ Q V4 I+ R. cterone, which is a more potent metabolite, is more
: s, Z3 q/ c5 C6 Tactive in young children exposed to testosterone! V. f- C4 Z! M s
exogenously7; however, we did not measure a dihy-
2 D( @7 K2 Y# r2 D$ ?3 Jdrotestosterone level in our patient. In addition to
* O$ \! D5 q+ M4 R2 {virilization, exposure to exogenous testosterone in
7 F8 {( e. g* W: h. v. echildren results in an increase in growth velocity and
, @- l2 L( E6 i9 zadvanced bone age, as seen in our patient.4 B7 _% Y( f9 m8 ?0 ^" N1 K
The long-term effect of androgen exposure during+ y8 q3 v) f5 o" _
early childhood on pubertal development and final. y) U( H% w* @* h& a2 C9 u* ^
adult height are not fully known and always remain; [: D' X0 T- ~ [
a concern. Children treated with short-term testos-
/ E. Y H) o* e: H0 E0 Zterone injection or topical androgen may exhibit some" X5 i& F" b+ `" e0 S" @" k
acceleration of the skeletal maturation; however, after
7 k G. o; \; V2 |cessation of treatment, the rate of bone maturation
j2 Q6 X) Z R4 ?decelerates and gradually returns to normal.8,9
% s. q) P1 W' ]$ t: ^+ M' \There are conflicting reports and controversy
# Y [/ a# y- v1 \+ Bover the effect of early androgen exposure on adult& G0 P6 g+ G j& H, ^4 H
penile length.10,11 Some reports suggest subnormal
, G; N4 o) r- j2 y1 vadult penile length, apparently because of downreg-
( S; h0 Y- L$ {ulation of androgen receptor number.10,12 However,# O; K @, J8 t
Sutherland et al13 did not find a correlation between8 k* _9 y1 _4 t$ i2 A8 f4 i
childhood testosterone exposure and reduced adult
2 A, P4 O1 K# @0 q2 Z7 _penile length in clinical studies.' n a \" e+ X4 V7 @
Nonetheless, we do not believe our patient is
9 P& ?: T0 W$ p$ ~" sgoing to experience any of the untoward effects from
) e! A6 w- h4 p9 ftestosterone exposure as mentioned earlier because6 n& o7 N/ ~8 Y9 r$ x* F& W: n
the exposure was not for a prolonged period of time.% P/ v% V" p8 ~& x" X
Although the bone age was advanced at the time of+ p$ }5 y/ _6 p. }
diagnosis, the child had a normal growth velocity at) Y, r1 v, T7 J
the follow-up visit. It is hoped that his final adult
- ~& h4 A& v& fheight will not be affected.# z' r7 J3 X( U
Although rarely reported, the widespread avail-
* y5 ]9 r, ]' d" i- S& Uability of androgen products in our society may
3 v7 F3 g) i6 c/ N2 W. v! tindeed cause more virilization in male or female( S6 Q7 Y+ q/ v5 L
children than one would realize. Exposure to andro-+ C* w4 D- {, @, T/ S- k$ @
gen products must be considered and specific ques-& V$ f3 v. y/ e- O
tioning about the use of a testosterone product or
: i% b3 o% W" q6 g/ |$ t2 x- G- kgel should be asked of the family members during
5 ]; [! d2 d4 U) p Vthe evaluation of any children who present with vir-
/ m e: [; Y g T' K2 \ilization or peripheral precocious puberty. The diag-
! ^( b- B- ]# Ynosis can be established by just a few tests and by9 a R" _ y' g" }
appropriate history. The inability to obtain such a, Q5 j# Y+ T7 V/ k
history, or failure to ask the specific questions, may
4 g+ L' \5 |* o% Mresult in extensive, unnecessary, and expensive
! |0 W) a. n' v/ x0 Finvestigation. The primary care physician should be- `+ d' g( U' m% X
aware of this fact, because most of these children7 y5 X# q [, e$ K7 t1 u
may initially present in their practice. The Physicians’/ a8 \4 g1 e6 k5 W# r
Desk Reference and package insert should also put a) N1 O3 |+ a+ M1 M
warning about the virilizing effect on a male or
0 P& s! H! X' r' ^& G: Bfemale child who might come in contact with some-$ }' e; J# x* H% x4 _" E1 I9 d4 ?
one using any of these products.
; u G( m7 s& }; L& o( qReferences
8 @% p2 I. \) ?3 z) x2 M1. Styne DM. The testes: disorder of sexual differentiation+ F0 ?1 I8 |. b
and puberty in the male. In: Sperling MA, ed. Pediatric
/ y0 t9 i! S4 B6 i7 _1 TEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' {5 @8 l* n6 s2002: 565-628.
: }) B: C3 V) K$ Z+ i2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. v( ~, U9 g4 ^. C& s
puberty in children with tumours of the suprasellar pineal |
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