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Sexual Precocity in a 16-Month-Old$ b% ^9 [ P( q0 H6 x
Boy Induced by Indirect Topical
9 e+ V! z* i6 U' BExposure to Testosterone
+ u: w j7 W3 T- N% q1 E U9 t6 dSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2' p& u. u q+ ]- b. F/ u, {
and Kenneth R. Rettig, MD1( _7 H; ~; l) _+ x- ~1 G
Clinical Pediatrics/ P/ d0 r2 Q6 ]9 W, l5 V
Volume 46 Number 6
. I5 u8 }' i* SJuly 2007 540-543( U! B; H/ R/ ]" q1 A
© 2007 Sage Publications
7 E+ Z2 H& F: q6 D9 O/ E10.1177/0009922806296651
2 ]9 A: t5 {$ g3 H9 e. w }" ]4 ehttp://clp.sagepub.com2 X) x+ C+ Q. f* I: Q* H. Y
hosted at5 A6 d) @6 P; M
http://online.sagepub.com
& w8 K) g) w: b4 i, b( _" \& [Precocious puberty in boys, central or peripheral,
% b: ?! z+ p5 J% M% v! vis a significant concern for physicians. Central
9 m E9 `' Z6 C6 h( wprecocious puberty (CPP), which is mediated
N, X& g, o( v8 L b% \- _7 A' ]3 nthrough the hypothalamic pituitary gonadal axis, has: j7 @9 a7 _1 x+ j0 `
a higher incidence of organic central nervous system
. }5 Y! A( Z6 hlesions in boys.1,2 Virilization in boys, as manifested0 l; r- j8 i7 I, p
by enlargement of the penis, development of pubic
, h! V/ ~' O4 G1 U. ^0 }hair, and facial acne without enlargement of testi-$ P A: q4 D: }. ]- P; ?7 K
cles, suggests peripheral or pseudopuberty.1-3 We
; {, m0 m+ i" Ureport a 16-month-old boy who presented with the4 s# q" _; }8 Y: R" y2 U
enlargement of the phallus and pubic hair develop-1 ]# q5 m( J# o+ y4 Q9 Z
ment without testicular enlargement, which was due
3 V% C' \( A2 Z0 G8 A3 C( q* Dto the unintentional exposure to androgen gel used by
* y: S. o9 |9 J0 Q/ E3 Ethe father. The family initially concealed this infor-+ C2 `% T, _9 p8 u/ w: @) o
mation, resulting in an extensive work-up for this# S. Z* G9 i) o& [, B- R* t2 Z5 Q
child. Given the widespread and easy availability of( ]: D8 D M9 p T
testosterone gel and cream, we believe this is proba-
1 x6 X8 l% f( n8 h- Q- Pbly more common than the rare case report in the4 V; `' t( y* [' T- \3 F; G6 H
literature.4& N( y6 D& f# i, h$ c* p
Patient Report
% C# y$ t" m r S3 X/ M- dA 16-month-old white child was referred to the7 N8 V* ?" _* L/ F0 q7 R: G; e, h
endocrine clinic by his pediatrician with the concern9 M7 w$ g1 ]) ], B
of early sexual development. His mother noticed) A2 n3 \8 b: N0 L/ J U
light colored pubic hair development when he was8 p; ?+ L" B6 v& B/ h: T3 |9 C
From the 1Division of Pediatric Endocrinology, 2University of
; T! C6 m# e) q) [4 c. a3 ASouth Alabama Medical Center, Mobile, Alabama.
& \% X% F( p c3 F+ yAddress correspondence to: Samar K. Bhowmick, MD, FACE,. J6 J: \ t: [
Professor of Pediatrics, University of South Alabama, College of& y& H1 ]& @. \0 g1 ]$ u
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
* H' J ~; a9 c* n1 j s le-mail: [email protected].
7 i( f' z6 F$ |; y5 qabout 6 to 7 months old, which progressively became" }& T0 l, Y, d5 I4 v2 ?% X
darker. She was also concerned about the enlarge-
) h) ]+ ?; h [+ \' h5 j6 cment of his penis and frequent erections. The child; Q$ E% a+ f- C! u
was the product of a full-term normal delivery, with3 \' v Y( d' O0 Z$ o% L3 b( J+ p
a birth weight of 7 lb 14 oz, and birth length of
0 j2 e7 L* z {8 O2 G20 inches. He was breast-fed throughout the first year: D% S! P, ]2 B/ k7 ^, C+ D' g
of life and was still receiving breast milk along with
4 L; I, o/ C8 n3 jsolid food. He had no hospitalizations or surgery,9 C! l$ M Y5 P; V$ T
and his psychosocial and psychomotor development7 s" Z9 ^7 u; h6 d1 N# i6 Q- Z7 S, J
was age appropriate.
9 W- P9 l% D3 S6 J/ t' d4 uThe family history was remarkable for the father,
! o/ { _9 b8 Y. ywho was diagnosed with hypothyroidism at age 16,+ h2 ^4 e& V# }0 ? ?! T
which was treated with thyroxine. The father’s
' e$ v Z/ D- X9 `5 Z2 V2 Mheight was 6 feet, and he went through a somewhat
6 W/ ~. R, e4 t# Q& I1 l Oearly puberty and had stopped growing by age 14.* C, a- L( ]0 m0 f8 ]
The father denied taking any other medication. The
- T; j: v3 w' L' L. F @% vchild’s mother was in good health. Her menarche0 |: U( N& W8 B! Y
was at 11 years of age, and her height was at 5 feet
8 w8 O0 C$ L5 p1 M- c9 T/ L0 W1 A5 inches. There was no other family history of pre-- g5 ]4 s0 K, K4 j
cocious sexual development in the first-degree rela-
) @& Q M9 W, e2 X3 F) B1 a: K2 ptives. There were no siblings./ ?% g& k! g9 a+ v5 C
Physical Examination
* r3 ~5 k% g; b' i0 i* wThe physical examination revealed a very active,
! D1 j6 I" ?$ rplayful, and healthy boy. The vital signs documented# j) ?- {0 u7 d, r/ S+ J1 ?
a blood pressure of 85/50 mm Hg, his length was# Y; G6 A% o ]" {: v
90 cm (>97th percentile), and his weight was 14.4 kg
' Y, P U, R& e, D(also >97th percentile). The observed yearly growth# P3 I0 P: w. N7 b. a
velocity was 30 cm (12 inches). The examination of
$ P& F, v- B+ A3 r: Gthe neck revealed no thyroid enlargement.: Q6 {. D* }1 v6 @7 n1 n: d( o
The genitourinary examination was remarkable for1 Z" v$ @, Y+ f+ Z: L) z
enlargement of the penis, with a stretched length of
2 F# q, N# d3 w0 x& s8 cm and a width of 2 cm. The glans penis was very well2 y, B v+ Z) Z: n
developed. The pubic hair was Tanner II, mostly around
. X6 r( v# R; N5 w6 j, _5 l/ a540
" V/ m3 D. ]0 ?# V9 i2 Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* H @) `0 K# m1 D3 @9 @0 a
the base of the phallus and was dark and curled. The
$ p0 v: U' w& b* E' stesticular volume was prepubertal at 2 mL each.
/ @! K+ Y2 x% C5 k$ gThe skin was moist and smooth and somewhat
! ?% ~& [$ S' _0 y) u0 boily. No axillary hair was noted. There were no
+ r$ R8 ]' r0 V. [$ |/ r2 P# U+ S' r8 |abnormal skin pigmentations or café-au-lait spots.
& { n* z) M, v4 V: |) fNeurologic evaluation showed deep tendon reflex 2+: V" ~6 B( D& I( |
bilateral and symmetrical. There was no suggestion
S+ d4 [1 A6 eof papilledema.8 a* }5 d% b9 ~+ C
Laboratory Evaluation/ ~3 d, s" z. r6 _4 C k* k# ]
The bone age was consistent with 28 months by T8 m- E8 S' O) h
using the standard of Greulich and Pyle at a chrono-
: L& X8 g: Y: o- ylogic age of 16 months (advanced).5 Chromosomal
9 S, P" s1 S$ k# `8 b. w, kkaryotype was 46XY. The thyroid function test: H1 @1 ^. ?$ Y3 \1 Z
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
K6 G7 b O, Clating hormone level was 1.3 µIU/mL (both normal).
0 e5 g" ^) w2 ?1 fThe concentrations of serum electrolytes, blood* x, g6 h. g' M8 K/ G ?
urea nitrogen, creatinine, and calcium all were
: J4 J+ p6 k: N0 \within normal range for his age. The concentration! Y/ f% a0 Q9 ]% }4 y; [
of serum 17-hydroxyprogesterone was 16 ng/dL
8 v& @: r# Y+ Q& }1 [(normal, 3 to 90 ng/dL), androstenedione was 20# k1 X7 O3 i$ k8 T: F4 B
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-( S+ c0 |" m2 O+ t) `
terone was 38 ng/dL (normal, 50 to 760 ng/dL),7 B) F' Y( z* K
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
, E. Z0 ^) q, Q" h49ng/dL), 11-desoxycortisol (specific compound S)1 w5 G4 k7 H1 w
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! A8 z6 u! A4 k$ Htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ d4 j$ n" k8 M% g1 i j% T5 m* Vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),% g+ b5 f, a: z& o# ]1 S
and β-human chorionic gonadotropin was less than6 b7 C$ l5 T$ }: \* u# N
5 mIU/mL (normal <5 mIU/mL). Serum follicular' z+ \2 r% z$ v. s+ o4 b7 X7 E
stimulating hormone and leuteinizing hormone
. D* e) b! N: c$ Q2 zconcentrations were less than 0.05 mIU/mL
3 J1 w6 u5 y% ^2 P& j(prepubertal).
+ d) o+ A! p, j- a. A* aThe parents were notified about the laboratory( c: W" Y! T( K7 a# p! Z$ f1 I: n' [
results and were informed that all of the tests were
8 y9 s1 B2 B) c5 W4 ~normal except the testosterone level was high. The
# H8 D1 [' D8 q4 s4 mfollow-up visit was arranged within a few weeks to
- ^0 ?% N( {2 G2 Hobtain testicular and abdominal sonograms; how-
4 p4 i- u: Z" a0 V, J6 aever, the family did not return for 4 months.
* r1 s1 |7 V, l" N& `. N7 g: g" W- n9 Z& _Physical examination at this time revealed that the
( h9 P4 {5 C; z* g" X ichild had grown 2.5 cm in 4 months and had gained& D% ~. ~2 ~# P* ~0 ~ s: _1 {
2 kg of weight. Physical examination remained
/ b; C1 d% p9 z$ u- tunchanged. Surprisingly, the pubic hair almost com-
8 ~$ z* y, ?7 G, y: Jpletely disappeared except for a few vellous hairs at- l5 T; z- ^# K0 C7 \$ z
the base of the phallus. Testicular volume was still 2# {9 L. G" o7 ]: h1 o
mL, and the size of the penis remained unchanged.
5 f9 Q, S% m- i4 I4 | x5 }8 [4 \$ cThe mother also said that the boy was no longer hav-8 z* H# N S* n/ u$ X9 n
ing frequent erections.
! R1 ]. y9 W6 r$ P6 t! m! ZBoth parents were again questioned about use of ]+ s% T/ f7 h! e# W1 t- t i
any ointment/creams that they may have applied to
8 p7 S, y( P3 \the child’s skin. This time the father admitted the8 C$ s% S( g% }4 o8 O
Topical Testosterone Exposure / Bhowmick et al 541: R7 T2 R2 [0 [( M6 u. r
use of testosterone gel twice daily that he was apply- R3 i3 s5 }- `4 z1 ^
ing over his own shoulders, chest, and back area for& ?9 B1 V. }! E" M" v
a year. The father also revealed he was embarrassed/ Y5 ], ~/ }, a2 t$ |
to disclose that he was using a testosterone gel pre-
5 _; e+ ^7 f! V2 M) cscribed by his family physician for decreased libido. P5 ~: |2 Z8 ?% ^9 U* s& Y% Y
secondary to depression.
2 ]. M' v8 ?7 x! wThe child slept in the same bed with parents. v/ |+ v: E% x7 \' J
The father would hug the baby and hold him on his+ f7 J8 k& P7 D1 ~" c
chest for a considerable period of time, causing sig-
7 u: M6 O/ x7 ^# q0 f: r" Lnificant bare skin contact between baby and father.
' n, U' x6 w* v8 M# YThe father also admitted that after the phone call,
. b, M% S5 K; E7 O" x0 Cwhen he learned the testosterone level in the baby: c/ N% H, {- n
was high, he then read the product information
- o! a; y1 B5 T& upacket and concluded that it was most likely the rea-2 R3 }. c# a. }8 S1 |$ C. [
son for the child’s virilization. At that time, they% G1 @' a( H7 h5 F) [; X8 e& l" d
decided to put the baby in a separate bed, and the* \7 q2 `- i8 t6 \* I
father was not hugging him with bare skin and had4 t; I( a' V$ ~
been using protective clothing. A repeat testosterone- T4 w( F# G) O$ b' L
test was ordered, but the family did not go to the- f( q( Z# x! S1 x2 c! X% e9 \
laboratory to obtain the test.
; `1 {7 [+ a" vDiscussion
: c1 Y) ^9 ?5 u9 |) T9 B9 D5 hPrecocious puberty in boys is defined as secondary
. e/ F, ?7 K6 E* f; usexual development before 9 years of age.1,4
n# A: P+ \4 [Precocious puberty is termed as central (true) when# A1 P* N4 P2 S! |9 t# D; S) _' Z
it is caused by the premature activation of hypo-$ _" i6 k5 L% H8 ]/ o3 E
thalamic pituitary gonadal axis. CPP is more com-
0 d/ i+ ^- d* _, Gmon in girls than in boys.1,3 Most boys with CPP4 D) p7 ?; D. \, W
may have a central nervous system lesion that is7 C+ V3 {' j1 l0 z
responsible for the early activation of the hypothal-' O( V5 I' W- S6 F0 v" s# z2 h
amic pituitary gonadal axis.1-3 Thus, greater empha-
' i# J, P9 ], T' [3 d( Asis has been given to neuroradiologic imaging in
; n; b: w8 G7 ^. ]; ?4 x# C7 z) a) Gboys with precocious puberty. In addition to viril-6 u9 H- F; N1 }( b2 ^) _
ization, the clinical hallmark of CPP is the symmet-) D, ]/ y2 {& J4 I- E1 p$ P* b
rical testicular growth secondary to stimulation by6 o- ?4 W1 n$ s( Y
gonadotropins.1,3
3 m4 `- J) S9 {' I NGonadotropin-independent peripheral preco-
% a1 i$ E* v8 X/ `+ Wcious puberty in boys also results from inappropriate
$ d/ `2 L" p4 S0 Y% f* V# F* landrogenic stimulation from either endogenous or! V p% z; q* n4 L% G7 v
exogenous sources, nonpituitary gonadotropin stim-
& T q# n+ ]1 B1 h! [ulation, and rare activating mutations.3 Virilizing+ y: U1 I6 o2 p! e/ M& Z
congenital adrenal hyperplasia producing excessive
# ^3 B3 g8 k# S9 V0 r( e- `adrenal androgens is a common cause of precocious
. h% u( x* B; I+ e7 q/ Lpuberty in boys.3,42 ~: c* d: t0 ]* U/ x
The most common form of congenital adrenal
6 }) f$ P }' L" nhyperplasia is the 21-hydroxylase enzyme deficiency.
! E4 G E+ g0 e( Y. t4 EThe 11-β hydroxylase deficiency may also result in" w" R. j7 {- v3 }: Y2 n& `5 q
excessive adrenal androgen production, and rarely,* R6 D- X4 W3 U3 z! \
an adrenal tumor may also cause adrenal androgen9 d4 [3 o% z3 a8 P
excess.1,3
7 n- x( j: j. l$ @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( Y ?7 g q; R \$ z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 ~1 m9 |0 N" B$ U8 OA unique entity of male-limited gonadotropin-
" E) R0 D0 N4 g( i5 k) O5 Nindependent precocious puberty, which is also known0 |+ L3 E" N1 c/ P
as testotoxicosis, may cause precocious puberty at a
5 l" _5 T+ q# h9 b" n3 nvery young age. The physical findings in these boys
3 Y( }0 O$ o, [3 k* j9 C% ywith this disorder are full pubertal development,6 m6 J5 u! j: B! @- T
including bilateral testicular growth, similar to boys7 d# _8 |) y6 t" f0 ^, `
with CPP. The gonadotropin levels in this disorder4 B5 k. X8 m# h' i/ K
are suppressed to prepubertal levels and do not show9 @" w1 E5 B S( U: ^/ a
pubertal response of gonadotropin after gonadotropin-
- J& l* u% `& B+ D+ C+ Kreleasing hormone stimulation. This is a sex-linked
" M7 C" A7 u! g0 G8 [autosomal dominant disorder that affects only
$ _! b/ o; _4 A. {* }males; therefore, other male members of the family
! S; F! N) i; L( i4 L# g( W. o. }0 \. tmay have similar precocious puberty.3. i' ?0 {7 _8 l! l) f4 c% m! z. M( p
In our patient, physical examination was incon-
% V7 o% t6 r2 p9 q7 r! N* isistent with true precocious puberty since his testi-5 ?( p. S) Y' f/ n" f! Z
cles were prepubertal in size. However, testotoxicosis) ~$ N" Z x% T
was in the differential diagnosis because his father6 [0 j; d. y% s* ?" l$ R% A6 z: s* c
started puberty somewhat early, and occasionally,
$ k* U# P1 M! J; _testicular enlargement is not that evident in the5 H+ l' _0 e" c
beginning of this process.1 In the absence of a neg-
" s& l1 Y7 {% u* \- w5 s; U/ zative initial history of androgen exposure, our5 ^+ |3 h" v9 H& L2 t$ B9 w
biggest concern was virilizing adrenal hyperplasia,
+ t8 h }9 P; z/ I1 u% Seither 21-hydroxylase deficiency or 11-β hydroxylase
; B/ f% r+ k0 {6 Ndeficiency. Those diagnoses were excluded by find-& H) f. e" w; m7 b- ?1 i
ing the normal level of adrenal steroids.* K' u. \ }( `) M3 }$ V! h
The diagnosis of exogenous androgens was strongly9 o1 l9 U6 P& I1 G- J
suspected in a follow-up visit after 4 months because
1 E5 O+ i' N. N, e7 G* ~the physical examination revealed the complete disap-
0 B( f. g2 E# y" cpearance of pubic hair, normal growth velocity, and
4 u# m0 y4 s+ l6 @1 Z) x" K8 Sdecreased erections. The father admitted using a testos-9 l1 H+ Z! `2 ]1 x6 u- O0 a
terone gel, which he concealed at first visit. He was
) d. c$ x# G$ h; W7 p- n) Busing it rather frequently, twice a day. The Physicians’" n+ j. r8 o) b6 i# p e
Desk Reference, or package insert of this product, gel or& Y" i$ Y! `3 d0 I- T9 f
cream, cautions about dermal testosterone transfer to4 {' {9 b+ p O8 q# V
unprotected females through direct skin exposure.2 t! i9 j: J' ^" o8 n9 b
Serum testosterone level was found to be 2 times the
/ O' D. s4 V' @2 \7 A2 N& z5 ybaseline value in those females who were exposed to
' `9 i$ E$ r$ |3 o4 A2 U+ R5 ueven 15 minutes of direct skin contact with their male; K. m- W6 c2 i) R
partners.6 However, when a shirt covered the applica-
/ x! N1 C1 d1 {# r' stion site, this testosterone transfer was prevented.
2 b- m8 u* n# l/ U! OOur patient’s testosterone level was 60 ng/mL,
9 o5 k! P# E6 K z7 y8 M: z& O7 Uwhich was clearly high. Some studies suggest that
3 K: h V$ d" t) i4 w; T+ Zdermal conversion of testosterone to dihydrotestos-
" F7 z$ h- ~: ^/ G% Mterone, which is a more potent metabolite, is more
9 ?* v1 f H5 q2 |3 v" bactive in young children exposed to testosterone0 |* Q5 e% Y1 `/ X* E& n9 }# A
exogenously7; however, we did not measure a dihy-5 M2 Y9 @8 J. t4 r
drotestosterone level in our patient. In addition to
2 g4 j* L8 p2 N1 R5 pvirilization, exposure to exogenous testosterone in
' E% V$ l+ z7 j$ n3 p8 \children results in an increase in growth velocity and/ j! ~( s9 p& a- y
advanced bone age, as seen in our patient.! M' `! B. C8 M4 I9 |8 V
The long-term effect of androgen exposure during5 n( e6 V0 w6 ~7 }
early childhood on pubertal development and final
0 m& Z% \$ X( e5 Cadult height are not fully known and always remain
# s5 `6 e& n' D9 p- M) z- }a concern. Children treated with short-term testos-$ l6 ~ }+ A& u; j1 ^0 m* a9 y
terone injection or topical androgen may exhibit some: S' J% X" r# N8 D7 J: s- u5 w
acceleration of the skeletal maturation; however, after
& |) ~$ _" F% `0 zcessation of treatment, the rate of bone maturation" ]. g4 X' H4 I& [, w# m5 ~
decelerates and gradually returns to normal.8,94 Z4 W2 @+ P( m
There are conflicting reports and controversy" F' ? w: C' Q. `. O6 l
over the effect of early androgen exposure on adult
* D! }7 r( O0 }, o$ fpenile length.10,11 Some reports suggest subnormal
`$ @5 m* Y. D W; W5 I9 c5 b) Y& xadult penile length, apparently because of downreg-; s% ^" h& p" b/ I
ulation of androgen receptor number.10,12 However,! d. ~. ?; J( c! \; Z# z
Sutherland et al13 did not find a correlation between* P/ J+ |6 l! c$ X4 x5 e
childhood testosterone exposure and reduced adult
8 y7 w' E0 t+ B f2 S8 l; b- Q2 lpenile length in clinical studies./ e5 q3 ]+ m' j) H3 f. G+ i# W4 n( i
Nonetheless, we do not believe our patient is0 ?5 w% _; c6 i
going to experience any of the untoward effects from
1 j- {4 s/ P R# f" n; ytestosterone exposure as mentioned earlier because
* L# I& p) ?+ H8 _5 O& vthe exposure was not for a prolonged period of time.
' i0 j" S4 C9 M* F# P+ S+ PAlthough the bone age was advanced at the time of8 s7 O" I+ @& F4 J6 @# v
diagnosis, the child had a normal growth velocity at% z. @( z2 T; K& d
the follow-up visit. It is hoped that his final adult
+ v5 d; k1 Q6 }' Z8 mheight will not be affected.
0 @- ^2 x, B" c3 N- bAlthough rarely reported, the widespread avail-
3 W' B9 e! ^6 p0 s4 b+ _ Xability of androgen products in our society may6 V- W% ^7 V3 M4 {- V; v
indeed cause more virilization in male or female
* u! R: m4 y$ c3 S: y0 m+ I/ a& Y8 Y4 ?children than one would realize. Exposure to andro-
9 R: z, {$ q: F0 X& e; P3 ]4 ~gen products must be considered and specific ques-" d4 m6 z" g! K8 Q4 B7 H4 V/ F
tioning about the use of a testosterone product or
2 `6 i) Q/ m- }$ S: ]gel should be asked of the family members during- V* X) @4 U( a. ~% b: U; J3 O: U
the evaluation of any children who present with vir-" E/ O: \( V2 c& H; c+ k0 L7 {
ilization or peripheral precocious puberty. The diag-5 N7 [% u7 q7 O9 h" x2 O
nosis can be established by just a few tests and by4 r, O" x+ H; L$ U$ e ~3 u% o
appropriate history. The inability to obtain such a! x7 e( h( V, K# r7 C r
history, or failure to ask the specific questions, may
' m3 O0 B4 m3 z0 wresult in extensive, unnecessary, and expensive6 h; I- J' B4 A) d2 I) g' L
investigation. The primary care physician should be
5 J1 G+ O, [4 D$ r7 P3 R0 taware of this fact, because most of these children
+ o# ?# j @8 z: c3 |may initially present in their practice. The Physicians’* I! _* w% [! e( q# f4 j5 i
Desk Reference and package insert should also put a) h4 J. u4 Z8 f# \% d2 ~ e
warning about the virilizing effect on a male or( G2 A& F3 F. D2 a# ], R
female child who might come in contact with some-7 R5 ?" L! g9 j+ M
one using any of these products.. {9 _7 z4 z; n N/ d: K
References. Y& \- _! |, h7 m, A# x! ]
1. Styne DM. The testes: disorder of sexual differentiation
$ P$ e$ U" x7 l* F* ?and puberty in the male. In: Sperling MA, ed. Pediatric
, @* m& X4 E. aEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ t* y9 n' b1 w% k9 |2002: 565-628.$ W- U( H0 N8 O A2 Q
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious* j4 Z; U1 e# D
puberty in children with tumours of the suprasellar pineal |
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