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Sexual Precocity in a 16-Month-Old. L" J' A1 F3 z+ Z
Boy Induced by Indirect Topical
+ m* A" q3 V2 @8 z! ?- JExposure to Testosterone, B' E( V9 e& G Q' ~5 O) ?- R
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# b9 f" {1 o ]" p, k( S$ wand Kenneth R. Rettig, MD1
5 U1 W& v- }9 ]6 ^" y4 D; q0 t! fClinical Pediatrics
$ K0 z. W6 g1 z& `3 t+ VVolume 46 Number 6' S6 h2 V9 P/ L& _
July 2007 540-543
- w" d2 m; M% |: \© 2007 Sage Publications* ~2 v/ L6 p, U) t
10.1177/00099228062966519 X' [1 a1 ^$ y& r
http://clp.sagepub.com
7 H4 W& Y" g. R0 e: phosted at
$ T7 e9 O% |- |3 m! K4 G! uhttp://online.sagepub.com
% j( b9 P+ S) W0 A( TPrecocious puberty in boys, central or peripheral,
$ B5 t8 A" n( e( `( bis a significant concern for physicians. Central
$ \: q' x9 J* L- h" u& l5 ?, Mprecocious puberty (CPP), which is mediated
2 k, F' |% @9 E. }( A0 X$ I9 Dthrough the hypothalamic pituitary gonadal axis, has5 u; t8 C+ B" p
a higher incidence of organic central nervous system
' ]( d6 f2 \' Y+ _3 h0 {lesions in boys.1,2 Virilization in boys, as manifested
1 H1 V- c5 e: l Y) ^7 s% s- [0 C9 }by enlargement of the penis, development of pubic
4 N+ D2 r n1 i$ q' L$ Jhair, and facial acne without enlargement of testi-
% p% P6 G4 ]' t7 `. j' k7 lcles, suggests peripheral or pseudopuberty.1-3 We
% d/ ?3 v7 ^3 k$ }/ _report a 16-month-old boy who presented with the4 L, U6 D3 F( V; U. g
enlargement of the phallus and pubic hair develop-, S. i" T/ ]* r; y3 L
ment without testicular enlargement, which was due
, R; {) P/ \$ i6 ]% ~to the unintentional exposure to androgen gel used by
7 K) y) a$ l+ W6 c" Othe father. The family initially concealed this infor-) J. s2 ?* d6 Z% u( F
mation, resulting in an extensive work-up for this) j& B) P/ C7 X+ t- S
child. Given the widespread and easy availability of; w9 X/ f5 F3 s+ |! ~! j1 J
testosterone gel and cream, we believe this is proba-
% P0 n% a- p0 obly more common than the rare case report in the: _8 O* |5 t Q7 d
literature.42 `( S% y4 L- u% U$ I1 c
Patient Report( m- _$ q e; S+ [0 y9 V& h& G; ^
A 16-month-old white child was referred to the2 V+ r9 G4 c* p9 t6 Z% T
endocrine clinic by his pediatrician with the concern- }! e7 \. e2 ?- h K! {
of early sexual development. His mother noticed1 F* q6 [( H* x; x* o$ f3 |
light colored pubic hair development when he was. o/ ?7 n1 |% \' _
From the 1Division of Pediatric Endocrinology, 2University of& _ r* u+ V/ }0 S
South Alabama Medical Center, Mobile, Alabama.
" m$ E( [9 C, NAddress correspondence to: Samar K. Bhowmick, MD, FACE,1 @2 ]/ i( n# }7 s m
Professor of Pediatrics, University of South Alabama, College of% E3 j. g" t8 M4 e0 e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
+ C9 ?" t, Z8 I5 f: r$ l ve-mail: [email protected].
% F3 T5 |, |8 D! l h/ sabout 6 to 7 months old, which progressively became M* u- p$ `- p9 p2 T8 a1 h+ z
darker. She was also concerned about the enlarge-4 q* `6 s7 i. b6 F, h
ment of his penis and frequent erections. The child+ S: y, E; n+ c* z
was the product of a full-term normal delivery, with
) i/ _! U7 n' Ga birth weight of 7 lb 14 oz, and birth length of
; s- Y5 B' k* N5 ~- O" e: n20 inches. He was breast-fed throughout the first year9 d* k1 l. v5 d7 O; n
of life and was still receiving breast milk along with( V9 \( q( X8 I( @3 _+ t
solid food. He had no hospitalizations or surgery,
4 l$ _$ [2 A5 E) P; m6 a# kand his psychosocial and psychomotor development
/ ` q K- {, C1 o" n' Wwas age appropriate.
" _0 P: C# _8 [9 x0 w, UThe family history was remarkable for the father,, Y0 Y6 K. H" L! k g, b* p; ?/ w
who was diagnosed with hypothyroidism at age 16,5 V6 ?$ m- c. g$ Q: w. \
which was treated with thyroxine. The father’s
& t5 }" I* T; P3 R- z9 Qheight was 6 feet, and he went through a somewhat
) q% n: w& }0 _1 P$ d4 dearly puberty and had stopped growing by age 14.
9 v0 h5 B' d5 W* u, I5 |" _The father denied taking any other medication. The( C Y) _6 Z- x" Y0 L
child’s mother was in good health. Her menarche: s9 ^% C/ P) K8 d8 i
was at 11 years of age, and her height was at 5 feet
+ w) S# q5 f5 M' O; ~. p5 inches. There was no other family history of pre-; `' B( _6 ?% D2 m, }5 v2 c
cocious sexual development in the first-degree rela-9 F* J% y+ L* T Z3 h% ?2 N1 b3 v2 Q- F
tives. There were no siblings.
% `0 m; O! q _8 cPhysical Examination
6 L4 e1 r; J! {8 ]" g) X1 YThe physical examination revealed a very active,
; [3 g/ Z- O! d& F2 z) z& Z9 Mplayful, and healthy boy. The vital signs documented% }% c. a( o5 V' A7 a
a blood pressure of 85/50 mm Hg, his length was0 ~1 E7 T d! k9 ]! N9 W
90 cm (>97th percentile), and his weight was 14.4 kg
x& j. X# ` n. k0 r/ s(also >97th percentile). The observed yearly growth, i! `2 l6 }, |
velocity was 30 cm (12 inches). The examination of
h! [9 J/ `, h, z2 a5 p1 i0 othe neck revealed no thyroid enlargement.+ l3 k& b! R: y/ Y: i+ ^
The genitourinary examination was remarkable for$ A1 v+ O2 {) D/ B& `
enlargement of the penis, with a stretched length of
2 H9 E% o# K5 h1 v! i8 }8 cm and a width of 2 cm. The glans penis was very well8 ~# [6 T1 S, V3 R- s) U2 ?
developed. The pubic hair was Tanner II, mostly around
- L/ G1 X& q K- K/ D540/ h3 o- u8 z$ b" `& j% }) d$ v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: H: S: R; M( B& kthe base of the phallus and was dark and curled. The$ C4 u' R6 w/ b
testicular volume was prepubertal at 2 mL each.
& S$ w1 o* g9 n- Z' T# CThe skin was moist and smooth and somewhat
+ Q* E" t) u% x+ l z( O& Moily. No axillary hair was noted. There were no
. ]! x+ X, k! }; ]/ }abnormal skin pigmentations or café-au-lait spots.0 ^# b+ M& h; h) Y0 G" y/ U
Neurologic evaluation showed deep tendon reflex 2+
7 C4 t$ s$ B/ |bilateral and symmetrical. There was no suggestion4 x5 c- c5 p( d! f/ |2 r7 P
of papilledema.
3 S+ s! h% e# b# BLaboratory Evaluation& g0 }$ p# Z8 R' ?
The bone age was consistent with 28 months by ?8 l3 g4 h0 K- e
using the standard of Greulich and Pyle at a chrono-
. @; ^7 K+ ]& S, }" v8 N4 zlogic age of 16 months (advanced).5 Chromosomal2 ]5 O3 [9 Y- f# ~6 w* z! y
karyotype was 46XY. The thyroid function test( A' Y5 c3 }( ~( g4 F9 ]" ^' V
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
: ^- P; N2 `" o+ e* o% K% plating hormone level was 1.3 µIU/mL (both normal).
& K- |+ q3 t: ?; H6 F2 |7 R9 e, K5 vThe concentrations of serum electrolytes, blood
! f9 b' S: Y0 N" L2 @! r% curea nitrogen, creatinine, and calcium all were
2 m0 M1 y) t q/ m! y: m2 zwithin normal range for his age. The concentration; b; y/ u% ]8 K& K Q5 e4 E+ M0 h
of serum 17-hydroxyprogesterone was 16 ng/dL, I4 g" ^* L' r' |" J# E. U/ P2 ?
(normal, 3 to 90 ng/dL), androstenedione was 209 N; }2 V% T$ N4 L& E
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 O8 K; `3 V: ^5 [3 Dterone was 38 ng/dL (normal, 50 to 760 ng/dL),
) c W" J( K5 M( {; rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 d) }' \; P6 X U* B/ w49ng/dL), 11-desoxycortisol (specific compound S)
/ `# F" z/ V7 ~4 i9 b% C% `was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-& ~+ j. \" g0 U5 P3 |% `. e/ \
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 G: H* ^( M+ X) Q" U
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! ^2 P8 }9 U. M, {
and β-human chorionic gonadotropin was less than/ f9 {& t7 w" d# {4 I
5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 e7 ?, X& O$ ^* X& l) x6 Dstimulating hormone and leuteinizing hormone' z2 r- q C {' q8 y1 S3 J8 j
concentrations were less than 0.05 mIU/mL! t( t1 X, @5 |# Z8 \& r
(prepubertal).
0 m/ K( U( |& h( n. k7 i* H4 ?The parents were notified about the laboratory# Q# p8 _' p3 g5 W7 s
results and were informed that all of the tests were
5 s; S+ r5 c) V+ }normal except the testosterone level was high. The
6 W8 h/ M3 z" X3 _, \' Sfollow-up visit was arranged within a few weeks to) a+ l4 q7 w# |4 x4 q# m
obtain testicular and abdominal sonograms; how-
: ?! P# I2 b2 Z# Y' Z' tever, the family did not return for 4 months.
& P9 {! K! K2 f0 X; w5 @: J; VPhysical examination at this time revealed that the0 w. Z2 h: e* r: A3 {
child had grown 2.5 cm in 4 months and had gained
# r& m/ R, x4 i" S* J2 kg of weight. Physical examination remained
3 ^! m/ R* e- F2 Sunchanged. Surprisingly, the pubic hair almost com-
+ w0 u3 R# k3 @3 q4 c7 jpletely disappeared except for a few vellous hairs at* C4 b+ s. d) g1 v/ c
the base of the phallus. Testicular volume was still 2
5 I( r' i7 d) |) e! cmL, and the size of the penis remained unchanged.' r3 d4 Z; W; e" t! R. y6 @3 e1 T9 J
The mother also said that the boy was no longer hav-8 l- @; D, ]) H- H
ing frequent erections.( I* i3 ~& T$ K& N, { S3 s4 C, M
Both parents were again questioned about use of
, {) z4 J8 |; Y5 D `any ointment/creams that they may have applied to8 \4 M3 f; ` [2 `0 {3 r
the child’s skin. This time the father admitted the- e- _9 [6 _$ Y; k& E9 n) Q
Topical Testosterone Exposure / Bhowmick et al 541
. i, e$ a: d5 juse of testosterone gel twice daily that he was apply-
+ S) p! S7 w2 g5 ?7 @ing over his own shoulders, chest, and back area for8 \5 w5 w$ Y* v R8 z: P5 i+ H7 K) d
a year. The father also revealed he was embarrassed
4 O/ N% [% W9 f* o) i4 Z. F3 z. {to disclose that he was using a testosterone gel pre-1 j' e9 y" C: }% V& b
scribed by his family physician for decreased libido7 x' j( ~4 R! Y. }! h. |
secondary to depression./ J8 ~% U( k/ L+ Q) a
The child slept in the same bed with parents.- q2 m6 {+ V5 q" o2 R4 s/ `7 ]
The father would hug the baby and hold him on his
$ K' X- B% G! E" I' [% N; Lchest for a considerable period of time, causing sig-
' P# |- |1 Y, e* Q6 Jnificant bare skin contact between baby and father.) Y; ^0 _# r# @, ^' ~2 X
The father also admitted that after the phone call,
- t0 C9 l* y6 Awhen he learned the testosterone level in the baby
6 _ O/ w% k% F- m5 R Q, hwas high, he then read the product information
9 a/ G+ D C" N- Q+ bpacket and concluded that it was most likely the rea-1 {. C% c ?6 |3 s
son for the child’s virilization. At that time, they
& k9 P, _3 y- S$ P% Z `decided to put the baby in a separate bed, and the
7 J. H5 k1 D* _7 ]father was not hugging him with bare skin and had; C; V, i; E. h, }
been using protective clothing. A repeat testosterone
4 Y5 i, {7 |* c" y+ K. \ ?test was ordered, but the family did not go to the
1 j( I3 u+ n9 f9 v6 j+ Vlaboratory to obtain the test.
5 {% K/ C2 m" f6 |# r% |" CDiscussion) R! a5 e/ }/ A' w
Precocious puberty in boys is defined as secondary
4 w" q' ?' {" C( psexual development before 9 years of age.1,4
) M; C* ]# T: R+ c8 o, P; YPrecocious puberty is termed as central (true) when
/ q6 V/ F; V4 C* C, ?9 h" X: xit is caused by the premature activation of hypo-
) x5 ~1 U5 |+ m$ F" I: W4 {thalamic pituitary gonadal axis. CPP is more com-
$ T: A- z; Z' b- Q' ?mon in girls than in boys.1,3 Most boys with CPP
[" L2 H+ f5 o4 B& ymay have a central nervous system lesion that is9 s5 Q5 D9 W+ g) v1 ~
responsible for the early activation of the hypothal-9 R4 ?4 I! V9 ~- b3 C
amic pituitary gonadal axis.1-3 Thus, greater empha-$ d8 ^* L4 {, @# P" N X% u$ O1 G
sis has been given to neuroradiologic imaging in: A# M0 Z a! K
boys with precocious puberty. In addition to viril-$ {) Z. V% M2 z+ t
ization, the clinical hallmark of CPP is the symmet-* u0 T6 C8 o q+ c+ W
rical testicular growth secondary to stimulation by
1 q$ S+ F, n3 c5 {" T, pgonadotropins.1,3
: l' v' R3 d& C }# S+ LGonadotropin-independent peripheral preco-
- f1 g' }. O5 a5 f }1 x; Acious puberty in boys also results from inappropriate
8 k. u( S5 ^$ G. Yandrogenic stimulation from either endogenous or
' `+ T' A9 N; h( h6 Kexogenous sources, nonpituitary gonadotropin stim-2 ? d t& {" ~
ulation, and rare activating mutations.3 Virilizing2 e/ U0 W2 k+ H0 u5 o9 S% t; m
congenital adrenal hyperplasia producing excessive
6 M0 |' f1 V7 q. U I9 Dadrenal androgens is a common cause of precocious" ^" h/ m8 L2 E; Q/ M5 ^
puberty in boys.3,4
2 O, X6 w6 o, k0 U. u& v7 |The most common form of congenital adrenal
' @2 e/ z# D. c e0 S1 F: G5 Z4 }hyperplasia is the 21-hydroxylase enzyme deficiency.0 |0 {: c% N/ m( E
The 11-β hydroxylase deficiency may also result in
; X& v" e7 S9 q: x# Zexcessive adrenal androgen production, and rarely,
" t- I! J2 C' W0 E1 Gan adrenal tumor may also cause adrenal androgen
2 }/ w7 z. P9 |1 fexcess.1,3+ B4 C5 g0 n: F1 ~! W# ]; A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 i3 w$ b( @- |' v+ J2 k7 P8 B
542 Clinical Pediatrics / Vol. 46, No. 6, July 20075 l0 M8 ]) i: V* V4 u1 W6 U) ]
A unique entity of male-limited gonadotropin-. }, H$ _' @) C: N
independent precocious puberty, which is also known
& n, @ A5 m5 Eas testotoxicosis, may cause precocious puberty at a
/ k. [( ]! `4 Mvery young age. The physical findings in these boys6 S5 k3 o& L2 d6 g
with this disorder are full pubertal development,
' v7 j/ S+ \3 Zincluding bilateral testicular growth, similar to boys# Y$ X: n( {- x: }, Y8 d# E
with CPP. The gonadotropin levels in this disorder
! X5 T2 _; G ]8 U' Eare suppressed to prepubertal levels and do not show
, R) W4 f! }* u, B7 u" gpubertal response of gonadotropin after gonadotropin-
& i- l( Y8 V* [) treleasing hormone stimulation. This is a sex-linked1 H7 u% B; Z. ^3 w9 I" o
autosomal dominant disorder that affects only& W2 b+ a# M4 d/ B* p4 E9 q
males; therefore, other male members of the family2 s9 |* d( \! }( S1 K
may have similar precocious puberty.3
" b/ e# k9 k, aIn our patient, physical examination was incon-
/ `( f( u% [3 ~' f+ Bsistent with true precocious puberty since his testi-9 O( g. W: C" Z
cles were prepubertal in size. However, testotoxicosis& d) T1 @1 w( x- J! D& y
was in the differential diagnosis because his father
2 a2 z6 l0 F6 Y: G* Q' xstarted puberty somewhat early, and occasionally," @4 d; r6 S. a
testicular enlargement is not that evident in the( \$ c V) E: P
beginning of this process.1 In the absence of a neg-% }' l# S7 J' p3 L ~+ Z
ative initial history of androgen exposure, our8 k. Q1 I" ]4 n- I
biggest concern was virilizing adrenal hyperplasia,: S& ]7 z- E, }' {- F% |
either 21-hydroxylase deficiency or 11-β hydroxylase& t2 r2 Q9 N9 w( s3 U7 p& k* G
deficiency. Those diagnoses were excluded by find-
" @9 K3 E6 Z: [2 n% o8 [ing the normal level of adrenal steroids.4 S) \2 ~) F6 D O1 v0 b, r: B
The diagnosis of exogenous androgens was strongly5 k9 ?$ }9 x- l7 \. \: E8 \
suspected in a follow-up visit after 4 months because
. i. a u, ?+ z1 m0 W7 K8 fthe physical examination revealed the complete disap-
2 C5 [- m7 E! [; l& npearance of pubic hair, normal growth velocity, and
) @8 C1 ?0 @6 x) i3 [decreased erections. The father admitted using a testos-
, D# w" J+ K# S1 S) j. w% iterone gel, which he concealed at first visit. He was, K% y6 A: }( R+ k+ f2 r( W) E
using it rather frequently, twice a day. The Physicians’
, g! ]% m2 _( |5 ]Desk Reference, or package insert of this product, gel or
! [$ D o- p) X7 Q5 Gcream, cautions about dermal testosterone transfer to
9 |: u2 v% X& M' F( R2 G- g4 Punprotected females through direct skin exposure.
! {" h& k- b* B' t6 D# @0 NSerum testosterone level was found to be 2 times the0 ~$ d( S7 {0 G. i w+ V j
baseline value in those females who were exposed to7 B, ?6 f) r% ~" U n5 W6 r/ B
even 15 minutes of direct skin contact with their male1 C0 ^* r+ W2 o7 U/ P
partners.6 However, when a shirt covered the applica-
9 K. U2 n2 P( S* E. t( P- O1 j! R. `tion site, this testosterone transfer was prevented./ C8 p' [: A5 w; ~. U( g6 F
Our patient’s testosterone level was 60 ng/mL,8 D$ f1 q7 e: H. ]6 K, [
which was clearly high. Some studies suggest that6 i7 a' [+ y: y9 f8 K3 X% a9 f
dermal conversion of testosterone to dihydrotestos-- \+ P! s2 [# x, h
terone, which is a more potent metabolite, is more
0 C J2 ^3 G0 h, k& D R' Q4 nactive in young children exposed to testosterone! b7 e& Y- c& C8 {) C& l
exogenously7; however, we did not measure a dihy-8 p4 t1 C! B: C
drotestosterone level in our patient. In addition to
. |3 |5 Q" }! ^1 M) t# Xvirilization, exposure to exogenous testosterone in& ?, z+ j) t6 t# O- N) c6 K3 ^
children results in an increase in growth velocity and3 E9 p4 |1 f: h6 @6 ?: n+ l" a
advanced bone age, as seen in our patient.4 X- r$ b8 N8 n- m: D
The long-term effect of androgen exposure during
T! X* ^: L( ?& ^1 B' T, a4 dearly childhood on pubertal development and final0 e0 _+ r0 z( \: g; K4 k
adult height are not fully known and always remain1 K1 i0 }: b4 C* ~5 _ z* f* d1 C
a concern. Children treated with short-term testos-# u3 g A* w- m# M0 I
terone injection or topical androgen may exhibit some
& e4 U( D) a( ^' Q# Sacceleration of the skeletal maturation; however, after" x: N0 f! d5 [
cessation of treatment, the rate of bone maturation
, q( [: n7 V2 E2 `8 `3 b9 rdecelerates and gradually returns to normal.8,9
. j7 l8 }' h, KThere are conflicting reports and controversy
4 b7 g. P( K/ j' L$ Nover the effect of early androgen exposure on adult2 y1 a# R1 U& R: I4 E9 G# M$ ?+ \0 X
penile length.10,11 Some reports suggest subnormal. a l3 z* |$ j/ z
adult penile length, apparently because of downreg-8 S6 v" L: k" {. H# k& ?- J& [) B
ulation of androgen receptor number.10,12 However,
5 t) w2 R' o! iSutherland et al13 did not find a correlation between6 X6 G: p# k2 W. p) c5 ?( U& [
childhood testosterone exposure and reduced adult
3 D0 g$ ?; O! @: R Upenile length in clinical studies.
- a0 B6 l& f5 `Nonetheless, we do not believe our patient is. r" f' J+ a# p2 _, _
going to experience any of the untoward effects from
/ R6 _! [, Q0 M$ Ttestosterone exposure as mentioned earlier because- h7 X( i% Y9 j. }
the exposure was not for a prolonged period of time.1 C$ b' J- |* l. p
Although the bone age was advanced at the time of
) \( ]: R' D* Ndiagnosis, the child had a normal growth velocity at8 Z2 E P3 O. Q n7 ]- Y& U/ \
the follow-up visit. It is hoped that his final adult$ I% Q' h+ g' p$ ~- l" k
height will not be affected.
" @. b c4 r% S- f5 jAlthough rarely reported, the widespread avail-9 |5 i8 m% J9 V" Z, e
ability of androgen products in our society may$ r" S& n" Q5 M
indeed cause more virilization in male or female$ ^, D! M2 ^. r9 D+ F1 c
children than one would realize. Exposure to andro-+ ]" q/ I$ w2 w- x% n5 K* i: r
gen products must be considered and specific ques-2 k' a! \- j0 B1 \- T
tioning about the use of a testosterone product or. a4 j4 l4 \6 u3 K
gel should be asked of the family members during
/ b8 K9 Z( P) Z* ~) q. c3 I6 m- Mthe evaluation of any children who present with vir-
0 _3 |: y/ R @- ]; ~ilization or peripheral precocious puberty. The diag-
! x: K# _( z- j1 {# onosis can be established by just a few tests and by7 X! M3 p" }: b# i$ m$ x! b
appropriate history. The inability to obtain such a! f, T. E0 e9 G. h
history, or failure to ask the specific questions, may
. D$ A7 Y0 T0 U2 S. Vresult in extensive, unnecessary, and expensive
0 ^- O# j2 P4 P0 Y0 Uinvestigation. The primary care physician should be
6 h; m7 V' F! m6 [/ |aware of this fact, because most of these children2 F/ j5 B( [2 y9 U# y
may initially present in their practice. The Physicians’/ }4 }& d2 W+ Q6 }8 n9 S+ E
Desk Reference and package insert should also put a
v8 f, D, B9 R3 C/ p3 ~! }7 twarning about the virilizing effect on a male or
- V: C& W( w, V }$ n# \7 G7 Tfemale child who might come in contact with some-
. P' O7 ]. V1 e5 I% C% gone using any of these products.
2 l% g: Q% Q! w+ \" |, y- gReferences% }: t9 k% r7 O9 r: [( Y
1. Styne DM. The testes: disorder of sexual differentiation: @* ~0 `- B! G4 c& ] X" I; m. n
and puberty in the male. In: Sperling MA, ed. Pediatric
9 r4 e4 A7 I# i1 ?" b. [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 n2 s( ]' P b. P* p. W2002: 565-628.0 V4 h0 S+ L, c2 E0 \7 F0 y9 }1 _1 i
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious/ }4 A3 e& \* ?1 h/ q: G4 X
puberty in children with tumours of the suprasellar pineal |
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