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Sexual Precocity in a 16-Month-Old c4 E& H% f4 z1 d- l" X
Boy Induced by Indirect Topical9 W7 Z3 ~/ s, p$ L' v
Exposure to Testosterone3 J: c c+ G1 f& y$ s# j
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: x/ |6 }. v% aand Kenneth R. Rettig, MD1
; c) f% V% {3 v$ G, eClinical Pediatrics
5 U3 _- C9 t* ^' E" ?) |& dVolume 46 Number 6. s' h8 _$ S5 b% p9 Y% t% d% W
July 2007 540-543
. ]7 K7 t, S u4 N/ F© 2007 Sage Publications6 g, Y; G( r$ o8 W+ S
10.1177/0009922806296651& {. }+ K0 N8 Q8 z. |
http://clp.sagepub.com: G( g: s$ P& Y6 f6 _, w" d: o% i4 t! s
hosted at
\5 D6 I1 N9 t, b) P3 [http://online.sagepub.com
6 l. ^/ ]% J( p* }, |& }0 XPrecocious puberty in boys, central or peripheral,9 i/ N6 ]+ ]6 S4 F, ^& r1 l
is a significant concern for physicians. Central9 |" a0 s- j$ G
precocious puberty (CPP), which is mediated
0 u8 d7 V+ \' ^2 qthrough the hypothalamic pituitary gonadal axis, has
/ J3 F X$ r' y& @! o$ c0 s1 U) Ga higher incidence of organic central nervous system7 o3 m @: [6 h) n' [
lesions in boys.1,2 Virilization in boys, as manifested
$ @# F( L- C: B1 _9 K$ ]* Mby enlargement of the penis, development of pubic8 m+ Q$ A9 @- Z5 q* _
hair, and facial acne without enlargement of testi-
% r+ x7 y) S/ Z/ W" Rcles, suggests peripheral or pseudopuberty.1-3 We
' n5 I, {) i$ m0 e" H* k, R n; Preport a 16-month-old boy who presented with the
/ n( L( Z2 {' |0 t8 n% e/ Kenlargement of the phallus and pubic hair develop-, L7 g/ @. s1 {
ment without testicular enlargement, which was due9 q, s3 p1 {3 T* u5 R
to the unintentional exposure to androgen gel used by1 ^/ c: [& h) o$ O2 L" f* l" K5 |1 I
the father. The family initially concealed this infor-
& ~$ C6 _$ X5 T/ c, ymation, resulting in an extensive work-up for this4 L7 F: a3 u6 n
child. Given the widespread and easy availability of$ e6 [- }* ?% d+ L
testosterone gel and cream, we believe this is proba-2 H. A {; s. P* ?' w5 s+ r7 Z7 A
bly more common than the rare case report in the
# i+ O- f* U, `( @literature.4
" x0 K- O/ A( j! D8 O. bPatient Report
0 X! D& U: `8 F, d7 FA 16-month-old white child was referred to the' J2 B# z! _8 \
endocrine clinic by his pediatrician with the concern9 F8 B, u4 N; u7 E$ p* S
of early sexual development. His mother noticed
, d) ], Y/ s5 }3 F2 W; Xlight colored pubic hair development when he was
( g! `2 z9 W& i& ]. @9 wFrom the 1Division of Pediatric Endocrinology, 2University of
$ N( I' x. R& x7 K3 L5 \South Alabama Medical Center, Mobile, Alabama.
7 \! b% e8 g9 Z; iAddress correspondence to: Samar K. Bhowmick, MD, FACE,
- `' J! p4 M) U3 @, J/ b$ XProfessor of Pediatrics, University of South Alabama, College of
# X9 R9 b+ l+ Z3 ~Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 D, Z' l% s3 K
e-mail: [email protected].
) N# T! Y: t$ d7 sabout 6 to 7 months old, which progressively became! R; |' Z" h% m S5 a
darker. She was also concerned about the enlarge-2 I" r1 u' M+ \7 q
ment of his penis and frequent erections. The child9 e* Q& Y; v4 w" t" q F, K
was the product of a full-term normal delivery, with
$ h! r* m. B. z+ E- C Y' Ya birth weight of 7 lb 14 oz, and birth length of
- g0 ^% g0 n$ J5 H: G20 inches. He was breast-fed throughout the first year7 F" e# W$ m5 S
of life and was still receiving breast milk along with
- m8 U9 O- V4 i$ e: E( osolid food. He had no hospitalizations or surgery,' ^# ~% R, x [. _8 ]& b
and his psychosocial and psychomotor development6 Z( p* i% f5 f( s+ ]" ^
was age appropriate.* B' F' O, l; U2 ?, h9 M
The family history was remarkable for the father,
6 D% U* g9 k$ ?8 ~" R% Y! R. hwho was diagnosed with hypothyroidism at age 16,, z$ \) I; T& p8 r
which was treated with thyroxine. The father’s
# t& L) {/ k# ?5 aheight was 6 feet, and he went through a somewhat* V! V" ?) G! o9 H3 Z
early puberty and had stopped growing by age 14.4 D0 Y$ Y# I* K2 {
The father denied taking any other medication. The
. x3 F# ^0 I( W8 H1 Ochild’s mother was in good health. Her menarche
3 P3 K$ e4 P( T1 f! cwas at 11 years of age, and her height was at 5 feet3 S- l% L) F1 p5 N& g( H: a
5 inches. There was no other family history of pre-
2 K. b. T; p6 u1 A6 M% Kcocious sexual development in the first-degree rela-6 r9 L) S1 _6 A2 z3 b
tives. There were no siblings.% X( |, \' P% F5 N
Physical Examination" [, W+ Q/ N+ @* z R1 o
The physical examination revealed a very active,
( g# j; ~4 _1 p; Iplayful, and healthy boy. The vital signs documented
; U* B/ T$ ?) r+ R( j% ~a blood pressure of 85/50 mm Hg, his length was
9 b: Z1 x6 w! c# g5 g, d8 g+ [+ r90 cm (>97th percentile), and his weight was 14.4 kg
0 `" s/ D3 o7 n% c(also >97th percentile). The observed yearly growth
. |5 S, w- C( U( W0 P1 y9 N. X; jvelocity was 30 cm (12 inches). The examination of s, b1 |# N( E
the neck revealed no thyroid enlargement.. v" F; q4 t: X4 W
The genitourinary examination was remarkable for
. J3 v9 ]5 f, ?# Z! Q) Menlargement of the penis, with a stretched length of
7 Y: U3 F, s6 f% r- o8 cm and a width of 2 cm. The glans penis was very well# r- Q/ Z1 {3 L& z% }$ |" X
developed. The pubic hair was Tanner II, mostly around- O' }3 b1 p; E a @
5404 o+ m- J2 g% X; d2 _& l5 E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ O& Z* x3 ~0 H8 `& ` k( s( Uthe base of the phallus and was dark and curled. The0 r$ t1 T8 J2 n$ u9 ]3 \, ]& S/ \7 u
testicular volume was prepubertal at 2 mL each., O2 O% x% V% ?, T, T
The skin was moist and smooth and somewhat6 R' U9 ^* O( n& d
oily. No axillary hair was noted. There were no) P3 [# j$ @7 g
abnormal skin pigmentations or café-au-lait spots./ {6 T1 }4 e3 y3 @ n i% T
Neurologic evaluation showed deep tendon reflex 2+
8 k9 \4 Z7 q/ Sbilateral and symmetrical. There was no suggestion( e* q; D' T9 |6 o5 y- T
of papilledema.3 H9 j! E7 v, a6 l( \, f8 w
Laboratory Evaluation
, i8 v! \, g: F4 ^ IThe bone age was consistent with 28 months by
& L3 U" W; G, I# [% N2 w3 Musing the standard of Greulich and Pyle at a chrono-7 d9 `1 G' H0 V& [7 u: S, d* l
logic age of 16 months (advanced).5 Chromosomal9 P8 [2 A0 b; Q+ g3 n' [4 F$ G
karyotype was 46XY. The thyroid function test+ q1 B" c% E. ?" G) c
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 W% M% d1 A. l0 slating hormone level was 1.3 µIU/mL (both normal).
0 C3 n6 E1 n0 X; B \9 f; M3 k7 U/ [The concentrations of serum electrolytes, blood
& v+ |4 J1 V+ Durea nitrogen, creatinine, and calcium all were
: |4 n' f# {" Twithin normal range for his age. The concentration
# L$ G" f. P) I- S( y( iof serum 17-hydroxyprogesterone was 16 ng/dL
: w3 g' W1 x. T; f6 @(normal, 3 to 90 ng/dL), androstenedione was 20
2 K6 h9 }! f- h( n0 B `# c v8 k9 Z. |ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, p e; d' F$ g$ Y! tterone was 38 ng/dL (normal, 50 to 760 ng/dL),
; \" F5 W. I7 ~2 o( Cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to" u: j) P( ]3 P+ A) e$ P
49ng/dL), 11-desoxycortisol (specific compound S)
2 Q9 Z/ F" T4 ~( ]; e; Zwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 d- K. o7 m- K( p7 U' e
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 @* i0 ]5 {1 a' T
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# S9 N% ]5 f2 h n; M4 Oand β-human chorionic gonadotropin was less than* n& ?7 G, z) G
5 mIU/mL (normal <5 mIU/mL). Serum follicular' Y- }- ~7 f* R
stimulating hormone and leuteinizing hormone7 o" o$ c4 Y. D$ K( u, G6 a5 k% q* m9 o
concentrations were less than 0.05 mIU/mL
8 e0 k) r) t* L, O, k w(prepubertal)." @3 L* B; n9 Q
The parents were notified about the laboratory/ q% c% T# C: Z
results and were informed that all of the tests were; P' o! x' N* B
normal except the testosterone level was high. The3 B) S2 e, p" k/ f- _0 r
follow-up visit was arranged within a few weeks to
6 U% s- c! d. sobtain testicular and abdominal sonograms; how-7 _, G1 q5 j- s* B$ O
ever, the family did not return for 4 months.
, s+ Z H8 a2 g8 H" F9 [4 [# mPhysical examination at this time revealed that the& ?, `/ J6 J* y( ]
child had grown 2.5 cm in 4 months and had gained
. }- i6 M3 K5 [3 d2 kg of weight. Physical examination remained' V# i6 R/ Y" h' o/ R1 P- @
unchanged. Surprisingly, the pubic hair almost com-
. x- S ], I' {' {2 Ipletely disappeared except for a few vellous hairs at5 O$ x# B& V9 b4 C, p
the base of the phallus. Testicular volume was still 2( v: F! g5 @- k+ `& W) [/ @% b& K0 z& N
mL, and the size of the penis remained unchanged.
- h. o7 y$ R6 I1 WThe mother also said that the boy was no longer hav-
R6 O& u* M+ A z5 Iing frequent erections.( ?/ g+ a1 [) q' Q# L1 K5 h$ R
Both parents were again questioned about use of# W ?" o9 |& @1 ?/ O7 g
any ointment/creams that they may have applied to4 f* O; }% Z* Q' \7 f$ c' J: |
the child’s skin. This time the father admitted the5 D6 M& ?- s! E: B9 _1 p! ~
Topical Testosterone Exposure / Bhowmick et al 541
9 Q! u7 q5 w2 v; m$ q; Vuse of testosterone gel twice daily that he was apply-
" l9 U; Q7 z/ E0 z: H' ^4 wing over his own shoulders, chest, and back area for
7 _# ]- s, Y8 ~( _" @- ja year. The father also revealed he was embarrassed
6 s: I/ E( g" c$ x6 M* y- v8 cto disclose that he was using a testosterone gel pre-
$ C" B% @ S' r0 z, K. Wscribed by his family physician for decreased libido5 n" ], j, X" u) d
secondary to depression.
: P$ E8 o& V( c0 |* rThe child slept in the same bed with parents.# y+ M( T& c3 t! F- j2 n6 Q& x
The father would hug the baby and hold him on his
% \/ ~/ I2 K+ D! L3 o) e7 o0 s8 p g# Jchest for a considerable period of time, causing sig-& T$ [7 r2 h, `! Z; D. ~
nificant bare skin contact between baby and father.
1 @* ~9 Y1 Z- Y0 g3 w$ I eThe father also admitted that after the phone call,
# f2 ?. `6 K0 Z4 B- Rwhen he learned the testosterone level in the baby! Y% E1 W2 ]8 K1 B3 g4 t
was high, he then read the product information$ u) e- C D4 w$ n! y% t1 x
packet and concluded that it was most likely the rea-
9 A2 ^" h, `. tson for the child’s virilization. At that time, they
2 `0 x' v* N- x, U& _/ G4 fdecided to put the baby in a separate bed, and the
3 z! @3 u, C3 H- r0 `) D, Bfather was not hugging him with bare skin and had i/ k. q( s7 G. @2 s. r; J
been using protective clothing. A repeat testosterone& n6 f0 Z& A# x. [8 L8 j
test was ordered, but the family did not go to the
k; i4 E. ]- K0 H m2 m, wlaboratory to obtain the test.
) ?% }, Q. O2 k0 L" VDiscussion
, m m; Q* S6 t7 v: ePrecocious puberty in boys is defined as secondary. U6 t# k o/ ^7 y; \; o6 x' Y
sexual development before 9 years of age.1,4. X! a; F# w# L7 p( `
Precocious puberty is termed as central (true) when
6 q/ P5 ]! p& W) |. e: j# A' [it is caused by the premature activation of hypo-
2 m1 Q0 U, t4 \' Rthalamic pituitary gonadal axis. CPP is more com-* ^! e* W& F2 ?4 R/ f
mon in girls than in boys.1,3 Most boys with CPP R e h4 s3 ~8 I
may have a central nervous system lesion that is
5 x; b# p: l% e- i2 ]responsible for the early activation of the hypothal-
1 O/ g5 v/ P* n% Y- Q2 g5 famic pituitary gonadal axis.1-3 Thus, greater empha-. J/ e F: o5 |+ J, [4 K5 _9 q" r
sis has been given to neuroradiologic imaging in5 ~6 F) d% G+ o( l t
boys with precocious puberty. In addition to viril-6 l/ e. J+ W b
ization, the clinical hallmark of CPP is the symmet-9 ^0 r" x1 N+ U: C
rical testicular growth secondary to stimulation by3 l: g* N0 K+ j2 d) c, A
gonadotropins.1,30 W+ R" b2 Z3 O! A1 o. d
Gonadotropin-independent peripheral preco-
' |! V# M. V: _* q4 ~9 C/ }+ V# y/ ^cious puberty in boys also results from inappropriate, R/ R9 j7 u+ {9 i& c) R
androgenic stimulation from either endogenous or$ g8 C, ?4 w" ~. c; H B- C9 F
exogenous sources, nonpituitary gonadotropin stim- Q4 ]& W! [7 {5 @
ulation, and rare activating mutations.3 Virilizing- t1 W2 w5 G3 A! C
congenital adrenal hyperplasia producing excessive( S% ~3 n7 C% T, y+ p
adrenal androgens is a common cause of precocious/ ~4 U6 @: d5 Y/ n& F1 G: z9 u" c# I
puberty in boys.3,4
, M% V* a- I: Z ~4 DThe most common form of congenital adrenal( a- ]* U# ~0 G. {( I% L/ z/ j
hyperplasia is the 21-hydroxylase enzyme deficiency.
; ]: w+ u) G* J, V: \The 11-β hydroxylase deficiency may also result in, T+ s* X! R1 r) A" m
excessive adrenal androgen production, and rarely,6 D. o# w; m" Y0 n$ y5 X
an adrenal tumor may also cause adrenal androgen; S$ Z1 p& w ~+ Z+ W% b
excess.1,3
6 Z/ M2 ]4 Z w2 C8 ~8 ~$ V0 fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# l* b2 s2 c% @: w7 s) X
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007 K0 n/ H4 r, H. T N" R
A unique entity of male-limited gonadotropin-$ N+ ], Y1 Q. a
independent precocious puberty, which is also known
+ y9 A1 k# v+ Yas testotoxicosis, may cause precocious puberty at a
! ]) S, h0 _, Z: l0 ]very young age. The physical findings in these boys
1 u; H4 }% M h- w. Iwith this disorder are full pubertal development,
4 q- D) \; k2 ^5 M3 W, T- Dincluding bilateral testicular growth, similar to boys1 v( l: U- ?6 @+ R
with CPP. The gonadotropin levels in this disorder
: E, ^3 H: x+ ]2 J/ kare suppressed to prepubertal levels and do not show
) Z. e; q' D' c( npubertal response of gonadotropin after gonadotropin-
; T9 p$ h$ r$ |0 U7 Treleasing hormone stimulation. This is a sex-linked h: w( g6 G5 ^
autosomal dominant disorder that affects only
" r+ T; L7 G: J, t2 Vmales; therefore, other male members of the family
7 Y5 ]/ b2 h2 Mmay have similar precocious puberty.3
4 A7 |/ ~, Q1 t2 ]7 ]' YIn our patient, physical examination was incon-
8 O. j R0 e$ X ^' Rsistent with true precocious puberty since his testi-) c( A i" n7 l
cles were prepubertal in size. However, testotoxicosis' ~1 Z3 ~. `0 J" Q4 y" S) b% ]) D
was in the differential diagnosis because his father" z* H$ H9 G+ @% W1 Z) N% ~
started puberty somewhat early, and occasionally,
! ]( Z# o+ [# e2 o( u" O" ctesticular enlargement is not that evident in the, |/ r1 @3 Y+ c" G/ v% O; |
beginning of this process.1 In the absence of a neg-
# X9 L/ W0 s }1 a* F. vative initial history of androgen exposure, our6 u& Q1 H k$ V$ N' w: t3 J
biggest concern was virilizing adrenal hyperplasia,
7 |3 w" _3 P; y% `' peither 21-hydroxylase deficiency or 11-β hydroxylase
5 i& u E# O: {+ |/ gdeficiency. Those diagnoses were excluded by find-5 L, L& R, h! G& K: i
ing the normal level of adrenal steroids.. V' z$ ?, t/ [+ Q
The diagnosis of exogenous androgens was strongly& s! T, r2 X% J4 n1 o% p
suspected in a follow-up visit after 4 months because
5 Q; [5 D- o; k/ k; Uthe physical examination revealed the complete disap-
' G/ Y; s0 C0 _+ upearance of pubic hair, normal growth velocity, and
: ^3 F: }) x+ n9 M1 @: gdecreased erections. The father admitted using a testos-
& i" \7 W& t3 {terone gel, which he concealed at first visit. He was
1 d& N" v; H; ^1 r; cusing it rather frequently, twice a day. The Physicians’
% Y3 L/ J4 u* @$ N L- y2 v1 HDesk Reference, or package insert of this product, gel or. i5 ~# q1 f% R5 p4 S
cream, cautions about dermal testosterone transfer to- v* V; O5 f9 Y1 o2 h/ P" d
unprotected females through direct skin exposure.
) F2 Y. S, O: G. P( cSerum testosterone level was found to be 2 times the
- |2 L' I( A7 B- w/ `baseline value in those females who were exposed to" l9 q* K# w# V9 r
even 15 minutes of direct skin contact with their male0 y5 \2 W' k8 b* G
partners.6 However, when a shirt covered the applica-
9 \# e9 J( ]2 M$ Ntion site, this testosterone transfer was prevented.
9 V, z7 Z3 v, H5 t- r3 o% H6 a: sOur patient’s testosterone level was 60 ng/mL,
7 Q, b$ m6 O, Bwhich was clearly high. Some studies suggest that0 v5 |3 Z3 K3 e/ ], m6 z- Z1 q
dermal conversion of testosterone to dihydrotestos-, |, q% ]9 k6 G% D+ q, m! C
terone, which is a more potent metabolite, is more
' C3 O9 m4 R8 b; f; ractive in young children exposed to testosterone% a: i$ M' i( z2 b* x8 R* d9 F4 M, i
exogenously7; however, we did not measure a dihy-4 g) U4 a* x1 e( B; s- j
drotestosterone level in our patient. In addition to) @% R1 Y0 H1 [( L7 R6 w
virilization, exposure to exogenous testosterone in
6 p1 P& p/ M4 Y2 v. R6 \/ W& q9 tchildren results in an increase in growth velocity and) c( l$ ^' z4 ?' |& h
advanced bone age, as seen in our patient.( J$ L& k: k* M& @
The long-term effect of androgen exposure during: m, d$ t- d3 D' w; _2 K
early childhood on pubertal development and final
$ S8 _' t6 v6 kadult height are not fully known and always remain
" _8 h, ]& c% b/ l' Ea concern. Children treated with short-term testos-+ j0 f/ N) C: W+ b5 |
terone injection or topical androgen may exhibit some" `0 E8 E7 m* W% t7 R6 t# A- ?
acceleration of the skeletal maturation; however, after2 L/ T g6 t" _2 L, E
cessation of treatment, the rate of bone maturation" j3 b& d, R- x- n$ E
decelerates and gradually returns to normal.8,99 l& O6 i( D+ {* d. i+ z' X
There are conflicting reports and controversy* D' o' i# H' Q, k5 o( a1 m
over the effect of early androgen exposure on adult
. T- X1 G! R, `' k1 V) Cpenile length.10,11 Some reports suggest subnormal9 W8 o( G# L# I' U; Q# d+ j5 ~$ g, `5 |! R
adult penile length, apparently because of downreg-
/ k) \$ l E: [ M; i, B0 _ulation of androgen receptor number.10,12 However,0 u% y- Y& c& b& x% h, C: f
Sutherland et al13 did not find a correlation between
! U& U* _$ B) M9 W* F# A9 wchildhood testosterone exposure and reduced adult
1 n( g. c2 v! U" E$ a# D: Y0 hpenile length in clinical studies.9 s8 f9 u4 R0 S3 z* b
Nonetheless, we do not believe our patient is4 }7 j( o2 {- w2 B3 g
going to experience any of the untoward effects from
1 V. l6 H& F+ M) x5 O1 ttestosterone exposure as mentioned earlier because: f, N# A8 x: Z( G
the exposure was not for a prolonged period of time.
, F1 W9 \" r# o) I5 E' T- DAlthough the bone age was advanced at the time of
& `1 {; Z0 l0 d9 `9 S; L2 |0 Pdiagnosis, the child had a normal growth velocity at
2 e: a, |( A$ Q6 p# xthe follow-up visit. It is hoped that his final adult
: H# v6 Z* Y) l# ~4 ^/ ?height will not be affected.
5 V. j9 }4 X, _6 _; o1 RAlthough rarely reported, the widespread avail-
7 I8 A/ Q! E# c% e, @2 jability of androgen products in our society may
4 Z; x: Z* K6 B% S4 lindeed cause more virilization in male or female% w9 ~0 \& Y) D! W6 @
children than one would realize. Exposure to andro-2 X9 M0 y1 u7 e" x6 y3 X& d
gen products must be considered and specific ques-% L! {: M( O5 F* I* H, u
tioning about the use of a testosterone product or
2 }6 i- M8 x8 h, c5 c% v4 G3 Fgel should be asked of the family members during: \0 f% x, H6 ?9 I
the evaluation of any children who present with vir-
5 Q: a I; T, b, F1 }3 X. Lilization or peripheral precocious puberty. The diag-
& p4 A# `2 Q7 |2 I' d fnosis can be established by just a few tests and by
{* y$ V' h( L2 e; v& Yappropriate history. The inability to obtain such a
g j, `6 {6 T3 m4 _5 T8 Q! A% qhistory, or failure to ask the specific questions, may$ c" v* |& d$ l6 l. \- Q% y
result in extensive, unnecessary, and expensive
y7 x. c& [$ X: e3 Qinvestigation. The primary care physician should be
+ T' _* x# N2 D) R$ v laware of this fact, because most of these children
* U3 L9 d: g3 c+ g) M7 O# A Emay initially present in their practice. The Physicians’
1 e. R3 a# O( C3 A6 aDesk Reference and package insert should also put a( E' I/ F" _0 C) U4 q
warning about the virilizing effect on a male or
0 a4 X5 D$ C- t. l7 Ifemale child who might come in contact with some-
. G* r2 D& ]& a1 d0 d: mone using any of these products.3 z# Z; |. S6 A: k* y3 Z
References
6 q' Q. G" n5 R" ?6 g9 i: r8 y. I: {9 b1. Styne DM. The testes: disorder of sexual differentiation/ O8 `2 r+ f( T$ R8 j
and puberty in the male. In: Sperling MA, ed. Pediatric0 _6 i. W q H) k
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 H) [- p4 W0 C9 A2 P# J- W. H. G+ I! ^/ {
2002: 565-628.# m" p1 a5 y7 m7 G) }: J# Q& G4 x
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 Q# Y8 w' e. ypuberty in children with tumours of the suprasellar pineal |
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