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Sexual Precocity in a 16-Month-Old
4 c( R1 D& y6 g) zBoy Induced by Indirect Topical: @& o. o, v- |2 p& {
Exposure to Testosterone
, z7 s+ v9 [/ R& z( \Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! ~4 ?1 b0 F+ h2 K
and Kenneth R. Rettig, MD1$ u4 [7 k% Z& o) Y$ Z
Clinical Pediatrics# _6 K0 d/ q a+ ~8 |# B" S6 C
Volume 46 Number 6
, I' ?0 o, z! v( M& qJuly 2007 540-543
3 X0 [1 v7 B4 m# V, R2 w* Y ~; z© 2007 Sage Publications
7 Z2 G5 _$ w7 {( b& q10.1177/0009922806296651
/ `# z* r6 L4 }" M4 d# Whttp://clp.sagepub.com
' |; V8 U( b! ~3 S4 K5 t; T. ?9 Chosted at7 r5 I$ L% E% O2 k" L0 e
http://online.sagepub.com$ N6 c( E& r* C& K
Precocious puberty in boys, central or peripheral,( R" h' n" S& O0 n1 S5 b9 O) ^2 X
is a significant concern for physicians. Central
. K. s3 ]9 l+ ~3 g: eprecocious puberty (CPP), which is mediated7 Z( w8 D- k2 G1 s/ n
through the hypothalamic pituitary gonadal axis, has7 L1 }" ?9 ]$ D) r3 p: [& \* Q7 H: v
a higher incidence of organic central nervous system
1 U# f$ e: L$ y/ \( M3 r$ g2 j [lesions in boys.1,2 Virilization in boys, as manifested& W7 X$ s6 b! R K, y$ k
by enlargement of the penis, development of pubic
% ]- e6 T: S3 U0 n" R0 u) [- ^hair, and facial acne without enlargement of testi-2 }5 b1 d, N9 G3 L+ ?
cles, suggests peripheral or pseudopuberty.1-3 We
6 G& X7 ^7 S3 y2 @ Ereport a 16-month-old boy who presented with the
& c+ v# Q, B8 t% J) O, Nenlargement of the phallus and pubic hair develop-
1 T5 }% u4 }5 q7 \4 Hment without testicular enlargement, which was due) I7 h' P. J8 Q, X8 b( g
to the unintentional exposure to androgen gel used by
2 E3 T2 E2 l. b6 pthe father. The family initially concealed this infor-
. I: I& v& c3 r5 z" X# ymation, resulting in an extensive work-up for this
9 w& W' n% K- `child. Given the widespread and easy availability of
8 \5 t- C* W8 G' d$ ^testosterone gel and cream, we believe this is proba-
7 S# t3 b1 q" y; ?& L" x% I' x" M3 z, vbly more common than the rare case report in the
2 |. u. G) R/ I6 r/ ^6 _literature.41 W# j9 N) ]* {8 c
Patient Report: j& J% q- p% @: \7 c/ M
A 16-month-old white child was referred to the X0 c( n- x+ ^; d0 b
endocrine clinic by his pediatrician with the concern
& w# c5 X! N" a# G& rof early sexual development. His mother noticed
% D! A* K# M8 ^: llight colored pubic hair development when he was
" U, p- n- |8 ?: q* m/ OFrom the 1Division of Pediatric Endocrinology, 2University of% d4 ~2 D) h* G; n% |! ~8 s
South Alabama Medical Center, Mobile, Alabama.
* H3 R8 F: G; Z% R) n6 DAddress correspondence to: Samar K. Bhowmick, MD, FACE,2 n5 y! {2 E2 m) Z5 M* ]) E; i! W: T
Professor of Pediatrics, University of South Alabama, College of6 z7 C' N0 L* t; a; m* V
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 V6 e3 x+ |1 g7 N! {e-mail: [email protected].
+ _5 h5 N8 n2 s& V- E" pabout 6 to 7 months old, which progressively became5 ^8 U5 d6 K7 q. p9 o
darker. She was also concerned about the enlarge-1 w; c( N W' X9 T: Y, Z
ment of his penis and frequent erections. The child
5 B- F0 ^! C+ s7 o/ z' k3 g6 Iwas the product of a full-term normal delivery, with
4 X5 V4 Y7 }' ha birth weight of 7 lb 14 oz, and birth length of
* K0 K6 n) o3 y3 n) k. W20 inches. He was breast-fed throughout the first year% U' J4 `- w; K6 A4 L6 i% g! P
of life and was still receiving breast milk along with
' X# E$ w% Z/ q5 R- Z0 U& S' @5 `solid food. He had no hospitalizations or surgery,
, e' ?3 G2 i* I. b- ]and his psychosocial and psychomotor development
- H$ f/ M- R( {$ Owas age appropriate.
% g: D2 w3 z `( s% M: dThe family history was remarkable for the father," P; s' x& v" T9 _
who was diagnosed with hypothyroidism at age 16,
$ G; \6 l9 ]* V; x& U+ Gwhich was treated with thyroxine. The father’s
, N9 c/ ]/ n, [' K' K) K5 ~/ N( B6 Oheight was 6 feet, and he went through a somewhat$ t: f% Q8 W& p0 ]
early puberty and had stopped growing by age 14.1 y* w* p' y3 ~
The father denied taking any other medication. The
3 N) g$ |0 h( d1 ?9 ^child’s mother was in good health. Her menarche
4 _% K% W9 A6 _0 l5 kwas at 11 years of age, and her height was at 5 feet
/ C5 U! t) X; v( ~ s! v: {5 inches. There was no other family history of pre-
6 S* ?) \( w/ a) A M2 Lcocious sexual development in the first-degree rela-2 x* s. x9 f6 Z9 C- k y
tives. There were no siblings.. U5 t: G. l* _- r3 P. L
Physical Examination4 |9 V/ a( z9 s6 c
The physical examination revealed a very active,5 t# F+ j' y) ?6 I
playful, and healthy boy. The vital signs documented
+ L* _4 [3 c. _$ oa blood pressure of 85/50 mm Hg, his length was
& [0 r' D4 W/ _6 z7 s1 K, u6 u9 |2 x7 z90 cm (>97th percentile), and his weight was 14.4 kg
& \% q C% v. {* J: `+ c2 h(also >97th percentile). The observed yearly growth
& b$ L1 _( E6 u0 B$ Rvelocity was 30 cm (12 inches). The examination of
|9 A% _8 j7 ^! Zthe neck revealed no thyroid enlargement.
8 ?/ c" T( E/ S/ }1 CThe genitourinary examination was remarkable for1 ^( O! s2 @; u! e
enlargement of the penis, with a stretched length of6 F1 X0 ^3 Z, E2 |: Y& E
8 cm and a width of 2 cm. The glans penis was very well
7 U: P: x5 u" Y. Rdeveloped. The pubic hair was Tanner II, mostly around) j# f9 X! Q; J4 y& i% `
540. ?+ I. C9 q4 H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* Z) w) B$ \! \1 K0 l' S% |the base of the phallus and was dark and curled. The, {) D4 ?- B5 R+ S5 L9 R
testicular volume was prepubertal at 2 mL each.
$ ` c. M1 S( a' ^0 ZThe skin was moist and smooth and somewhat
9 e# R, g/ t. ]" I+ K2 h# Roily. No axillary hair was noted. There were no- _$ h' F. H$ `; m& ]( x: q( ?9 n
abnormal skin pigmentations or café-au-lait spots." m9 \6 @; R# [( `
Neurologic evaluation showed deep tendon reflex 2+' b" }3 M4 h+ }2 t9 I1 g
bilateral and symmetrical. There was no suggestion* J$ U+ C& j2 \$ N! c8 w
of papilledema.; ]0 R0 j4 S' D; W& }* V' Q% @
Laboratory Evaluation. z- h9 ?! r8 |6 S8 A
The bone age was consistent with 28 months by
/ h# F1 r2 y1 |8 h% }/ k0 kusing the standard of Greulich and Pyle at a chrono-* v& o8 k; m* D9 r
logic age of 16 months (advanced).5 Chromosomal5 q+ i U; j; y3 [8 N- G
karyotype was 46XY. The thyroid function test% P# C4 |# `, S7 L
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
! e: c- q% k8 Z& f. I+ flating hormone level was 1.3 µIU/mL (both normal).
. S4 y6 ^" h, d/ L1 z* VThe concentrations of serum electrolytes, blood; ~, e8 N! `- v* {2 |6 Y
urea nitrogen, creatinine, and calcium all were; j3 {, ]$ ^. S8 h j9 A
within normal range for his age. The concentration
- s$ U. B( V! [3 V- r0 e, Dof serum 17-hydroxyprogesterone was 16 ng/dL
2 F1 S9 g2 {9 |(normal, 3 to 90 ng/dL), androstenedione was 201 C) u a1 m; M5 [6 M$ J4 K
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-7 h' K4 B+ @) v9 B6 h# S0 g4 x7 _
terone was 38 ng/dL (normal, 50 to 760 ng/dL),& I4 j/ o' G" t* g
desoxycorticosterone was 4.3 ng/dL (normal, 7 to0 m! ?, g) r! m
49ng/dL), 11-desoxycortisol (specific compound S)
2 U0 h1 b* C8 v, {, {& Cwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
" ^1 i0 y1 _5 }( J7 K: Ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total, s1 y: F+ U, i1 I2 ?
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 }) T2 m6 M6 i" \+ ` W
and β-human chorionic gonadotropin was less than
. K0 j9 d, ?) z4 G: f# D5 mIU/mL (normal <5 mIU/mL). Serum follicular& C% f) o. D5 q- [6 u: I
stimulating hormone and leuteinizing hormone# w6 Q7 i# A% a, [. A, [1 I1 _
concentrations were less than 0.05 mIU/mL9 e! G* Z9 ], F; B
(prepubertal).
( Q7 \7 k/ T( R" J; L- XThe parents were notified about the laboratory
$ ?/ G$ T- v! |8 v/ u3 G1 Y' Nresults and were informed that all of the tests were1 b* N7 K3 d9 g; ~/ E% V# d+ C
normal except the testosterone level was high. The" E2 j1 i+ |! J4 M7 \
follow-up visit was arranged within a few weeks to
- E) s3 P, F& c5 s5 {. T! R2 Robtain testicular and abdominal sonograms; how-
. {' f6 B! d1 @; u( _ever, the family did not return for 4 months.+ @, z! _% ]* j' Z0 u3 r+ m
Physical examination at this time revealed that the
* R5 b! Q0 b' t% p8 Q7 Ichild had grown 2.5 cm in 4 months and had gained$ }( K2 N x, C: V. Z$ p# u# P( E) Y x2 ]
2 kg of weight. Physical examination remained. h% K, T, a9 s+ f+ H
unchanged. Surprisingly, the pubic hair almost com-! H0 q1 Q/ e, T6 C! ?5 T. u
pletely disappeared except for a few vellous hairs at
9 O. ?+ v$ Z* \' k' Y" \0 Jthe base of the phallus. Testicular volume was still 2
" B% _! K1 j7 _1 N8 W3 k% b! hmL, and the size of the penis remained unchanged.2 A) b( }! ^; s
The mother also said that the boy was no longer hav-
4 \! _3 h/ s7 a9 t" m( j: `' F6 |( @3 \: eing frequent erections.
( s' f# d& u" T. u6 l, Q3 q1 Z* FBoth parents were again questioned about use of
! j& n0 J# f3 J3 x: I/ {any ointment/creams that they may have applied to! V3 i G" O) W* N2 \
the child’s skin. This time the father admitted the
& B' v) \2 H3 o, @" D9 d& tTopical Testosterone Exposure / Bhowmick et al 541
* A3 P5 M1 b9 juse of testosterone gel twice daily that he was apply-5 y& Q. w6 W5 s) b) w
ing over his own shoulders, chest, and back area for* Q+ L( W* P/ \$ @, q) \
a year. The father also revealed he was embarrassed
7 I- @8 \& j: y- f3 M( h9 lto disclose that he was using a testosterone gel pre-
; r& A; ?% ~& N, h+ W8 F/ T) z( O- F" Lscribed by his family physician for decreased libido
% d G$ L4 \9 tsecondary to depression.8 g0 ^" I- Z1 Q& o- @8 n
The child slept in the same bed with parents.4 y2 a1 v8 J9 s
The father would hug the baby and hold him on his
+ A. h/ B% J0 |( k7 U4 i9 [chest for a considerable period of time, causing sig-
! Y: x9 \4 s. k% Z) B0 Xnificant bare skin contact between baby and father.8 ?* d7 g: c9 x
The father also admitted that after the phone call,
, ~/ x) e+ t, j# {' o& `8 xwhen he learned the testosterone level in the baby0 D: {7 k* @$ i$ ~
was high, he then read the product information
1 t; c. l' U% @9 r9 V3 E' |6 Spacket and concluded that it was most likely the rea-
5 L! \4 q4 |$ N5 T! ]2 }) L# F( {son for the child’s virilization. At that time, they
; Q1 M. v- n% x. R$ Mdecided to put the baby in a separate bed, and the
0 {* \3 {& i# y5 e; G" v0 t5 Vfather was not hugging him with bare skin and had/ |2 A/ B4 h# I9 B# O
been using protective clothing. A repeat testosterone
7 g% n. l' N# M Z% r+ Jtest was ordered, but the family did not go to the
$ E0 ^! C, C; ^: X2 J: ~laboratory to obtain the test. j5 f+ \1 B) {1 {0 d4 k( [
Discussion' U o+ b5 z5 h$ J6 d
Precocious puberty in boys is defined as secondary5 Q% O$ ?) [' ]0 N
sexual development before 9 years of age.1,4: h& l, E1 [: T V# |/ F4 l+ r
Precocious puberty is termed as central (true) when0 J+ o) I/ \ r# Q! J1 A, K
it is caused by the premature activation of hypo-
4 U9 T- w8 r* k9 cthalamic pituitary gonadal axis. CPP is more com-
7 B, y! n' G$ zmon in girls than in boys.1,3 Most boys with CPP; y+ q( E: d0 O
may have a central nervous system lesion that is. R7 z& j. ~. y" @) t
responsible for the early activation of the hypothal-
8 b% M, m8 M& lamic pituitary gonadal axis.1-3 Thus, greater empha-- G! Z x. o& L. Y; E2 I. q
sis has been given to neuroradiologic imaging in0 Y8 A; r2 B/ Y
boys with precocious puberty. In addition to viril-, f2 K5 s j, U, y
ization, the clinical hallmark of CPP is the symmet-) p/ Y% {; t0 j+ ~5 [
rical testicular growth secondary to stimulation by
" |) F$ B5 K- V& Q; `/ `# r& J7 Wgonadotropins.1,32 v3 k5 D1 D& c% U& o5 T1 x J
Gonadotropin-independent peripheral preco-
/ G3 K. I7 q) H- l8 b" n vcious puberty in boys also results from inappropriate; z2 I! N6 ~% `6 \; |1 b% p
androgenic stimulation from either endogenous or* O0 R' Q7 J1 d8 h
exogenous sources, nonpituitary gonadotropin stim-& U* r4 t. @& g9 l' o6 D
ulation, and rare activating mutations.3 Virilizing( }: W3 m1 Q) D3 o( V7 F- R" l
congenital adrenal hyperplasia producing excessive
* h9 g. u9 Q4 O( p4 o0 Y5 A# Nadrenal androgens is a common cause of precocious
" A3 E7 h" C! p) a* b9 Mpuberty in boys.3,4
, Q/ t1 T8 f% _* FThe most common form of congenital adrenal
+ n y& V+ H' B; I" I3 dhyperplasia is the 21-hydroxylase enzyme deficiency.9 [' u" J% V3 H" ?1 x
The 11-β hydroxylase deficiency may also result in
7 u5 E5 \# h& m2 t4 Wexcessive adrenal androgen production, and rarely,' t2 s- f. _. w% J9 }! ^; s! L% D
an adrenal tumor may also cause adrenal androgen
; d( g& B5 W! Y$ i: {' R; v3 Sexcess.1,3
; y& t# ]6 a% Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ V) v9 @0 L) b9 f# `542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 v1 f7 f, \! jA unique entity of male-limited gonadotropin-
* F7 K( P4 T: ^independent precocious puberty, which is also known( O2 t, ~& @: h9 G# Y
as testotoxicosis, may cause precocious puberty at a& c# F% ^$ n$ F5 C
very young age. The physical findings in these boys
0 G4 R( z7 d. E X1 bwith this disorder are full pubertal development,& v1 L/ Q, o, p4 ]. m6 B
including bilateral testicular growth, similar to boys
- v# f+ z- F f* b+ e# Z" Qwith CPP. The gonadotropin levels in this disorder
: K7 C1 i& m' X Uare suppressed to prepubertal levels and do not show# E. V% e. a% r {, j
pubertal response of gonadotropin after gonadotropin-
( p# Z1 L) S# `$ ?9 s. Creleasing hormone stimulation. This is a sex-linked8 ]& K, f, I& |' W) i* L
autosomal dominant disorder that affects only7 {3 Z7 R' d4 z9 Y' B
males; therefore, other male members of the family
0 W. I( l" @! N- y6 dmay have similar precocious puberty.38 x4 D: F, O2 c! i4 u$ Z
In our patient, physical examination was incon-% h% u# `% \$ f, J! q8 B* F- r
sistent with true precocious puberty since his testi-8 {) u8 _( z; U" L" O
cles were prepubertal in size. However, testotoxicosis) p: o' l& i1 B( q. t
was in the differential diagnosis because his father) h# B8 `$ b) E+ Z8 G: b
started puberty somewhat early, and occasionally, @; g4 G+ d( c/ g
testicular enlargement is not that evident in the+ ~# L6 p3 P% F$ _% s
beginning of this process.1 In the absence of a neg-' _9 r* A! q3 r- V0 P
ative initial history of androgen exposure, our
' K' A1 L' c6 l+ D# vbiggest concern was virilizing adrenal hyperplasia,
* O1 M1 I9 V' }/ t& ieither 21-hydroxylase deficiency or 11-β hydroxylase
/ T0 H; M: k* u* udeficiency. Those diagnoses were excluded by find-0 ]! ?* r0 v! I5 m" q
ing the normal level of adrenal steroids.
3 s# c8 L2 K0 m1 oThe diagnosis of exogenous androgens was strongly
& N( Y9 m- |5 H. A, C, u& U0 v, ususpected in a follow-up visit after 4 months because
& Y5 \5 ?9 o+ x0 Cthe physical examination revealed the complete disap-
5 {( b! `5 O1 B; \( @pearance of pubic hair, normal growth velocity, and
: [5 a& ~# _, U& B- edecreased erections. The father admitted using a testos- X, n/ }3 ]9 S8 E" I" T. h6 S5 e: \
terone gel, which he concealed at first visit. He was6 \1 P, F( Y |
using it rather frequently, twice a day. The Physicians’% ]+ F: ~4 ^# s; R: @6 O5 G k
Desk Reference, or package insert of this product, gel or
8 P: w2 U0 C* |$ V& jcream, cautions about dermal testosterone transfer to
9 g5 K; v9 G0 l/ junprotected females through direct skin exposure.+ `$ t, L( \# W8 Z/ T+ K
Serum testosterone level was found to be 2 times the
; B$ T% ^) ]$ G y) obaseline value in those females who were exposed to4 R1 ` r$ ~1 P' k% J; p& ^, V
even 15 minutes of direct skin contact with their male. }" f+ ]* B5 g0 w- K1 ^4 ^0 D
partners.6 However, when a shirt covered the applica-
6 `6 G& K" D: l Y8 Mtion site, this testosterone transfer was prevented./ _' z- v4 b; e! P& Y1 H
Our patient’s testosterone level was 60 ng/mL,. s3 |8 Y4 h7 I$ w9 u, e: e
which was clearly high. Some studies suggest that
; G8 L# ]6 C: S. [+ J3 _: U& Adermal conversion of testosterone to dihydrotestos-+ G7 l: _+ r! C& L! U6 m
terone, which is a more potent metabolite, is more
; c4 _& q- b+ X3 [" q7 m5 vactive in young children exposed to testosterone
9 x% o- H+ V' |/ W% \2 pexogenously7; however, we did not measure a dihy-) w {% |7 L" G7 P3 A3 [
drotestosterone level in our patient. In addition to
5 T; M4 F# b5 y. Qvirilization, exposure to exogenous testosterone in8 _, Z$ ^# I ~* t
children results in an increase in growth velocity and
. U$ g5 M0 C& u) E! D c; U+ _advanced bone age, as seen in our patient.
1 }) h" F# c3 Y! N5 A6 SThe long-term effect of androgen exposure during
( S m% M9 w* g( s) W3 dearly childhood on pubertal development and final3 S6 D& c6 c `3 q- Y9 F3 R a
adult height are not fully known and always remain
: L7 c) p1 T# {2 }1 wa concern. Children treated with short-term testos-. j& L( K1 K9 I# m$ k5 C6 @/ {
terone injection or topical androgen may exhibit some
2 Y z$ W; X# e( H' f6 vacceleration of the skeletal maturation; however, after; o0 {& Y8 S4 o- F
cessation of treatment, the rate of bone maturation; S( M4 b3 f1 ~
decelerates and gradually returns to normal.8,9" t7 c- F3 C$ O. C
There are conflicting reports and controversy8 R* V, ]* V# k$ o
over the effect of early androgen exposure on adult5 E% I. P( T2 s6 q$ l4 Z
penile length.10,11 Some reports suggest subnormal
" G+ w* i3 N- [adult penile length, apparently because of downreg-5 @# o2 L8 R% C; z3 ]
ulation of androgen receptor number.10,12 However,' N" }. {, {$ `# Z8 z- Z, H
Sutherland et al13 did not find a correlation between. S+ F$ l& V X" w2 t* P$ D
childhood testosterone exposure and reduced adult
9 u8 V$ E) g) _1 T! Tpenile length in clinical studies.
" [/ y- D2 k; y5 qNonetheless, we do not believe our patient is4 k- P# V& b% m4 Z+ K3 ?1 {/ k
going to experience any of the untoward effects from5 l) d x1 R, d3 A) S2 V* d
testosterone exposure as mentioned earlier because# J6 l/ J4 o( F6 v' z
the exposure was not for a prolonged period of time.( ~( b. j, ]8 t& x5 I" Y! C
Although the bone age was advanced at the time of
. R6 \6 O: \0 z' r! q3 @0 I% mdiagnosis, the child had a normal growth velocity at* K) K. ^; R. c7 G/ z4 z8 w9 j
the follow-up visit. It is hoped that his final adult
+ l$ D. ?/ \% z" {: P( s Q: F* hheight will not be affected.
0 \# `; \" k4 h. C2 N5 w. f- wAlthough rarely reported, the widespread avail-/ b& R" o! j U- x" J% _ \
ability of androgen products in our society may4 s! b [" T7 l1 C6 q' R8 G: m
indeed cause more virilization in male or female1 Z" A+ d( r0 u
children than one would realize. Exposure to andro-
4 @% V: t& r# t8 |* ^" F% N: Zgen products must be considered and specific ques-9 S, w, T3 M* f3 d0 h) P
tioning about the use of a testosterone product or4 W3 A B$ ^8 ^ H
gel should be asked of the family members during
u/ [3 ~( |/ A$ S M- ythe evaluation of any children who present with vir-6 Q+ C ]. p, G$ s
ilization or peripheral precocious puberty. The diag-
! B2 S9 P. H1 `0 ^/ A; \$ `nosis can be established by just a few tests and by
( r* O) ?) r- {- q8 V; j: Rappropriate history. The inability to obtain such a3 ]; w% x, Z9 ?. A7 a1 _
history, or failure to ask the specific questions, may' R0 h8 L6 E% w1 c. [) {: W/ `7 ?
result in extensive, unnecessary, and expensive# h. I0 a8 s) b; ^ Q1 u
investigation. The primary care physician should be
0 l& Y' V+ [3 E, ~7 w8 eaware of this fact, because most of these children3 u, W8 j1 M- h. Y
may initially present in their practice. The Physicians’- O3 J3 _) b( w2 l p1 o
Desk Reference and package insert should also put a0 A+ W# {! B7 O% |$ F2 r5 i9 x
warning about the virilizing effect on a male or
" g- ~4 ~" r. y" W; N. x: D) `/ ?female child who might come in contact with some-4 L& j3 ~+ B$ s9 G
one using any of these products.
3 P+ Y0 K9 j! m# f8 SReferences
" i( L8 j: y/ g# r1. Styne DM. The testes: disorder of sexual differentiation& j' K7 R) Q# X( H% M3 v j
and puberty in the male. In: Sperling MA, ed. Pediatric
" ]/ P& H) Q2 {$ n$ m7 _, u& HEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;! O( Z1 t" C0 ? S g7 h( L+ S: q/ G; _
2002: 565-628.
1 E% F- ?( S9 F% B3 |/ {& V2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& v& H; f: W+ l _/ u) j
puberty in children with tumours of the suprasellar pineal |
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