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Sexual Precocity in a 16-Month-Old1 ~4 o4 D$ L# i
Boy Induced by Indirect Topical
! t( Y, U# P6 I: Q0 N! P3 fExposure to Testosterone
, j, \" P" ^- V5 e. [8 s: `Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! n, |* f! ^: o' h- ]1 q8 y1 b* y, |
and Kenneth R. Rettig, MD10 E( o8 M) L3 @) p, E
Clinical Pediatrics/ q3 z3 Z% A* ^7 v: ^6 n, _9 }
Volume 46 Number 6; x/ _1 g7 o y' f$ G7 N+ w
July 2007 540-543: L. L: k7 U* q4 {* I, B6 d
© 2007 Sage Publications+ o% d! Y) o# ~+ J
10.1177/0009922806296651& y/ U: F, F. {' w. W
http://clp.sagepub.com; m9 a. M9 {3 M
hosted at4 i& J7 [7 |% x9 O; Y! ?+ k* U
http://online.sagepub.com
& x( L3 C2 q1 b4 I) UPrecocious puberty in boys, central or peripheral,
5 s$ Q6 t x1 e. w. U$ B1 [is a significant concern for physicians. Central+ _) C7 t j) m1 c S- C+ I( U9 T. D
precocious puberty (CPP), which is mediated3 j$ i' ]+ x* z: f$ u9 H
through the hypothalamic pituitary gonadal axis, has# j( S, e3 T$ `9 a! @% m0 Q
a higher incidence of organic central nervous system! t* g% q9 I8 i1 N2 [2 Y
lesions in boys.1,2 Virilization in boys, as manifested
8 U- C" q* B0 ~$ Lby enlargement of the penis, development of pubic6 ?9 l7 ^; w5 C+ ~# `5 s9 s
hair, and facial acne without enlargement of testi-3 r0 Z1 F5 `* S5 \3 I- d% J
cles, suggests peripheral or pseudopuberty.1-3 We
% z- G& E* e c3 o7 zreport a 16-month-old boy who presented with the4 Q9 A& c! j- E! A, V8 G( o4 k$ H) i# Q
enlargement of the phallus and pubic hair develop-
; M2 y4 Q6 c# {: x6 ]/ Fment without testicular enlargement, which was due C% v, O3 [& h& W+ i
to the unintentional exposure to androgen gel used by/ E j# D+ g2 p" F9 v
the father. The family initially concealed this infor-) P! c( Q F) U3 m, g
mation, resulting in an extensive work-up for this
% R8 v! U# V% g( `child. Given the widespread and easy availability of
5 o4 l. U9 u# ?+ d* Jtestosterone gel and cream, we believe this is proba-7 i! c, o) M+ r& {. S) w
bly more common than the rare case report in the
% H G) L, @& s/ Q# U# g( ~; rliterature.43 e8 V( f6 U9 }, y0 u5 O
Patient Report
' N5 V5 m9 \& J3 ` vA 16-month-old white child was referred to the
! Q% L, V" H: I" R, `( uendocrine clinic by his pediatrician with the concern. |: v! \. |; D" N. r' Q3 v! x, |
of early sexual development. His mother noticed
+ f) u& ?5 E3 |$ llight colored pubic hair development when he was
) Y" \# k8 {2 b6 [4 l2 ^) iFrom the 1Division of Pediatric Endocrinology, 2University of
P" u9 v5 X% R5 OSouth Alabama Medical Center, Mobile, Alabama.! ?/ m# I1 z0 F0 ?& \% S8 X
Address correspondence to: Samar K. Bhowmick, MD, FACE,; }( N) L i- O" G
Professor of Pediatrics, University of South Alabama, College of; T9 C! c+ ^3 _ `
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
/ b4 b4 f o. [! L w) y1 h0 Te-mail: [email protected]. h' M& W0 ^3 i6 G% _
about 6 to 7 months old, which progressively became
6 F6 {, r( h6 tdarker. She was also concerned about the enlarge-
5 A" A9 M2 T$ Rment of his penis and frequent erections. The child
1 d$ k1 ]& | Q: w) \was the product of a full-term normal delivery, with) D+ o: T# |7 }( T
a birth weight of 7 lb 14 oz, and birth length of1 l9 `. `0 U# N, I
20 inches. He was breast-fed throughout the first year7 }: j. l" _" V& R8 _6 C
of life and was still receiving breast milk along with% e$ w$ P) `0 a3 a+ E: Z1 V% K; W9 {
solid food. He had no hospitalizations or surgery,3 u5 ]7 X% {& ]* E) m/ t
and his psychosocial and psychomotor development
4 |$ U9 j7 F( `2 ~5 f5 qwas age appropriate.
1 `9 T% Z! u$ }6 h+ W# O; Y6 ?The family history was remarkable for the father,5 X+ R5 e. S$ T. R+ h0 e/ X
who was diagnosed with hypothyroidism at age 16,
+ D& v/ H! C% _9 P" kwhich was treated with thyroxine. The father’s
3 q8 A1 f+ S- D x( [* B1 o& Sheight was 6 feet, and he went through a somewhat
* m8 S6 R/ ?7 }3 f" o7 ]5 Nearly puberty and had stopped growing by age 14.
. R5 W- N/ E5 [! IThe father denied taking any other medication. The: Q4 }; O, E1 @& S# p
child’s mother was in good health. Her menarche
9 `# i" c% M4 z3 L p0 e; kwas at 11 years of age, and her height was at 5 feet
0 I4 K, W- m5 x1 F, F2 s/ Z5 inches. There was no other family history of pre-8 E3 B# p- ]$ ]
cocious sexual development in the first-degree rela-
0 M% F! z* i* Z2 C: ~tives. There were no siblings.
: H1 K" V# n' j6 |! lPhysical Examination
& w$ B' n. t4 U$ T, [The physical examination revealed a very active, _+ D% p8 O) ~
playful, and healthy boy. The vital signs documented
' b$ \* ]; ~2 V# ?a blood pressure of 85/50 mm Hg, his length was4 v" R- q/ P" B7 H
90 cm (>97th percentile), and his weight was 14.4 kg: i _' k& q& A2 L1 U8 y7 w# t
(also >97th percentile). The observed yearly growth
, J, ?! W; h h1 n7 R/ B9 D5 qvelocity was 30 cm (12 inches). The examination of
/ }: @0 Q, j( O0 V( T7 C4 R# Uthe neck revealed no thyroid enlargement.
/ M2 ]+ S( n9 Q7 qThe genitourinary examination was remarkable for+ Y# A W2 r, {: d/ w. ^
enlargement of the penis, with a stretched length of5 B: O/ _2 u. L# g* c, q
8 cm and a width of 2 cm. The glans penis was very well
8 U% I6 G) I" T2 V% g5 Odeveloped. The pubic hair was Tanner II, mostly around/ A, h' r& M! h9 z
540
9 y+ T8 u% e/ n" B9 t1 Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 c! \. Z* p! x% f4 O) Z2 Hthe base of the phallus and was dark and curled. The, {) E' Z$ U a* P% M' n
testicular volume was prepubertal at 2 mL each.' T2 E/ Q4 x% y; g) F
The skin was moist and smooth and somewhat1 G0 P* s* ^5 B5 ~4 \
oily. No axillary hair was noted. There were no
( `: g' N4 T6 ^1 R o, q+ L0 Oabnormal skin pigmentations or café-au-lait spots.
$ n! ~" O( _0 I T2 cNeurologic evaluation showed deep tendon reflex 2+* ]# m3 O; q& q" T
bilateral and symmetrical. There was no suggestion
5 b5 J# [$ V) r4 F. {of papilledema.
" C3 g* Z9 C" X6 v5 s$ r$ [+ aLaboratory Evaluation
, r, m* `1 t8 G# ?+ E+ G$ aThe bone age was consistent with 28 months by
7 f. Z2 N# i/ E; R3 ?) F5 Cusing the standard of Greulich and Pyle at a chrono-7 R8 d6 y4 l. h- |7 ]9 l4 W
logic age of 16 months (advanced).5 Chromosomal
8 \# s" D; h- f- t1 Ykaryotype was 46XY. The thyroid function test j- ^6 a: m4 B* U! C2 a1 d
showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ d1 d3 i+ S+ P1 \1 b* a
lating hormone level was 1.3 µIU/mL (both normal)." L. N& p4 ?/ H8 q* |
The concentrations of serum electrolytes, blood
1 W5 F2 e. @( ourea nitrogen, creatinine, and calcium all were
' r, W4 C X& Q1 q' j, }- @within normal range for his age. The concentration4 U+ k& y& ]6 ]# N; ^
of serum 17-hydroxyprogesterone was 16 ng/dL* q8 }$ i, |0 U0 n; \. }8 c9 ]
(normal, 3 to 90 ng/dL), androstenedione was 20
+ b K4 }/ u6 C- F% x$ {9 bng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, ]% [, s: Y* B, B5 Uterone was 38 ng/dL (normal, 50 to 760 ng/dL),/ T& w; d0 h2 j5 L6 a j) J4 A; N4 v9 p
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
# L6 e" X; n) _, g: [- E% q49ng/dL), 11-desoxycortisol (specific compound S)
! B, P+ f, `$ f, m& u0 Q& Cwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 Y( J8 e# K7 E/ J! A. U4 d( b2 A0 G
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 r& D2 t0 a9 G/ ^3 V: xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" S( H$ O# C6 H" g3 X# G# {% Y( s, Iand β-human chorionic gonadotropin was less than
, v9 B* O1 O; E5 mIU/mL (normal <5 mIU/mL). Serum follicular
) }: T- ?& K) W8 G W/ E: I4 ]8 xstimulating hormone and leuteinizing hormone9 `2 n3 I9 a% `4 a
concentrations were less than 0.05 mIU/mL
# \+ F; v% ~4 J' O5 |0 r(prepubertal).
! {' Q: |5 B! ^3 U0 OThe parents were notified about the laboratory% m4 h' _; Y; X, x# d
results and were informed that all of the tests were
% n$ E# y# [, G5 d# X$ ?normal except the testosterone level was high. The
7 Q: V- P$ y" R N8 y8 M; G2 Ofollow-up visit was arranged within a few weeks to; g2 D, l! Q2 z) `! K' B
obtain testicular and abdominal sonograms; how-
l% i* U3 e6 m# L- u/ {7 U, Qever, the family did not return for 4 months.6 ?5 _8 z3 o6 E
Physical examination at this time revealed that the
: ~" H- _( E5 Y* ]* uchild had grown 2.5 cm in 4 months and had gained; b$ Q, L( U7 n& H! S* V4 T& j
2 kg of weight. Physical examination remained
; k2 K& Q; _* \$ u( Punchanged. Surprisingly, the pubic hair almost com- d7 C$ l5 t) o& q& ?- [# s. s
pletely disappeared except for a few vellous hairs at: D$ b0 O! Y: u x3 J2 V! C
the base of the phallus. Testicular volume was still 2! q3 J. S: ^) i; S3 w
mL, and the size of the penis remained unchanged.
$ I5 s, O6 X! q5 P( ]0 TThe mother also said that the boy was no longer hav-/ i' W5 w8 v. X5 X; X, D
ing frequent erections.
# ]2 \ I) p3 H; A2 ^+ B/ yBoth parents were again questioned about use of
7 F. X: A& G7 W( V- f$ _any ointment/creams that they may have applied to
5 D+ F$ e$ `: C& rthe child’s skin. This time the father admitted the: X# L: s8 o* i( W
Topical Testosterone Exposure / Bhowmick et al 541
/ W* y2 ], z" K0 Euse of testosterone gel twice daily that he was apply- e1 B1 o0 g( L; S2 ^" F# U
ing over his own shoulders, chest, and back area for
) b# Z0 V! k* fa year. The father also revealed he was embarrassed' e6 J0 b, t" o) n9 Z$ L
to disclose that he was using a testosterone gel pre-
$ ?+ ?* `% ?8 m1 d- W7 Vscribed by his family physician for decreased libido
9 e! a* H% v0 l# L8 V' `+ `secondary to depression.
5 `7 m$ w% x1 j5 G1 AThe child slept in the same bed with parents.
" J8 R# V6 W2 t: p+ @: fThe father would hug the baby and hold him on his1 \! [7 q& v. p8 m
chest for a considerable period of time, causing sig-; @/ f0 y& l+ V# G+ {
nificant bare skin contact between baby and father." X9 k' P+ d, V( d* {- E2 [+ K. D/ `
The father also admitted that after the phone call,
' |0 F& ?' D* D; X- k$ dwhen he learned the testosterone level in the baby
/ c4 o2 |: ^/ o8 f6 rwas high, he then read the product information
8 ?4 P- ^- q% T) q& ypacket and concluded that it was most likely the rea-! Q( S7 M0 Z) y1 n2 ?+ L3 J
son for the child’s virilization. At that time, they
/ D- p* M w. W+ e# I% Jdecided to put the baby in a separate bed, and the7 H$ ?& |" o3 r: ?* Z
father was not hugging him with bare skin and had7 k6 s6 T! R3 I: E
been using protective clothing. A repeat testosterone4 Z2 |" A% M9 |+ C
test was ordered, but the family did not go to the" u& }3 v) u$ F$ ]: T# Y
laboratory to obtain the test.
, w1 \. s! a+ b( N8 ~0 k0 |Discussion
8 b3 l9 f2 o" U' vPrecocious puberty in boys is defined as secondary
! a* A& q8 a; I2 F1 asexual development before 9 years of age.1,4" U; u7 k9 g7 O0 P& Q( ]
Precocious puberty is termed as central (true) when0 j/ ?' x( |, d
it is caused by the premature activation of hypo-3 j5 @) U; N* \: J; q* T+ w+ [7 m
thalamic pituitary gonadal axis. CPP is more com-: Z( L- Y C) ]* l( B5 X
mon in girls than in boys.1,3 Most boys with CPP
: P0 f* d( E! Q6 F- rmay have a central nervous system lesion that is( ]# g, S9 x" o" ^$ X
responsible for the early activation of the hypothal-
V& ]! c' T2 L# A: oamic pituitary gonadal axis.1-3 Thus, greater empha-6 l m# E' w5 P4 P/ I
sis has been given to neuroradiologic imaging in$ T/ u o* I" u/ }7 Z8 J/ U
boys with precocious puberty. In addition to viril-* {4 _+ X* w# W# I) X
ization, the clinical hallmark of CPP is the symmet-
4 u, D) `" j' {: S/ trical testicular growth secondary to stimulation by; t- K& p. }/ ?
gonadotropins.1,31 b7 o9 y2 Z, ?$ Z
Gonadotropin-independent peripheral preco-
2 d3 {5 y4 A0 q2 B& ocious puberty in boys also results from inappropriate% ^. M; N; z' z/ M# {( D
androgenic stimulation from either endogenous or
, R5 a- {( N( h( \2 Oexogenous sources, nonpituitary gonadotropin stim-" ^4 e/ }* V: W+ L
ulation, and rare activating mutations.3 Virilizing* q R: g* C: p: U0 \
congenital adrenal hyperplasia producing excessive6 X% y, ^0 j* S( q" v h
adrenal androgens is a common cause of precocious
8 v; I6 h! w/ ^4 [* f! d& fpuberty in boys.3,4
1 F3 K* O7 v6 Q, F7 jThe most common form of congenital adrenal* }; g/ W+ {4 @5 W" m& r) ~
hyperplasia is the 21-hydroxylase enzyme deficiency., M3 j$ q2 n# a# F+ h: C
The 11-β hydroxylase deficiency may also result in
5 K7 y# _5 }7 I5 X7 C1 y& B) Yexcessive adrenal androgen production, and rarely,
" [/ ?! p* \8 a* l1 {an adrenal tumor may also cause adrenal androgen% z' L6 H; V1 d) t, e# w' u( H
excess.1,30 g$ C9 D" O/ R _; Y# c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 \# \" E( r& p/ G8 X* L542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ e6 Z/ V. R8 mA unique entity of male-limited gonadotropin-
6 l% } l. z. ^+ c) eindependent precocious puberty, which is also known
; ^1 y4 g s6 m( P( ?; gas testotoxicosis, may cause precocious puberty at a0 A/ M; P5 x$ d Q+ [$ X V6 C
very young age. The physical findings in these boys! V5 E: _; a X
with this disorder are full pubertal development,
) Q X6 V! c; `' d3 m! iincluding bilateral testicular growth, similar to boys7 K- r: S+ l9 u' N- t( V3 a @
with CPP. The gonadotropin levels in this disorder
0 `' H$ t3 s5 l" q/ oare suppressed to prepubertal levels and do not show
7 A$ d6 g0 C1 J6 i2 X$ Epubertal response of gonadotropin after gonadotropin-
. O$ O# l# W( c( [; W q5 }releasing hormone stimulation. This is a sex-linked
# E, }( x' W! o9 D. aautosomal dominant disorder that affects only
1 s( |( o: K5 z! ^; Ymales; therefore, other male members of the family( m" l& y6 O# b0 i$ m! S, I
may have similar precocious puberty.3- h8 ]- y) a1 O; y; h5 s0 C8 h2 n
In our patient, physical examination was incon-
$ B$ m0 A" p( f8 ]" P) Nsistent with true precocious puberty since his testi-* h4 }/ U$ a# {& S. }7 O
cles were prepubertal in size. However, testotoxicosis
8 K* Y5 M( m% c& ~$ B Awas in the differential diagnosis because his father1 y* h2 _% P4 j. F( X. N3 }# F
started puberty somewhat early, and occasionally,0 k+ ]" m4 ]. d* h. v+ v" x
testicular enlargement is not that evident in the3 @ M7 b2 t9 ~" x4 J
beginning of this process.1 In the absence of a neg-7 `. ^ B9 @+ m& e0 i
ative initial history of androgen exposure, our. o4 ^, N! P0 i6 u0 d! I
biggest concern was virilizing adrenal hyperplasia,0 @' q- p. z% n% \) e
either 21-hydroxylase deficiency or 11-β hydroxylase; A+ ]! S u, H* A% @
deficiency. Those diagnoses were excluded by find-. b9 i( s) N* }' E6 m9 J0 [
ing the normal level of adrenal steroids.- r S1 D4 d+ {1 ~; O. w: @4 i' ?
The diagnosis of exogenous androgens was strongly
) e& B6 f! X- i3 |: t) Msuspected in a follow-up visit after 4 months because0 S& d* [9 Z o0 ]8 R/ N* q
the physical examination revealed the complete disap-
1 q& g7 P J! R/ F- \pearance of pubic hair, normal growth velocity, and8 ]+ d( @' m3 @7 Y
decreased erections. The father admitted using a testos-
' s- v0 o: E' Y& O. q6 `terone gel, which he concealed at first visit. He was* x* H$ g* f/ H9 }1 a
using it rather frequently, twice a day. The Physicians’. ?& |/ E9 k0 n% r6 F
Desk Reference, or package insert of this product, gel or
) X, F! Q9 _9 {! d ccream, cautions about dermal testosterone transfer to: w# u- g: y* [6 ?5 x3 ~* @
unprotected females through direct skin exposure.
5 y; g, _4 T: ?) K, vSerum testosterone level was found to be 2 times the6 e4 Q/ B# Q; I
baseline value in those females who were exposed to
- Z! Q N; [& c9 Veven 15 minutes of direct skin contact with their male2 k$ p' e- a# o0 o* y# {
partners.6 However, when a shirt covered the applica-
0 d8 ~# b7 F9 D# E3 f$ ition site, this testosterone transfer was prevented.
( i$ t" f5 O4 Z5 c- yOur patient’s testosterone level was 60 ng/mL,
6 ]$ }# w% D( L4 A' D4 Bwhich was clearly high. Some studies suggest that% B) a" a# }6 w9 }
dermal conversion of testosterone to dihydrotestos-
7 W" O1 u/ X. c- C) S( {: `9 y0 Wterone, which is a more potent metabolite, is more
+ t% h( I6 L% x) ~. _7 u* Tactive in young children exposed to testosterone% O7 T3 r6 [% n1 G
exogenously7; however, we did not measure a dihy-
6 a. r: W, S( H0 a8 E$ S" @3 l( \drotestosterone level in our patient. In addition to
6 T- o# d5 l* M* jvirilization, exposure to exogenous testosterone in
$ ]! e* s3 s* b# Pchildren results in an increase in growth velocity and
v+ c' G/ E# Z+ [2 Radvanced bone age, as seen in our patient.
$ b- C p- N* b) g7 x( t0 l4 m- ^8 CThe long-term effect of androgen exposure during( `0 F# y, ^/ t, T% q
early childhood on pubertal development and final
$ y4 ]: n" M1 G! j5 v, O8 Nadult height are not fully known and always remain5 s9 N& X' X! R- a5 |
a concern. Children treated with short-term testos-) C- ?# {& W0 Y" [3 a7 K1 p+ I
terone injection or topical androgen may exhibit some5 F% I. \) D4 _
acceleration of the skeletal maturation; however, after
) B# K# i2 c* v" g1 Xcessation of treatment, the rate of bone maturation7 h# `3 v' Y6 L) f: m3 j
decelerates and gradually returns to normal.8,91 o# ?7 z/ ^4 S) o% e2 ]
There are conflicting reports and controversy
. |$ ?; Q5 ?2 ]6 R! o' G: s$ |% |0 Eover the effect of early androgen exposure on adult
+ l& b3 P; M W/ G1 Rpenile length.10,11 Some reports suggest subnormal- I6 Z# d) h( H! n$ t
adult penile length, apparently because of downreg-; W3 l3 Y: q/ T1 g4 k
ulation of androgen receptor number.10,12 However,; i; r$ E5 K- ?# [ Y; m& u7 k
Sutherland et al13 did not find a correlation between
: l" h: _ S& p0 achildhood testosterone exposure and reduced adult& G' @1 B2 N2 A0 Y. j% @2 b
penile length in clinical studies.
9 {, w. A: v# F/ cNonetheless, we do not believe our patient is
9 k5 }7 n, [# |$ u; Hgoing to experience any of the untoward effects from
, ~; l$ n0 `* k9 q+ n0 Mtestosterone exposure as mentioned earlier because( e4 D4 [. G9 D. H! E
the exposure was not for a prolonged period of time.
1 E; U0 I9 e H# NAlthough the bone age was advanced at the time of
: c% J, e$ D2 N- x. gdiagnosis, the child had a normal growth velocity at
9 g: s% ^* e9 x' I3 o! ~2 tthe follow-up visit. It is hoped that his final adult, _$ I, w& e$ X+ _% N
height will not be affected.
$ b5 p7 w6 Z4 c( ^' q# @Although rarely reported, the widespread avail-4 x, M1 u6 Y" T! `# r A: I
ability of androgen products in our society may
; k/ D; W0 ^6 s# [6 d# Z: zindeed cause more virilization in male or female! J) B/ a$ h1 G% t
children than one would realize. Exposure to andro-
; U' T. K6 r- H; z3 t" M+ C: Vgen products must be considered and specific ques-! q1 w5 S8 S0 c% [# d6 ~
tioning about the use of a testosterone product or
. W1 V6 Z3 o6 g9 g6 bgel should be asked of the family members during
8 R a, M2 I# n- ~4 Ithe evaluation of any children who present with vir-
1 e O( a; I: T8 s4 y8 iilization or peripheral precocious puberty. The diag-' f5 i& j9 }4 R; P. E8 t
nosis can be established by just a few tests and by
9 _8 ]$ y J j `appropriate history. The inability to obtain such a
* V7 }' X# C( G: D/ |history, or failure to ask the specific questions, may
6 D/ w. u& T6 V3 {. ]! x& fresult in extensive, unnecessary, and expensive
1 t/ R1 C$ }, R. Q0 ~8 minvestigation. The primary care physician should be) K! o3 M4 Y2 H8 B4 }! S# t
aware of this fact, because most of these children
8 ?" i8 t: F1 S+ amay initially present in their practice. The Physicians’
9 [/ T. B7 ?4 O* \+ K5 G7 l7 tDesk Reference and package insert should also put a* ?6 \/ y) E( \2 _' Z% R- x
warning about the virilizing effect on a male or9 D3 Y* {( n6 @. @" n; f
female child who might come in contact with some-
1 H7 m: N& ? Y: W- Y5 _, v8 kone using any of these products., l- x; E! ^1 A$ |3 k) q8 J
References% ^. H0 n1 o% p! _; y" Q8 D
1. Styne DM. The testes: disorder of sexual differentiation: o! p4 j6 J* Z6 x2 `
and puberty in the male. In: Sperling MA, ed. Pediatric5 e. B7 Z9 p' x5 y
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ Q4 I/ p( a4 V$ i" H2002: 565-628.: C+ q0 d$ Y; I4 B, F
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 c3 n: a) I9 C) `
puberty in children with tumours of the suprasellar pineal |
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