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Sexual Precocity in a 16-Month-Old5 W) w8 D- w1 y/ \) b
Boy Induced by Indirect Topical
) w0 e8 T W B" q* M. V5 O+ DExposure to Testosterone
% w6 o9 H/ p) L/ Q( Y3 I( KSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 b! M( r+ ]2 I; ]) U3 yand Kenneth R. Rettig, MD1
: h. f, P3 @0 j# t/ f% BClinical Pediatrics# D" z( K5 P& U3 ^" ~8 {
Volume 46 Number 6
1 L8 e- R1 A% KJuly 2007 540-543
% n/ W% b: L& j, ]$ E© 2007 Sage Publications
+ k8 @: G' U y4 u' q, @) \10.1177/0009922806296651. d0 H5 h1 b6 q( p p
http://clp.sagepub.com7 U* [' F+ y. ^* }7 U; _
hosted at
+ z7 @* y" ]/ X& g7 p5 Q* Zhttp://online.sagepub.com. C5 r' A L# d4 q( V4 @
Precocious puberty in boys, central or peripheral,0 u: P8 k6 O: [' r
is a significant concern for physicians. Central8 w; u/ e% k I/ k R% E+ f
precocious puberty (CPP), which is mediated7 e! \! M3 @' [/ {
through the hypothalamic pituitary gonadal axis, has6 h& i# v/ M0 F2 e5 P3 _- Q
a higher incidence of organic central nervous system& \( [: ~+ g+ ]7 E
lesions in boys.1,2 Virilization in boys, as manifested
& X: A/ X' ?& }' o" }$ {0 ?by enlargement of the penis, development of pubic
; R/ a+ X; s1 S, i# c/ n- h. Thair, and facial acne without enlargement of testi-
- @; P4 q' c! m$ N& Mcles, suggests peripheral or pseudopuberty.1-3 We
. f+ I, [" ?; ]0 z# u3 Ureport a 16-month-old boy who presented with the) l0 q, y, w- J3 I6 Y: H2 U+ S8 e9 ?
enlargement of the phallus and pubic hair develop-/ H. h! D0 ]3 G6 A
ment without testicular enlargement, which was due7 G$ d# y! Y& X! ~3 J
to the unintentional exposure to androgen gel used by9 r4 L2 Z v/ b. ^$ p
the father. The family initially concealed this infor-6 o9 [6 o2 ?- P) F9 ?/ u
mation, resulting in an extensive work-up for this
! o8 w! x( T; l1 c2 A5 R& Lchild. Given the widespread and easy availability of- Q# Y, w" o' C$ M* ]
testosterone gel and cream, we believe this is proba-
6 [0 f: x1 ^$ pbly more common than the rare case report in the' X' L4 n5 }6 r# p) F. n
literature.40 ?5 Q# r. @. }) P* J7 P
Patient Report' w, i0 n7 Y9 r7 j/ d1 d
A 16-month-old white child was referred to the: u5 `+ \! g i6 u* D
endocrine clinic by his pediatrician with the concern3 k1 B) x5 n* f
of early sexual development. His mother noticed9 H9 b2 [ S7 T% ^3 b% `1 N
light colored pubic hair development when he was
}3 S8 }0 t; vFrom the 1Division of Pediatric Endocrinology, 2University of5 Z$ k* W5 }( N5 i3 e2 y
South Alabama Medical Center, Mobile, Alabama.: \" u' ~' \. i. \- R
Address correspondence to: Samar K. Bhowmick, MD, FACE,
* m) A# h3 a% w8 o: T) @3 DProfessor of Pediatrics, University of South Alabama, College of
' v' y2 i. a1 r$ p7 F1 VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ I+ B3 z3 j; ? K8 F
e-mail: [email protected].
/ I9 W; G! K* M' T1 f5 v2 n# O3 Habout 6 to 7 months old, which progressively became
3 B9 t% U' @" a5 u9 v2 D k& `darker. She was also concerned about the enlarge-/ ~; `& b. s3 h: }) F3 w# B/ R, l
ment of his penis and frequent erections. The child$ o! V# T: H. k) O/ ?) `" Z
was the product of a full-term normal delivery, with
6 F& ?( d. i4 M, c6 g9 M, w za birth weight of 7 lb 14 oz, and birth length of C+ @: p5 O+ [7 _
20 inches. He was breast-fed throughout the first year0 ?- B7 }% _# O% \# |' R8 v7 x9 I5 Y
of life and was still receiving breast milk along with
/ z5 K2 R3 g8 P% ~, b# Rsolid food. He had no hospitalizations or surgery,$ N8 B% n) H( f* G" ?* K
and his psychosocial and psychomotor development
/ \# ^$ k- ~: B p: nwas age appropriate.& h* C6 { l& ~7 v& Z
The family history was remarkable for the father,5 m+ D2 R6 |* b7 `6 G
who was diagnosed with hypothyroidism at age 16,* m. }: n! W; |. O
which was treated with thyroxine. The father’s( b! s" b& @0 ^6 l q
height was 6 feet, and he went through a somewhat& J! h: y& C: u5 d( x! J
early puberty and had stopped growing by age 14.
& u5 X) w" U7 c- N. `The father denied taking any other medication. The
4 G' Q% O9 X+ _4 h, j( j3 z0 r7 cchild’s mother was in good health. Her menarche
6 |) {- P, }8 Q( ?# U( d4 K: @was at 11 years of age, and her height was at 5 feet* i1 c! k% Q- _7 l
5 inches. There was no other family history of pre-% u! T2 x9 @$ A# e* D1 j
cocious sexual development in the first-degree rela-
* q9 @( b! A, g* T4 x X* Atives. There were no siblings.7 ]9 G' }5 ^) I* b
Physical Examination
" O( p2 q& J$ \+ J$ @; t& ^% VThe physical examination revealed a very active,9 d2 @- I" B' X4 y1 F
playful, and healthy boy. The vital signs documented
7 t/ \( \& s/ I' g% n- Ba blood pressure of 85/50 mm Hg, his length was
" H0 i% L. w2 l ?# X. i8 }2 C+ y90 cm (>97th percentile), and his weight was 14.4 kg# z& i* |1 X9 Y" f( }; \1 x: Q
(also >97th percentile). The observed yearly growth
- N: N' z: p' c" t$ Tvelocity was 30 cm (12 inches). The examination of! ^' O H2 ?: F, ]+ L, f& Z3 {
the neck revealed no thyroid enlargement.
; b# t2 u' U+ T8 N1 B& m% JThe genitourinary examination was remarkable for" N9 P- M N$ `1 r: p
enlargement of the penis, with a stretched length of5 _: u9 ]% `# E8 l+ C+ B
8 cm and a width of 2 cm. The glans penis was very well/ I& K3 I" e& B& M% i, f0 r; [
developed. The pubic hair was Tanner II, mostly around! D5 `3 X7 ~, y7 t* H7 G3 j9 ]
5400 t2 n+ z$ G2 A/ E1 z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% K X$ f" L% l, M2 e4 Y
the base of the phallus and was dark and curled. The0 F1 R3 g. l: D! T
testicular volume was prepubertal at 2 mL each.% y$ m4 \- s6 k8 ^" R' n
The skin was moist and smooth and somewhat1 v; M% p- m& E# l
oily. No axillary hair was noted. There were no
, i' t& i( X% E9 |- |, eabnormal skin pigmentations or café-au-lait spots.! g- O& T6 p/ ]
Neurologic evaluation showed deep tendon reflex 2+6 M3 z6 x! z; R' j% {+ m
bilateral and symmetrical. There was no suggestion
: W# T2 r5 d5 G0 V0 F# qof papilledema.
7 O. Y# O9 @+ U* f( NLaboratory Evaluation& z y$ i- p; g+ k0 j- y) k0 N* r n7 H
The bone age was consistent with 28 months by
4 O" V2 C% W' D' [( Cusing the standard of Greulich and Pyle at a chrono-9 D+ \# w% H) Z
logic age of 16 months (advanced).5 Chromosomal' j& L. i) M0 Q" a7 b
karyotype was 46XY. The thyroid function test$ a Z5 @& U. F$ \
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% {' _! Q# v! A clating hormone level was 1.3 µIU/mL (both normal).
- U/ W$ v* \8 {9 wThe concentrations of serum electrolytes, blood
Z$ u0 c8 r6 Durea nitrogen, creatinine, and calcium all were; a& y+ X+ F$ _: |% D
within normal range for his age. The concentration
1 ^8 T, |1 O6 k+ c7 fof serum 17-hydroxyprogesterone was 16 ng/dL( U, R% Q; a# \
(normal, 3 to 90 ng/dL), androstenedione was 20
9 v$ a l) F) ^# o) sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& a6 o& |6 V$ e4 [8 N/ Aterone was 38 ng/dL (normal, 50 to 760 ng/dL),# F* ^6 X" L$ C0 w$ c4 \/ q0 w
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
6 B# ]5 `0 J3 X49ng/dL), 11-desoxycortisol (specific compound S)
& Z7 C2 r" @% y3 rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 K3 L- C9 ? M s" utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) U. B- N( Y6 p- |4 U. C: atestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
( l, d6 X* d. _" n1 X" jand β-human chorionic gonadotropin was less than
+ M7 U$ H# h A& _) F6 d5 mIU/mL (normal <5 mIU/mL). Serum follicular3 D0 _; ^) A7 s
stimulating hormone and leuteinizing hormone
' x# c% y# {. e% x/ Zconcentrations were less than 0.05 mIU/mL* Y( [6 F: F* a( y- `6 E4 g
(prepubertal).- _& C9 c% W" E0 C8 b4 x( u0 O
The parents were notified about the laboratory; E% ], Z! R3 I% b$ D
results and were informed that all of the tests were
( u5 v. G# u% \3 D) bnormal except the testosterone level was high. The
; C! V" }' g# E) vfollow-up visit was arranged within a few weeks to
! t, y+ W( \: u4 v1 Mobtain testicular and abdominal sonograms; how-1 v6 h+ f3 v; l4 M+ u( d( ~! d
ever, the family did not return for 4 months.4 H7 m5 s/ D, _& v# @7 R
Physical examination at this time revealed that the/ W* d$ k& P, P1 A
child had grown 2.5 cm in 4 months and had gained% f1 J' `+ q; Z% x
2 kg of weight. Physical examination remained( n. Q' \' d1 @/ L. {
unchanged. Surprisingly, the pubic hair almost com-
- @- f0 \ y/ S. j+ L4 gpletely disappeared except for a few vellous hairs at
9 {0 G. D: f) q3 Rthe base of the phallus. Testicular volume was still 2
; L S, Z& P4 z5 ?$ }! m9 \mL, and the size of the penis remained unchanged.5 U2 K1 x8 M. z D3 B
The mother also said that the boy was no longer hav-% K1 z2 N9 J* A) o! I% O( i0 k) ^7 w
ing frequent erections.' \- B* M; C; [: [- f1 r/ f
Both parents were again questioned about use of
+ X2 J" k9 E8 S! U9 ]0 Cany ointment/creams that they may have applied to0 \! O- _9 A+ V6 h, T. T# o; N, `
the child’s skin. This time the father admitted the" z2 Q; @4 u7 |- [
Topical Testosterone Exposure / Bhowmick et al 541
; T1 k2 E2 R& M- nuse of testosterone gel twice daily that he was apply-
# w) p2 s9 T4 c/ u* w3 \ing over his own shoulders, chest, and back area for
; @% K4 @' y% y0 Ba year. The father also revealed he was embarrassed. ]' ?* d/ i! p& c& s
to disclose that he was using a testosterone gel pre-
( O1 X3 b6 a/ G+ Q Iscribed by his family physician for decreased libido
& t g, @; R" _# isecondary to depression.
, k5 N: Q$ q- u( Z% BThe child slept in the same bed with parents.
8 V; a% o; Y$ V! TThe father would hug the baby and hold him on his
8 S+ G, p% |8 V! p& S' I7 K( c+ kchest for a considerable period of time, causing sig-
4 Q$ K; ]7 |9 S2 J" cnificant bare skin contact between baby and father.' F9 u2 o. f9 s! x4 _; Z3 J
The father also admitted that after the phone call,5 N! D% {1 n+ c+ w* ~$ h3 t2 h+ x
when he learned the testosterone level in the baby$ N+ V* C* M+ ~! p
was high, he then read the product information2 B5 {0 b; ^: Z, b
packet and concluded that it was most likely the rea-2 ?! Z1 F; l* m5 A; r4 H
son for the child’s virilization. At that time, they& Q* e4 I9 r2 C
decided to put the baby in a separate bed, and the! h# e! O& y2 m% x
father was not hugging him with bare skin and had
% @& l7 W4 m8 x/ J* W1 W* ^) R1 mbeen using protective clothing. A repeat testosterone
1 H, X- K2 ~) R5 Vtest was ordered, but the family did not go to the
6 U( [) n; H0 v3 U7 `# d% \ @laboratory to obtain the test.
4 p4 C# `4 g3 A" e1 {Discussion: }: p% @' F# ] Y- b. A4 n* ?7 T
Precocious puberty in boys is defined as secondary
# R3 P% T# W; q+ L: S+ jsexual development before 9 years of age.1,4
( ^. e& V6 ^# }Precocious puberty is termed as central (true) when4 W! ?1 l! M5 s# R4 J' b8 K) E) c6 D
it is caused by the premature activation of hypo-. ~# {; m) n, e) G8 I0 i
thalamic pituitary gonadal axis. CPP is more com-
+ l2 L ^# s B3 d+ |mon in girls than in boys.1,3 Most boys with CPP/ k6 b$ S1 \3 W. _) j1 p9 w
may have a central nervous system lesion that is
$ C8 X; b d3 p0 r; t, @/ l) Iresponsible for the early activation of the hypothal-
/ b; J. S% E A/ L9 |5 ?* e- }amic pituitary gonadal axis.1-3 Thus, greater empha-4 h4 ^, j# S- ?) F n) k
sis has been given to neuroradiologic imaging in3 d$ i# ?; k8 |2 R, V# i
boys with precocious puberty. In addition to viril-. D' W, @. Q4 I' O
ization, the clinical hallmark of CPP is the symmet-
9 R: c& _0 s+ B& b* d" s; z& Y0 urical testicular growth secondary to stimulation by
. y$ h; f/ k9 c( E9 }' n' V; `gonadotropins.1,3 w# [+ Z: ^# u0 J3 b
Gonadotropin-independent peripheral preco-
/ i% Y5 Q! o: o; ^9 u- p% ocious puberty in boys also results from inappropriate
3 w7 ~7 |7 x/ a& Oandrogenic stimulation from either endogenous or
6 E4 _0 O4 }+ F. n# Gexogenous sources, nonpituitary gonadotropin stim-+ O7 J6 a, I2 G$ v' b6 E9 [' Q
ulation, and rare activating mutations.3 Virilizing
9 A; ]' }0 m5 k, Rcongenital adrenal hyperplasia producing excessive& V" d8 h2 A9 K
adrenal androgens is a common cause of precocious
: n6 ]2 b( N7 O0 I* X9 E4 ypuberty in boys.3,4+ y& k: u2 X3 K V
The most common form of congenital adrenal7 W% }) B1 Y' g- ^
hyperplasia is the 21-hydroxylase enzyme deficiency.& j7 | Q3 O- f% r8 j1 h1 N
The 11-β hydroxylase deficiency may also result in
4 a0 n: F _9 v9 j& l$ p6 gexcessive adrenal androgen production, and rarely,
) n% a2 G$ q6 D5 S. Aan adrenal tumor may also cause adrenal androgen& y a4 V) ~/ u. s2 p, e9 U
excess.1,3) V/ d1 h1 X, q/ @- g m
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# }& O5 @+ I/ N% y* m
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007: x6 s' ^5 E; c5 }1 ^6 w7 h. @
A unique entity of male-limited gonadotropin-* Y' W- q& Y5 u' u& E1 s2 M
independent precocious puberty, which is also known, W/ A. e9 X4 x6 ^* B
as testotoxicosis, may cause precocious puberty at a/ v- A/ N/ D; X: ]* f- B
very young age. The physical findings in these boys
{6 h3 X4 F' v7 ?; iwith this disorder are full pubertal development,
5 l& d2 c7 K4 |6 w" rincluding bilateral testicular growth, similar to boys
2 f1 U1 S1 L: ?6 E1 L1 f! ? S! j. m# Bwith CPP. The gonadotropin levels in this disorder) B) [+ I& N3 y: c4 B2 R% p) {
are suppressed to prepubertal levels and do not show
+ o; a/ Q( t! m5 Lpubertal response of gonadotropin after gonadotropin-
( g" G1 g/ m* c. vreleasing hormone stimulation. This is a sex-linked( L, J t, h* l7 }: a! ~$ y* K3 l! s. f
autosomal dominant disorder that affects only
# @9 n# Q r8 {* M" I1 Ymales; therefore, other male members of the family
) J/ n, O/ T' ~. `& lmay have similar precocious puberty.3! _) d, }* R' d* [% O& y
In our patient, physical examination was incon- T/ T3 m7 u x& b$ f
sistent with true precocious puberty since his testi-
% n- y! x/ Z2 P/ z0 p9 zcles were prepubertal in size. However, testotoxicosis
) F* {9 v% ~2 M3 ~was in the differential diagnosis because his father6 L& ~. e, s4 r6 A4 W& k$ |: H9 @
started puberty somewhat early, and occasionally,
7 t! W* x `$ e: ]testicular enlargement is not that evident in the
* B0 U* U8 {& Y4 T, g0 nbeginning of this process.1 In the absence of a neg-2 m$ c1 O7 v5 [! `
ative initial history of androgen exposure, our* n' F& p: Q" S M! `" ~
biggest concern was virilizing adrenal hyperplasia,8 z4 \& g* z) p" f
either 21-hydroxylase deficiency or 11-β hydroxylase
/ y$ U1 B& D2 I; J& {- ideficiency. Those diagnoses were excluded by find-
& T. I" Y1 s _8 q8 q3 ? Sing the normal level of adrenal steroids.
0 s# c2 Y/ m3 w- V3 \' W1 SThe diagnosis of exogenous androgens was strongly+ M9 \9 [0 Q3 `1 I/ g" K
suspected in a follow-up visit after 4 months because
L6 Y' Q# u8 N8 m+ Othe physical examination revealed the complete disap-" E' h; A) R1 I
pearance of pubic hair, normal growth velocity, and; ]; |% O# q4 M' I' b, ^$ Q
decreased erections. The father admitted using a testos-8 H# X( D& U1 ?$ ]
terone gel, which he concealed at first visit. He was( i3 J+ B' P4 i2 a- v" Z
using it rather frequently, twice a day. The Physicians’
0 h7 C( ^: @. g5 P' |$ TDesk Reference, or package insert of this product, gel or
" V; I# X4 X* ]" {1 k' Hcream, cautions about dermal testosterone transfer to" f: R7 a1 U5 G/ `! e! j
unprotected females through direct skin exposure.
- f& v# ^) h' [+ Z' N! _Serum testosterone level was found to be 2 times the" d) d# l" w/ R, m9 ?& k( ~7 j
baseline value in those females who were exposed to
I( d9 T) W! p; C" Deven 15 minutes of direct skin contact with their male' P u+ p) T3 O$ y Y
partners.6 However, when a shirt covered the applica-# H, r. v ^5 G3 X5 B# l
tion site, this testosterone transfer was prevented.4 |4 K) V" h+ T% @& X! E+ S9 w' P
Our patient’s testosterone level was 60 ng/mL,
t+ d% `: v6 R* {1 C$ j$ a$ F1 wwhich was clearly high. Some studies suggest that9 ~. v' ^; H- z: |/ L
dermal conversion of testosterone to dihydrotestos-; I; e' ?6 {( ^ }# M5 P9 Q
terone, which is a more potent metabolite, is more* R+ R6 |, G* I6 [
active in young children exposed to testosterone0 o8 o0 K% j' V( t% f8 e% d# I$ s
exogenously7; however, we did not measure a dihy- ?0 B+ l4 ^+ E
drotestosterone level in our patient. In addition to
4 O8 C, z/ ^9 ?0 _( r! M1 Kvirilization, exposure to exogenous testosterone in( y6 f7 E! `; b! L# X
children results in an increase in growth velocity and
; b, s- m. W# a4 i c' Yadvanced bone age, as seen in our patient.
; [2 `$ Y1 W9 WThe long-term effect of androgen exposure during
" s4 Z8 M {$ Nearly childhood on pubertal development and final
; p8 u! y$ {$ m& Nadult height are not fully known and always remain+ M* C& o; Q- E; J
a concern. Children treated with short-term testos-
0 c7 k8 F/ J$ }) y. V: o5 {7 zterone injection or topical androgen may exhibit some
% |" v0 m2 \4 m, d% l; {) H4 u- G% macceleration of the skeletal maturation; however, after
) i" E* f) `0 z& Ycessation of treatment, the rate of bone maturation
+ [9 k) X5 S: e$ N& M5 [6 f4 X, T) ]decelerates and gradually returns to normal.8,9* o; M# {2 j" n6 J Q! t
There are conflicting reports and controversy0 f* H( g) m$ `2 Y9 Z" e4 L
over the effect of early androgen exposure on adult
5 |5 |2 v9 [# Cpenile length.10,11 Some reports suggest subnormal
, {7 I! o& |8 T8 b" j! P! jadult penile length, apparently because of downreg-! @' p+ z1 J* ~+ L, o+ ~
ulation of androgen receptor number.10,12 However,* C- R# z, N* T5 s2 Q9 ?$ w9 V
Sutherland et al13 did not find a correlation between& M; A( v% S3 ^* _/ v3 K
childhood testosterone exposure and reduced adult
w% X. O" ?* {) w" C& xpenile length in clinical studies.
" G6 O* Q# t8 r% N) G. R/ C `# X, yNonetheless, we do not believe our patient is5 K" ]9 p: X+ u# z" t7 X0 o( M
going to experience any of the untoward effects from
2 F' }9 U: _5 |6 t1 Jtestosterone exposure as mentioned earlier because. x [8 h/ h) s( O
the exposure was not for a prolonged period of time.
+ p7 q, v3 G: ^. aAlthough the bone age was advanced at the time of' l& D" A4 u7 P$ S2 A$ f
diagnosis, the child had a normal growth velocity at3 B! A5 o; o" ^& G
the follow-up visit. It is hoped that his final adult6 \$ [. c' R3 k
height will not be affected.
6 M& ?/ p* u2 O6 H0 w+ LAlthough rarely reported, the widespread avail-% Y' D0 F( c; G# d! f; x9 v
ability of androgen products in our society may# L( j' G1 S$ ?& h% d
indeed cause more virilization in male or female
8 l5 x( T \6 T. K. c$ k$ gchildren than one would realize. Exposure to andro-
) Q/ b) V9 l; m1 h$ _gen products must be considered and specific ques-! Y0 n( @; _2 t. x m% x) G2 H6 o0 n
tioning about the use of a testosterone product or, u4 r5 C1 Q# J4 O0 ~7 S
gel should be asked of the family members during4 `( r$ }0 _& C4 X/ w& ~
the evaluation of any children who present with vir-
) m& ]* m) n0 e" Dilization or peripheral precocious puberty. The diag-) B" d2 z6 L8 i) r
nosis can be established by just a few tests and by* W3 l7 g7 m7 A' c( u6 A4 U
appropriate history. The inability to obtain such a# j( T# Z3 }" V. j; D+ B5 X$ M! R) K
history, or failure to ask the specific questions, may
9 Q2 e n8 Q* i, b; zresult in extensive, unnecessary, and expensive
/ W" I- A2 n4 j% f" e# E- f' l# Minvestigation. The primary care physician should be; Z: F3 N7 R+ ~/ T1 u
aware of this fact, because most of these children
9 i; k: y z* Z/ S, k+ F" l: Nmay initially present in their practice. The Physicians’7 S# g5 A: F! P. r1 h8 y
Desk Reference and package insert should also put a. {5 T, u3 K' @! D/ E* e8 _, O
warning about the virilizing effect on a male or' N, w! E$ ^1 g& I; g
female child who might come in contact with some-
/ T% A' S+ Q( W0 \6 e, y5 ?one using any of these products.
/ ?3 [; P9 N, }References7 d; x. a, M, k6 G$ R# s& e' D
1. Styne DM. The testes: disorder of sexual differentiation
- R4 X, Y; c, \: Z6 h# Aand puberty in the male. In: Sperling MA, ed. Pediatric2 v: r% b5 r" G& \" r, q$ D- r
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 I! C4 ^1 ~8 [$ C$ V9 e, i" w2 S
2002: 565-628.
6 _/ g6 v" i& g4 f2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. @# j& b; q/ r9 D1 |3 j4 {
puberty in children with tumours of the suprasellar pineal |
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