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Sexual Precocity in a 16-Month-Old
3 p, j* S& H$ ABoy Induced by Indirect Topical
% D2 Q4 @$ Z- wExposure to Testosterone
# I5 }0 E1 k1 C8 E JSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 P9 d1 @4 o8 V, aand Kenneth R. Rettig, MD1
3 w1 ]% ^9 ~* h6 a$ yClinical Pediatrics
% b) Z% h# \3 P8 C: I1 [6 [Volume 46 Number 66 Z- @- q( ~. m0 J: s6 w
July 2007 540-543; }) B3 Q. M- g- ~
© 2007 Sage Publications
5 b% |# l- q: O: k: {% I& F10.1177/0009922806296651
: o& V% v# }- whttp://clp.sagepub.com1 ^' x4 a6 d8 t9 U. r: r
hosted at
+ z5 ~* I- Y# Z2 S: Y# ehttp://online.sagepub.com: o) U9 h; Q4 t. V% \) Q
Precocious puberty in boys, central or peripheral,9 z, r, w0 O# f* w/ L
is a significant concern for physicians. Central( }6 q4 Y9 H8 p- M) B( S
precocious puberty (CPP), which is mediated
# f3 y: E8 l4 ]7 A! ]; Zthrough the hypothalamic pituitary gonadal axis, has
6 n6 V. u6 e9 B: ^1 e1 B& N4 ma higher incidence of organic central nervous system
) O) P P; W- t) L2 [& Dlesions in boys.1,2 Virilization in boys, as manifested
; F3 w2 l" d+ i+ {4 {" Z- Q9 Iby enlargement of the penis, development of pubic
. v* @4 S r7 ^hair, and facial acne without enlargement of testi- ]- t" T% F( C2 m& M8 b) ]
cles, suggests peripheral or pseudopuberty.1-3 We+ v* i0 r! ]1 O' L2 g+ o0 T
report a 16-month-old boy who presented with the
2 K% N9 a7 D* @2 g7 @+ Z$ Menlargement of the phallus and pubic hair develop-# t. W- ]# r0 h8 m) G/ ~+ }9 I
ment without testicular enlargement, which was due7 b& L+ H! L' X3 Q6 o# P! E
to the unintentional exposure to androgen gel used by
# F0 I6 H4 ^! I3 ?- [- }the father. The family initially concealed this infor-6 x9 I& W0 I1 V
mation, resulting in an extensive work-up for this
V# E( k8 M4 X% N) Mchild. Given the widespread and easy availability of
) P3 `$ T( m9 E5 V0 ^2 ]( _- k. Ktestosterone gel and cream, we believe this is proba-
$ r% B7 v& C0 M7 Lbly more common than the rare case report in the7 n8 C0 n6 U4 h8 w4 h+ h0 W1 @
literature.4) j9 r, q7 W# p% K
Patient Report1 `8 b) o+ U7 j2 G1 v. a
A 16-month-old white child was referred to the7 }2 d! k b0 n, K; ], m
endocrine clinic by his pediatrician with the concern1 G) Q' n. u0 f4 J g9 L
of early sexual development. His mother noticed
9 p/ b2 I/ E# |6 l: S6 Q$ Alight colored pubic hair development when he was
# I: X1 H* D1 |( gFrom the 1Division of Pediatric Endocrinology, 2University of
& R9 r& _1 {! E7 S8 ESouth Alabama Medical Center, Mobile, Alabama.
3 [ W; O" C3 A+ X. A) CAddress correspondence to: Samar K. Bhowmick, MD, FACE,2 @: X% |- H3 E0 B4 i/ I
Professor of Pediatrics, University of South Alabama, College of
3 w( N, S' p. p% L0 bMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, A: @& P& l) a+ N H7 N5 u
e-mail: [email protected].
+ D0 o8 d4 y# \' ~7 Pabout 6 to 7 months old, which progressively became% G# h+ i' l0 C" R* C5 W
darker. She was also concerned about the enlarge-' {8 b! S# v$ O! r( g: e
ment of his penis and frequent erections. The child
- b. h2 N- Q- f* [2 W3 Cwas the product of a full-term normal delivery, with
- P% |+ P; D' Ia birth weight of 7 lb 14 oz, and birth length of
9 ~& U! f, A2 `8 T) f" v( w+ T. z" a20 inches. He was breast-fed throughout the first year
# ?1 a& g, w/ R0 lof life and was still receiving breast milk along with
+ a K- E5 [! E' z5 ?solid food. He had no hospitalizations or surgery,
1 K, q4 q6 c$ D1 _% b6 oand his psychosocial and psychomotor development
5 S, l. U# B3 f; ]was age appropriate.
! {' I" B& H8 ~' u- z S! M" rThe family history was remarkable for the father,
h3 b ?! W; Y9 Qwho was diagnosed with hypothyroidism at age 16,7 A5 M- f8 t& s" Z2 a3 v$ z1 S
which was treated with thyroxine. The father’s6 Y5 u, G: f7 o" `. w( V
height was 6 feet, and he went through a somewhat
+ [3 P6 X# p7 m. S& x: V l7 Wearly puberty and had stopped growing by age 14.
$ i& b: t5 w4 C! F! J' F/ KThe father denied taking any other medication. The2 E" {. \: f1 h( i8 I
child’s mother was in good health. Her menarche
. t( h# t/ y- B" U; H7 hwas at 11 years of age, and her height was at 5 feet% p2 L* b6 a2 v) x
5 inches. There was no other family history of pre-& g$ D2 J8 }3 w3 I
cocious sexual development in the first-degree rela-6 J/ I1 ~# K6 b: y( w
tives. There were no siblings.
( U1 P# G9 y) H9 F7 s! f, @# MPhysical Examination4 Z* f3 P( m& Y# Q
The physical examination revealed a very active,
, k# w# q! K- Eplayful, and healthy boy. The vital signs documented
# S d$ E; J; C! A0 \, ^6 s Ka blood pressure of 85/50 mm Hg, his length was
, _ ?# ^" z2 E90 cm (>97th percentile), and his weight was 14.4 kg# d3 C4 d1 L% Q+ I! ~8 P
(also >97th percentile). The observed yearly growth
7 v8 V5 V% }7 E1 ], H0 S; w% Uvelocity was 30 cm (12 inches). The examination of
" U! {; {4 z- Ithe neck revealed no thyroid enlargement.6 A* u) n' I! u1 Y9 _1 }3 Q
The genitourinary examination was remarkable for
' i6 f6 Z( i7 N) aenlargement of the penis, with a stretched length of6 n5 ~, n6 R u' ?3 k% W
8 cm and a width of 2 cm. The glans penis was very well% P% Z" \3 f2 H+ o, P8 P+ N- u9 F
developed. The pubic hair was Tanner II, mostly around
1 j% u, ]) z/ y; Q7 _540
2 ? N( U d( _. ~! @3 Rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' X( u+ F9 K& y& d
the base of the phallus and was dark and curled. The" x8 v% R. u8 e3 o3 V* _- f
testicular volume was prepubertal at 2 mL each. y' ?9 r+ h" z$ F3 t& Y% ]
The skin was moist and smooth and somewhat
% L1 G/ C5 l/ U; z7 N# k" `+ \0 Foily. No axillary hair was noted. There were no
: [" |/ A% d; |% T3 N: T0 rabnormal skin pigmentations or café-au-lait spots.
& \' R; v$ f) m h- LNeurologic evaluation showed deep tendon reflex 2+! U8 d. A% x- b% n- A* ]4 m& V
bilateral and symmetrical. There was no suggestion
5 {2 |+ T% ?1 Rof papilledema./ D# f3 P: u2 j7 {+ |
Laboratory Evaluation2 v: ^. J! h& d
The bone age was consistent with 28 months by9 ?. B0 H _8 E# W% O' L2 V
using the standard of Greulich and Pyle at a chrono-# X) E" |) f$ S8 [& q; N9 k+ ]5 V/ u
logic age of 16 months (advanced).5 Chromosomal
0 O J8 e1 s- t, v9 B9 Rkaryotype was 46XY. The thyroid function test% m7 v% v$ y& E- e! L. v0 H. w, ^
showed a free T4 of 1.69 ng/dL, and thyroid stimu-, X6 w5 v$ R; x
lating hormone level was 1.3 µIU/mL (both normal).8 _+ v$ o" P0 v1 B
The concentrations of serum electrolytes, blood _) U9 W1 ~' W( g7 U
urea nitrogen, creatinine, and calcium all were; i/ ^! g( H9 _* j. I5 j3 |
within normal range for his age. The concentration
& H) V9 S+ h" E+ g I' iof serum 17-hydroxyprogesterone was 16 ng/dL
, }+ ]7 G- a" s6 H7 y(normal, 3 to 90 ng/dL), androstenedione was 20- r6 e+ p( S4 v W
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
1 \+ N6 Q$ y8 l: h9 p kterone was 38 ng/dL (normal, 50 to 760 ng/dL),3 e7 i/ w8 E/ k: k
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
3 w8 s' p+ Q- O, j9 e. B49ng/dL), 11-desoxycortisol (specific compound S)6 o: p5 N' ?0 t' `
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
* N5 h; M- u( o+ ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total! B# a% m( f1 M. B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) S- V2 `' z; n# Nand β-human chorionic gonadotropin was less than
& R/ [4 ~! d0 O! c9 J5 mIU/mL (normal <5 mIU/mL). Serum follicular! M; w8 A6 {1 R* I9 Y
stimulating hormone and leuteinizing hormone
1 h# q" i8 B* B& L0 ]* r# Z( c# R) K, rconcentrations were less than 0.05 mIU/mL
7 t$ _2 i1 E2 a# o$ w( U) e9 B(prepubertal).
7 j- L5 M( X4 @7 dThe parents were notified about the laboratory" j* j5 v0 ^6 ?: H4 x! p
results and were informed that all of the tests were6 u0 n9 `' V0 }$ O( v3 E8 a
normal except the testosterone level was high. The% k( t0 V9 N3 Q9 A
follow-up visit was arranged within a few weeks to
; t4 M, S& i3 pobtain testicular and abdominal sonograms; how-0 \4 J7 P" d' ~4 ]
ever, the family did not return for 4 months.
% m0 \, m# t, }( c5 @9 KPhysical examination at this time revealed that the
5 G+ S A- {) g% i E. ]child had grown 2.5 cm in 4 months and had gained
, K9 E0 k/ Q9 h. B2 kg of weight. Physical examination remained
. b' E5 |& ?1 X w# ounchanged. Surprisingly, the pubic hair almost com-3 ~3 T! Y" H, S5 x' u6 b! r
pletely disappeared except for a few vellous hairs at6 R9 x; }& F# M7 F2 } r0 G
the base of the phallus. Testicular volume was still 2
4 T7 R3 c3 R/ r. umL, and the size of the penis remained unchanged.! I) h" o( P" Q& E
The mother also said that the boy was no longer hav-
, Z- @% t6 c. king frequent erections.' m7 U! @/ J5 x0 W4 X; Z8 l
Both parents were again questioned about use of% d g8 p6 [8 h9 v" j
any ointment/creams that they may have applied to
( O% A& o( N) n! W: r6 ithe child’s skin. This time the father admitted the( g. z: t. s, ^" o
Topical Testosterone Exposure / Bhowmick et al 541" F( D$ Z3 o! z& r N2 K- U
use of testosterone gel twice daily that he was apply-
) m3 W$ d! {( Y; B7 Ping over his own shoulders, chest, and back area for3 f$ }. B% z- M: T
a year. The father also revealed he was embarrassed
5 D- P C, V- G& B- Lto disclose that he was using a testosterone gel pre-2 {: z9 @: `/ c3 ?9 \
scribed by his family physician for decreased libido" |* w. e& z* _0 J9 {1 e
secondary to depression.
9 c4 ^8 a" u o" x* ]( AThe child slept in the same bed with parents.; z! U- q j- v: k1 p! Z* D0 g5 K
The father would hug the baby and hold him on his
( L6 G* X7 z$ k* Bchest for a considerable period of time, causing sig-
: T) M! r$ g$ x9 a! V6 i6 ]$ g" \# hnificant bare skin contact between baby and father.
& q, |$ F) Z% r$ Q: d. ^8 fThe father also admitted that after the phone call,
; w7 r* i) m0 |( g, wwhen he learned the testosterone level in the baby0 H9 o1 ^# A }) N V. e! U3 G
was high, he then read the product information
2 v# V" {+ W. }* H7 W% `+ |packet and concluded that it was most likely the rea-- \, G$ Z* K- A* ~2 w H3 W7 D
son for the child’s virilization. At that time, they) P4 C# B4 ^% e2 i, _/ m
decided to put the baby in a separate bed, and the% `* `' R6 D3 `9 s: r2 ]4 R% b
father was not hugging him with bare skin and had$ E2 Z9 ?% k# \+ v
been using protective clothing. A repeat testosterone
! ~3 q$ _5 j/ N6 ]5 U$ L- U8 Rtest was ordered, but the family did not go to the
- G. ^7 b9 h! b" b- K& ?& f% H7 N4 Elaboratory to obtain the test.
6 w$ b! W2 a/ W1 h$ d# ?Discussion, a3 w" _! C- b/ ~0 e
Precocious puberty in boys is defined as secondary
. A( A) L _) E' D0 s( [; Ksexual development before 9 years of age.1,4: b* j" ]8 `0 v, }, x! y
Precocious puberty is termed as central (true) when0 `* a. r* [, N
it is caused by the premature activation of hypo-0 a% n1 J y; ^: m0 m, } }% G
thalamic pituitary gonadal axis. CPP is more com-& v: u2 p9 R8 ?2 _6 d$ Z7 p
mon in girls than in boys.1,3 Most boys with CPP
. j- L. j. @+ wmay have a central nervous system lesion that is
. }9 e3 e, J5 Yresponsible for the early activation of the hypothal-2 ]' a, F) z! E2 N# L5 I
amic pituitary gonadal axis.1-3 Thus, greater empha-
3 O N+ w F$ Isis has been given to neuroradiologic imaging in2 `/ s) I0 h1 y- H
boys with precocious puberty. In addition to viril-
) f) P. y# V/ l: n0 g( Lization, the clinical hallmark of CPP is the symmet-
, [# H& w9 D* B9 t+ v* vrical testicular growth secondary to stimulation by1 N- x) Z$ D- q& ?' R
gonadotropins.1,3
( t1 ^3 z# P+ \5 i. {+ I0 a/ tGonadotropin-independent peripheral preco-
' m* e4 O! I4 ~- zcious puberty in boys also results from inappropriate. g" P) B5 r+ Y0 {7 X
androgenic stimulation from either endogenous or; u; B- j# _ q/ v& ^+ f, m
exogenous sources, nonpituitary gonadotropin stim-) j$ H1 b7 w6 x/ [% S7 S
ulation, and rare activating mutations.3 Virilizing
- x/ k3 ? e' A* s! G7 wcongenital adrenal hyperplasia producing excessive
0 |$ M5 d! [; j( g+ D6 Kadrenal androgens is a common cause of precocious2 z$ ]5 O& z/ f' Y2 w# B) x
puberty in boys.3,4* L6 b. {- M6 B: t" b2 I6 l
The most common form of congenital adrenal& K7 ~1 b' w7 ^6 z5 I+ n6 e
hyperplasia is the 21-hydroxylase enzyme deficiency.
! t, i& ^0 T+ Z) J8 }* CThe 11-β hydroxylase deficiency may also result in5 g. q/ m# u# C! o) A
excessive adrenal androgen production, and rarely," P3 V/ N1 k8 v& ]% _3 D
an adrenal tumor may also cause adrenal androgen! ^1 B E( `& c b' @
excess.1,3
; y& `" h6 _$ U/ M8 t8 eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. B) x9 P( H6 b& J0 G
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; B# v( K( F; t, k( m
A unique entity of male-limited gonadotropin-
3 {/ ~; ^% \7 C. ]! gindependent precocious puberty, which is also known' w% O8 t9 U# a7 u
as testotoxicosis, may cause precocious puberty at a6 [; [+ }# D1 q3 Y2 @ ]7 \
very young age. The physical findings in these boys2 q- `7 s# j1 W) }4 v# b
with this disorder are full pubertal development,
6 P- K9 l, V1 Sincluding bilateral testicular growth, similar to boys
5 r) n* v9 h/ f2 K9 M( H- Ewith CPP. The gonadotropin levels in this disorder
4 e8 C/ L0 F5 k7 |6 X7 N+ T& X+ zare suppressed to prepubertal levels and do not show
) H" z7 L! C* c0 f+ T' j/ t1 rpubertal response of gonadotropin after gonadotropin-9 b6 y s: u2 B# T, y
releasing hormone stimulation. This is a sex-linked
8 g+ R w ^% u* E5 m& \' tautosomal dominant disorder that affects only
+ M! S1 |; T3 K* k+ @+ Mmales; therefore, other male members of the family
@0 y' N4 z4 ?may have similar precocious puberty.3
- }: O, M& U5 \* dIn our patient, physical examination was incon-* H0 n+ C! a2 C; R, \
sistent with true precocious puberty since his testi-0 r0 H* @1 p4 l9 H! U/ F, }0 D5 ^4 x
cles were prepubertal in size. However, testotoxicosis
' s: q# m0 Z! ~5 _& rwas in the differential diagnosis because his father
( B0 c! S! [0 W+ s1 d6 estarted puberty somewhat early, and occasionally,) b" V. }) c# c% t) \) d
testicular enlargement is not that evident in the
' e# F( G' M. e( l& N: D6 X1 T. Ybeginning of this process.1 In the absence of a neg-
/ I8 O9 r6 E6 w4 D3 |+ b- l. {ative initial history of androgen exposure, our& D7 z' w3 [* E4 I
biggest concern was virilizing adrenal hyperplasia,
. Q! ^4 g- c+ {: Veither 21-hydroxylase deficiency or 11-β hydroxylase
2 Q0 Y$ C" ]1 w+ R& a2 E& ]deficiency. Those diagnoses were excluded by find-
/ ~8 K# N! @3 C0 i5 q. Ging the normal level of adrenal steroids.
8 h3 c, \7 i8 R% J/ e7 L# }( x+ sThe diagnosis of exogenous androgens was strongly
% b6 [( _! p% I# ~; ^, _suspected in a follow-up visit after 4 months because
% v1 X+ ^" x5 p# }. P: \the physical examination revealed the complete disap-
7 i! u6 @( i, Y2 Wpearance of pubic hair, normal growth velocity, and/ n! q) \% U$ |7 D$ ^1 i9 i% u8 M
decreased erections. The father admitted using a testos-
& o( U0 L9 h* ~terone gel, which he concealed at first visit. He was
" z' d7 {3 B$ ~+ B, y1 s, O1 gusing it rather frequently, twice a day. The Physicians’
1 m( r! D) z# _. V, f' n" D: _Desk Reference, or package insert of this product, gel or( [# m( X4 U. I) G4 e1 d. H' u: H
cream, cautions about dermal testosterone transfer to# n+ ?' i/ O. p. V9 L& V/ _
unprotected females through direct skin exposure.( G5 [: C+ H4 J
Serum testosterone level was found to be 2 times the
+ U7 J0 G5 e! s" L& a4 ~! [! abaseline value in those females who were exposed to5 f: f( ^0 D$ z
even 15 minutes of direct skin contact with their male
; n* \) b) x7 [, wpartners.6 However, when a shirt covered the applica-
; a# C0 _5 T6 i% ]tion site, this testosterone transfer was prevented.; w, l# B9 I. \: f
Our patient’s testosterone level was 60 ng/mL,4 e5 P( K' ?# N, n$ I _/ C5 b
which was clearly high. Some studies suggest that( h' e' W4 F( K: f( n& }
dermal conversion of testosterone to dihydrotestos-# q1 }. m; L! |* F' E( @8 K
terone, which is a more potent metabolite, is more
; H/ |2 \" q) i- F3 D, Iactive in young children exposed to testosterone
6 p2 ]8 V: x9 \ L8 D! A$ \# Iexogenously7; however, we did not measure a dihy-' M) l V% u4 y6 }" Z7 ]2 X
drotestosterone level in our patient. In addition to
' ^4 i; E5 W# G, r8 {, I: b5 {virilization, exposure to exogenous testosterone in
2 Z0 w$ v8 G Dchildren results in an increase in growth velocity and
T! U" ~/ w# V+ x4 L& k7 W: M# r+ iadvanced bone age, as seen in our patient.) z5 v0 V# q- T
The long-term effect of androgen exposure during
% _- u) q+ ?4 s$ y1 yearly childhood on pubertal development and final+ Z x; `' Y J, p
adult height are not fully known and always remain
8 v9 ]4 h: B) g$ i6 \a concern. Children treated with short-term testos-
/ k% O" _1 |( L2 R0 F6 L$ bterone injection or topical androgen may exhibit some
# w7 m- p& v6 C6 _9 M, Z2 P& ^acceleration of the skeletal maturation; however, after
* ~+ I# n5 b4 u9 mcessation of treatment, the rate of bone maturation- \4 M2 K: T7 V- Y ~
decelerates and gradually returns to normal.8,9
9 y$ p1 `- K A, S$ a5 e0 SThere are conflicting reports and controversy
% S/ q W2 r/ |( G. T0 a% aover the effect of early androgen exposure on adult
- h5 x( m; n4 y9 a7 T6 upenile length.10,11 Some reports suggest subnormal$ h: i0 E4 T p, W
adult penile length, apparently because of downreg-" u- X0 E; ]* w, z: L6 p9 M
ulation of androgen receptor number.10,12 However,
4 S9 `1 e) Z( ?1 a5 PSutherland et al13 did not find a correlation between+ F2 L' \( K7 R4 a
childhood testosterone exposure and reduced adult; ?/ B2 m/ c& N
penile length in clinical studies.: s! x% J, c% W9 z) Q
Nonetheless, we do not believe our patient is
9 a- v, E2 R; r) r: J: \, bgoing to experience any of the untoward effects from3 c h0 U, S- j6 \' [ z
testosterone exposure as mentioned earlier because
5 ]9 f6 N- X: z' mthe exposure was not for a prolonged period of time.# G/ i3 a* d, T% h
Although the bone age was advanced at the time of5 D S8 Y. @ S' E1 y) P) ?8 h0 A. Z6 @
diagnosis, the child had a normal growth velocity at
* V* L/ h6 E2 _ z$ E' vthe follow-up visit. It is hoped that his final adult
8 V8 X& E. [5 |' O! ?height will not be affected.
! Z0 Q; G4 s+ A2 QAlthough rarely reported, the widespread avail-4 b) a3 |# x U' t: b9 ?
ability of androgen products in our society may! f# v# F N) [- I" N4 m4 R
indeed cause more virilization in male or female
& f1 T, ?' _ |4 K; q+ [: w0 wchildren than one would realize. Exposure to andro-0 f- z; h) {4 d" e1 \0 J/ O; L
gen products must be considered and specific ques-
" \5 a1 q5 G+ p4 N. \5 qtioning about the use of a testosterone product or$ X3 e; G, k- }; [, r% \& X
gel should be asked of the family members during
4 l( P3 b- n o7 ~2 Z# @4 Ethe evaluation of any children who present with vir-
5 Z" k0 x/ T- j8 W% ?# e( A, ~ilization or peripheral precocious puberty. The diag-. R& j) J+ o, J; e+ \! p; u9 J
nosis can be established by just a few tests and by
; k- S2 \# t+ Z' _2 M5 z- Xappropriate history. The inability to obtain such a' O H3 G; E- A( a( r
history, or failure to ask the specific questions, may" Q2 b: h) k# Q8 j! F+ n9 n5 q
result in extensive, unnecessary, and expensive' _. g. }) H+ V3 K, i( ?+ l
investigation. The primary care physician should be7 e( _, a" l0 N4 W% S* ?' M3 y+ C
aware of this fact, because most of these children5 f9 Q+ s3 w6 [
may initially present in their practice. The Physicians’
! c: r6 I- X. X" x: A" NDesk Reference and package insert should also put a- W7 R: K" N1 t |
warning about the virilizing effect on a male or
2 b) e; h. T4 A8 o6 T$ I0 K% Lfemale child who might come in contact with some-
& r! o7 f' |: A* ?" Oone using any of these products.
$ x y. e+ R! O8 s; `" p8 ^References6 g6 T+ Q6 a7 {
1. Styne DM. The testes: disorder of sexual differentiation$ L$ A4 `0 f' i p/ i3 p4 Y* Q: M
and puberty in the male. In: Sperling MA, ed. Pediatric
}/ {3 ?/ |. D0 U' dEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ D5 Z3 u0 p c. r; F) z
2002: 565-628./ G5 C/ Q9 n! ?$ Y
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, k7 l1 N3 w( E& V. X6 _5 @puberty in children with tumours of the suprasellar pineal |
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