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Sexual Precocity in a 16-Month-Old
5 |- b1 n! Y0 N4 ]' b) j* WBoy Induced by Indirect Topical' Z3 Y% O- B1 ]+ P
Exposure to Testosterone
4 p6 T1 m' O1 X0 Z! Q" L8 W+ HSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' ]. ]9 o& ]: @and Kenneth R. Rettig, MD1( r# G4 w4 a- e$ a t
Clinical Pediatrics0 A( p- z2 J% Y/ [% y/ L7 w
Volume 46 Number 6$ x) p7 C4 B, x
July 2007 540-543
+ k) i5 @$ V7 p8 n7 s$ F© 2007 Sage Publications
% R6 b4 L% Q0 M ^2 T10.1177/0009922806296651
# r U5 c/ e- v+ K$ Nhttp://clp.sagepub.com
8 u& W; w$ L4 z, w; H3 Xhosted at5 [4 |! B+ S- D
http://online.sagepub.com: l$ G, s7 n, Y% [0 c
Precocious puberty in boys, central or peripheral,
5 r4 {) B) {: Kis a significant concern for physicians. Central( | ~7 V6 k r4 P( `8 T. A: n
precocious puberty (CPP), which is mediated
) W. E7 y' W5 o8 ^; othrough the hypothalamic pituitary gonadal axis, has
2 i) X1 \8 O2 ]; ^1 `3 X; I7 Xa higher incidence of organic central nervous system
' t; ]7 ]6 ?. f! p# t# _* Alesions in boys.1,2 Virilization in boys, as manifested) `6 Q+ n4 s# e0 E* N
by enlargement of the penis, development of pubic
1 B4 \5 w' y5 ]7 s5 } ?hair, and facial acne without enlargement of testi-, w' ]! P3 }! Y- o' E* ~
cles, suggests peripheral or pseudopuberty.1-3 We
. Z8 n3 Y2 L' A# v9 ^, f$ @report a 16-month-old boy who presented with the1 E6 I% [: R! u( R
enlargement of the phallus and pubic hair develop-+ J* c( ]# k8 R8 s9 T1 j
ment without testicular enlargement, which was due1 p' v) C7 ~/ M- V& u l
to the unintentional exposure to androgen gel used by
! `# K* q/ ^. C. g* Othe father. The family initially concealed this infor-4 i, z# N1 J- N1 k1 e; _+ }' X0 t
mation, resulting in an extensive work-up for this
9 G6 e: _' R2 A, u- B+ ]: e7 Uchild. Given the widespread and easy availability of' ?; c$ _8 L4 e% B! O
testosterone gel and cream, we believe this is proba-
6 N7 F' F' T: c* Wbly more common than the rare case report in the
. O9 B' T, q. h9 |1 |literature.4 V& A' _5 h4 ~
Patient Report c- Y5 l( V# I# V# Q
A 16-month-old white child was referred to the1 g) Q2 O% B- \* k2 x+ j, U
endocrine clinic by his pediatrician with the concern( F5 `1 G. l) M( A+ s3 r. L
of early sexual development. His mother noticed
* U9 U) y! y, x6 v# E4 e* Llight colored pubic hair development when he was1 M6 N! o F$ c3 }% e
From the 1Division of Pediatric Endocrinology, 2University of
8 `9 u l5 J0 R4 w N7 }2 \! J QSouth Alabama Medical Center, Mobile, Alabama.% f( {: N4 i) [, t5 B. k; p6 K
Address correspondence to: Samar K. Bhowmick, MD, FACE,
' L T6 H$ H; ~5 o# V: f4 lProfessor of Pediatrics, University of South Alabama, College of I+ z+ o+ P! i( D# v+ Q9 u
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ k/ s2 s4 Z- q# R' U
e-mail: [email protected].
& Y1 D2 R N0 Q, m0 S+ {7 s1 dabout 6 to 7 months old, which progressively became
. p/ K* }5 j- r/ X; H0 j1 A- jdarker. She was also concerned about the enlarge-0 B/ L1 i: r7 {4 c y' |
ment of his penis and frequent erections. The child
+ L) P0 g# S, w0 T6 X; Bwas the product of a full-term normal delivery, with
" j3 h+ m9 _9 {8 U m7 f" ]$ Ha birth weight of 7 lb 14 oz, and birth length of5 U C& I- m7 `1 E# }9 g
20 inches. He was breast-fed throughout the first year; e; d2 M. {4 n6 V) d; l
of life and was still receiving breast milk along with
2 q% x: J$ M. T: {1 W) esolid food. He had no hospitalizations or surgery,
% B, G9 f2 [ W1 ^2 v1 \4 J' `and his psychosocial and psychomotor development
* ^1 P- J. j( G: k2 gwas age appropriate.7 p$ e D; k2 l" F3 T, L
The family history was remarkable for the father,
( o. F& L" P0 x% B+ w2 P2 A7 swho was diagnosed with hypothyroidism at age 16,
5 g) K; N9 @% R' Fwhich was treated with thyroxine. The father’s: o/ t( U9 t: o# c! c1 o& A
height was 6 feet, and he went through a somewhat& x9 J: C, `( t x% j+ j
early puberty and had stopped growing by age 14.% I. I/ c5 l& a% [! N5 c
The father denied taking any other medication. The
, ?( L: \7 @& achild’s mother was in good health. Her menarche
' G+ A9 n4 @1 _# Iwas at 11 years of age, and her height was at 5 feet4 o# N2 s" _4 M- Q3 U* w, k3 l0 ]
5 inches. There was no other family history of pre- _( G/ n3 `- m c4 c
cocious sexual development in the first-degree rela-0 K x5 c1 J8 S) [: O3 y# k
tives. There were no siblings.
3 ~/ Y9 [, u$ u6 i9 H( U2 MPhysical Examination1 r: O, ?% x# P# f1 K1 h
The physical examination revealed a very active,* R# ^# {3 n5 a/ c6 e% q# ?
playful, and healthy boy. The vital signs documented9 r+ B1 [0 W- Q( R
a blood pressure of 85/50 mm Hg, his length was
, b/ V+ E0 B& p3 n1 l90 cm (>97th percentile), and his weight was 14.4 kg
5 U/ ^7 o! g. j( j) a X' S5 p(also >97th percentile). The observed yearly growth5 H( ]) x. B! r% o
velocity was 30 cm (12 inches). The examination of" @# N6 s, Z& L4 S, k; i
the neck revealed no thyroid enlargement." \5 ^! Z- }+ |+ \/ u' s5 R: N
The genitourinary examination was remarkable for
# C F* ^5 K3 I. kenlargement of the penis, with a stretched length of
% O5 x. F( J: `- D2 b8 cm and a width of 2 cm. The glans penis was very well
- p2 u: b! a8 n9 E) a& h" w- L/ adeveloped. The pubic hair was Tanner II, mostly around, W1 P: \# [- ]0 {: F
540$ X* W8 S: H+ G* {
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 S1 ^8 u* G, S
the base of the phallus and was dark and curled. The
; Q U. [! f# V$ `, n# Btesticular volume was prepubertal at 2 mL each.
0 {* A4 G @4 r, IThe skin was moist and smooth and somewhat. p) @8 f6 F/ X% D
oily. No axillary hair was noted. There were no0 L1 D m% I8 r9 X/ N
abnormal skin pigmentations or café-au-lait spots.
0 [8 j4 {- k' A- H" P5 fNeurologic evaluation showed deep tendon reflex 2+
- N5 z! N+ d& \bilateral and symmetrical. There was no suggestion+ V7 H3 f9 [* Z$ I H% q9 [7 h
of papilledema.6 O2 L7 l0 d; p- B4 J* L2 @
Laboratory Evaluation
' m& l) w+ r3 [1 ]. F& o& ]' MThe bone age was consistent with 28 months by
2 x* |7 _7 z, T) g! k6 yusing the standard of Greulich and Pyle at a chrono-2 v6 Z( A1 f3 r* @
logic age of 16 months (advanced).5 Chromosomal3 _. {/ m$ e- w8 ^! b. r
karyotype was 46XY. The thyroid function test; k4 l" _7 R/ b0 j
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: \% }* |: |' c' c3 m
lating hormone level was 1.3 µIU/mL (both normal).+ L) A! V7 C4 B2 y
The concentrations of serum electrolytes, blood# {3 t8 k l' l( V9 t8 |$ B
urea nitrogen, creatinine, and calcium all were
% |. i/ V) J7 |$ @1 Xwithin normal range for his age. The concentration3 `! |3 i$ P/ [$ ^
of serum 17-hydroxyprogesterone was 16 ng/dL' x. {1 }; w. G1 p
(normal, 3 to 90 ng/dL), androstenedione was 20
! p4 z- h& l; V$ t( |5 }ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) n# j3 f( q. @$ e8 \0 {5 w
terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ q) o; I& l, ?: U8 k" ^3 H7 M; \9 ?
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ |* i) \( r- s! l+ y/ U49ng/dL), 11-desoxycortisol (specific compound S)
, ?2 }! x9 x- ~5 |- p# Q! B5 |- Qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
% M2 z) b, I8 Otisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
8 S. h0 \7 \5 H1 }$ A: htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 [5 r0 w, A5 U5 w) X5 z& `3 Yand β-human chorionic gonadotropin was less than
( p7 \7 o0 q: S5 mIU/mL (normal <5 mIU/mL). Serum follicular: O" N1 e/ R, M: X+ a/ n! t
stimulating hormone and leuteinizing hormone
2 a5 c* S7 e1 z" W) B8 p' ~( r+ f4 aconcentrations were less than 0.05 mIU/mL% p! _. z2 h: |5 h8 w" y# A: e! {
(prepubertal).
! C% x/ z: W9 ?: T- p! mThe parents were notified about the laboratory- F$ T+ K2 C6 F) [
results and were informed that all of the tests were
2 e3 x0 l$ @& P8 j/ v0 ]( I8 Dnormal except the testosterone level was high. The
6 E7 z% n( V6 Z! \# k8 f) jfollow-up visit was arranged within a few weeks to/ D3 I. d' b/ X3 f
obtain testicular and abdominal sonograms; how-5 M( }* I) y# \
ever, the family did not return for 4 months.
0 `0 W. b: C, K" d1 p9 S6 ePhysical examination at this time revealed that the7 t* e: k# k4 e) |, d3 I
child had grown 2.5 cm in 4 months and had gained
; t1 V. U3 z) Z4 U4 Y' M' V2 kg of weight. Physical examination remained4 E1 g# F/ M* D/ L
unchanged. Surprisingly, the pubic hair almost com-
) T0 S3 a6 F, t- [, ^! ]pletely disappeared except for a few vellous hairs at
9 s& b& K. j! M. Uthe base of the phallus. Testicular volume was still 2
# t; _: }3 \% T/ VmL, and the size of the penis remained unchanged.
9 O; b5 e( p8 n _- n/ B+ yThe mother also said that the boy was no longer hav-
; S" G X" x* bing frequent erections.
) e# M3 t' `; j' O7 O& ]2 Y& ?Both parents were again questioned about use of5 F$ ~/ H, n- O3 ~: R# K2 w6 _
any ointment/creams that they may have applied to
" a9 }4 \% v; z, ]the child’s skin. This time the father admitted the7 `/ W8 i+ }3 n) {$ v5 {3 ?) k
Topical Testosterone Exposure / Bhowmick et al 541
* g2 q( F4 \' X( h3 Ouse of testosterone gel twice daily that he was apply-9 e1 {9 q$ J( c$ N8 c/ }2 J0 J7 G! G
ing over his own shoulders, chest, and back area for
2 W, ~' K) A0 k6 o Ga year. The father also revealed he was embarrassed
" U6 F! x" g3 G- R, K" ^0 z( }to disclose that he was using a testosterone gel pre-: N: N, `* b) H2 U) N
scribed by his family physician for decreased libido
8 J0 B( C: ~2 r$ W; M/ Z5 p5 Xsecondary to depression.( k* [9 j# L3 M
The child slept in the same bed with parents.
9 D" t% a+ p: }' [The father would hug the baby and hold him on his, @8 G" k* P; i4 h# V/ |% C
chest for a considerable period of time, causing sig-! d" U( l8 T) b( V
nificant bare skin contact between baby and father.
& K* p% X0 K5 t7 [$ M. d( SThe father also admitted that after the phone call,+ ^4 q1 H0 R+ X& }2 v
when he learned the testosterone level in the baby( k0 f/ ]! e* _7 Y% I$ |
was high, he then read the product information
' I7 D! M! O6 Cpacket and concluded that it was most likely the rea-
' c- E# Q% y4 a9 S3 |# zson for the child’s virilization. At that time, they
( _/ n, l, D. K# |: e) y" t+ y$ Fdecided to put the baby in a separate bed, and the
* j" ^) q+ \$ _! {; Kfather was not hugging him with bare skin and had
, U8 k: M4 Y) f/ cbeen using protective clothing. A repeat testosterone2 P$ [9 W$ F3 y" y# N5 }* p
test was ordered, but the family did not go to the
4 a% h9 w& q8 A; olaboratory to obtain the test.1 `& x& x; b0 u7 E U
Discussion
' |% \9 _" z' DPrecocious puberty in boys is defined as secondary; j0 u' S" u, j
sexual development before 9 years of age.1,4
4 {& [& s2 Y; V' pPrecocious puberty is termed as central (true) when
0 n1 X! R# W2 q L, Kit is caused by the premature activation of hypo-
* j2 n$ o9 N2 G. kthalamic pituitary gonadal axis. CPP is more com-3 }- U) Y; ]3 e& s' \3 z
mon in girls than in boys.1,3 Most boys with CPP
- l2 O% R2 O( `1 h/ Kmay have a central nervous system lesion that is
, z5 h% C4 Z: F1 ?responsible for the early activation of the hypothal-
+ m3 f. H- u. h0 m1 R5 Samic pituitary gonadal axis.1-3 Thus, greater empha-. n# \& S2 s: J/ a, i% U* q8 z
sis has been given to neuroradiologic imaging in4 d* ?( L7 R2 ^6 c# H1 ^8 O
boys with precocious puberty. In addition to viril-3 N0 Y2 v5 C5 q. C- l0 o6 [
ization, the clinical hallmark of CPP is the symmet-! T1 H& t! M: [/ f
rical testicular growth secondary to stimulation by; N. m+ u! | Y! I; `8 A4 n) h; W
gonadotropins.1,3 ]! }" z3 `( ~- w% m& \0 m
Gonadotropin-independent peripheral preco-, E0 h; u# [4 q0 d+ [
cious puberty in boys also results from inappropriate
; u2 g& `( t7 @. o" ~8 Mandrogenic stimulation from either endogenous or3 b+ B' t/ H2 x- x y+ W' }
exogenous sources, nonpituitary gonadotropin stim-
3 I4 U& w7 l& J5 Q, ]" v: e& j% Gulation, and rare activating mutations.3 Virilizing" b5 r* a% D6 k5 h/ D( x
congenital adrenal hyperplasia producing excessive c" Q$ m) O; j
adrenal androgens is a common cause of precocious1 U+ L) V6 q$ X, L9 g9 H
puberty in boys.3,4
% W0 [2 x- O, h7 e# n1 R: D8 BThe most common form of congenital adrenal+ q' D2 u2 M" _* N h; B% w3 v3 B
hyperplasia is the 21-hydroxylase enzyme deficiency.5 v* M4 F- f. \+ ]7 b3 E1 L6 ^
The 11-β hydroxylase deficiency may also result in! t) W8 D& h+ X% { A# c0 c3 p
excessive adrenal androgen production, and rarely,9 d( w" I# ~' K% L
an adrenal tumor may also cause adrenal androgen
" s1 ?( E8 m2 Y9 o7 xexcess.1,3: `; {7 B( A% w8 B% Y$ r
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# q! {: X6 j8 Q542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; ~( I9 P0 v) I& w
A unique entity of male-limited gonadotropin-
/ g6 u, P% }% j2 Mindependent precocious puberty, which is also known
# I3 u: m0 z0 Q8 y! u; gas testotoxicosis, may cause precocious puberty at a
, {" J, h' x: w+ f/ J) ~8 T* }; Tvery young age. The physical findings in these boys+ N3 e) {. h( u' A- e1 l2 \
with this disorder are full pubertal development,2 K8 f) |5 u0 y
including bilateral testicular growth, similar to boys5 @1 p J# X0 _+ G% k& i- W. |
with CPP. The gonadotropin levels in this disorder1 _. \4 V1 T y7 v9 }
are suppressed to prepubertal levels and do not show
( w. K. s( _; N! A. ^pubertal response of gonadotropin after gonadotropin-6 j3 V, ^* E! L: R9 G3 X) O
releasing hormone stimulation. This is a sex-linked
- g# k$ z! ~3 d' Z! Rautosomal dominant disorder that affects only0 R; t4 x; o: w$ k+ V! q% c1 t! S
males; therefore, other male members of the family' b. s! B/ N. B0 [
may have similar precocious puberty.3 P& N+ U2 S/ J' x- n5 c
In our patient, physical examination was incon-
$ M, V2 D% O6 i+ y- E e$ usistent with true precocious puberty since his testi-4 k7 A# s t9 O
cles were prepubertal in size. However, testotoxicosis5 a6 r3 w8 a7 n& K
was in the differential diagnosis because his father: h( C) l& l7 c, ]' X( q' H
started puberty somewhat early, and occasionally,
9 _' Z% z) J5 b& C. |testicular enlargement is not that evident in the
" n/ u6 ?# c Pbeginning of this process.1 In the absence of a neg-2 f4 Z4 r8 C9 ?
ative initial history of androgen exposure, our
; O; W$ A& {" p. E4 e1 abiggest concern was virilizing adrenal hyperplasia,
$ }: K" ]# A |5 F beither 21-hydroxylase deficiency or 11-β hydroxylase2 X: [# x) r; W3 g- b7 r& F
deficiency. Those diagnoses were excluded by find-
2 B* X; Y/ i) p3 [* G! Ying the normal level of adrenal steroids.- |6 {6 B C. B+ h5 S; f
The diagnosis of exogenous androgens was strongly+ Y: f, }2 h' Q V5 Z* z' ^
suspected in a follow-up visit after 4 months because
9 G h: b6 c! W& j0 R- G+ ~the physical examination revealed the complete disap-
, |( h9 ]! B a: U+ ]) `9 x4 Zpearance of pubic hair, normal growth velocity, and$ K, a* ^5 u* X
decreased erections. The father admitted using a testos-
4 j) ]& K' n. G8 _0 H, Tterone gel, which he concealed at first visit. He was
% a5 K2 b+ P+ g2 B2 tusing it rather frequently, twice a day. The Physicians’
( ]4 K3 S$ T' s) ^) S, e. O6 ZDesk Reference, or package insert of this product, gel or3 {; u, b3 I3 L9 r
cream, cautions about dermal testosterone transfer to* Q) u: H, ^0 }8 Z1 S9 c
unprotected females through direct skin exposure.
3 w- Q8 G9 m1 Q0 c. ESerum testosterone level was found to be 2 times the( D/ ?; G! J% d& i7 A
baseline value in those females who were exposed to
( `& H) A( H- u# D7 }7 jeven 15 minutes of direct skin contact with their male) q. a, ~( S% y2 a( `: N
partners.6 However, when a shirt covered the applica-
: Q4 w& o1 |- G; C( wtion site, this testosterone transfer was prevented., J4 \% z0 V8 ~& } T
Our patient’s testosterone level was 60 ng/mL,
, H4 _0 c5 Y" Z6 ?% ^% `which was clearly high. Some studies suggest that! @& M0 i& y, b0 E M& m
dermal conversion of testosterone to dihydrotestos- K& k, q1 P) I7 V
terone, which is a more potent metabolite, is more
) U- {# ^% w% o* |active in young children exposed to testosterone. v: S' v5 k# r [2 K; M0 x
exogenously7; however, we did not measure a dihy-& M) F" s' i, f+ a8 U2 ~/ D4 {" F
drotestosterone level in our patient. In addition to
+ z: _/ } n! [' J) Y& e+ u9 hvirilization, exposure to exogenous testosterone in/ b. _6 Y; g) R1 y0 C
children results in an increase in growth velocity and- r( a0 l# {5 ?9 g( M' v
advanced bone age, as seen in our patient.
, a! F- `) P: x9 T; B! cThe long-term effect of androgen exposure during
4 r" O6 Z4 b9 D" ^3 D) fearly childhood on pubertal development and final
: y; m) V: J0 x; c0 kadult height are not fully known and always remain
8 U3 j8 p: B% B5 _" n+ W ^# n& ma concern. Children treated with short-term testos-
# w, X5 D& w& l4 ~9 {terone injection or topical androgen may exhibit some
, d7 y8 p8 }4 L& `( ~& e/ t3 Iacceleration of the skeletal maturation; however, after# S7 W' L) c/ O) z7 H m( n
cessation of treatment, the rate of bone maturation: O+ r) ~( x2 `" e. k! f
decelerates and gradually returns to normal.8,9
3 S* B3 Y$ G% v/ i6 p5 E uThere are conflicting reports and controversy
( n3 W* J7 }+ x0 _8 n1 N& M% f3 ]/ {over the effect of early androgen exposure on adult
; f4 m' c6 [$ I4 a* K5 H. B& C8 Cpenile length.10,11 Some reports suggest subnormal6 Q" F( w0 v7 c! V) o
adult penile length, apparently because of downreg-
# K8 ?5 c/ [; I: z6 Qulation of androgen receptor number.10,12 However,9 e; [4 b2 \' E& U
Sutherland et al13 did not find a correlation between
" B5 M/ M4 R! d0 b* ?childhood testosterone exposure and reduced adult7 }- Q8 m! L9 L- q" A9 c3 r: Y
penile length in clinical studies.
) \0 \+ H) y" BNonetheless, we do not believe our patient is1 T) L5 s O$ S6 M
going to experience any of the untoward effects from. Z6 e& K: d+ `' f* }
testosterone exposure as mentioned earlier because
4 r* e0 t9 \) Q& D# d kthe exposure was not for a prolonged period of time.
9 I9 {& Q7 L) C6 I3 z3 q2 pAlthough the bone age was advanced at the time of0 w6 `; |9 @# g
diagnosis, the child had a normal growth velocity at
1 ^. V6 Z- B5 l# \1 T2 Kthe follow-up visit. It is hoped that his final adult# d/ i. p5 Z$ B( n! n
height will not be affected.8 A: W. A. C& _6 Z) ?; y
Although rarely reported, the widespread avail-
+ w4 y! g- s8 {ability of androgen products in our society may0 ] V' ^" Z5 x4 }# z# G
indeed cause more virilization in male or female
( ^# Z5 h) R# ^# N/ Nchildren than one would realize. Exposure to andro-2 J; t" |: R! r4 P9 j2 x# u. S( V
gen products must be considered and specific ques-
) W; X9 o& n. f itioning about the use of a testosterone product or; Z! e( d; U$ x! }5 h
gel should be asked of the family members during- d4 G1 w3 O2 Z- N/ h, V2 B
the evaluation of any children who present with vir-5 r" ^: ~5 N% N& a4 d; m
ilization or peripheral precocious puberty. The diag-: |2 o/ H4 S% ^5 o, I) }
nosis can be established by just a few tests and by
: [9 I- e/ L) F, F U- D7 X. Vappropriate history. The inability to obtain such a
1 ^" u1 m2 f& a: d; ~' [history, or failure to ask the specific questions, may; V) L1 f* B6 i; _# g8 C
result in extensive, unnecessary, and expensive
0 H) ?' K a y9 D/ }! C/ e: finvestigation. The primary care physician should be
' N: d/ d, n6 k- K- Aaware of this fact, because most of these children
0 n2 w8 E: i9 ]; J0 [$ {$ ?1 gmay initially present in their practice. The Physicians’8 N O0 o& ^# t+ ~* h* y, J* j8 ?
Desk Reference and package insert should also put a5 w# a* \. E+ O a3 g6 y
warning about the virilizing effect on a male or# i* o2 U$ }7 X+ h
female child who might come in contact with some-! _" O# E- G1 @7 u9 h
one using any of these products.
, \% E7 N0 h" [0 vReferences Y4 h. U1 j, `- C/ R- ~& s M
1. Styne DM. The testes: disorder of sexual differentiation: B3 r! M" r" C* W* Y a
and puberty in the male. In: Sperling MA, ed. Pediatric. |' Q5 V; {2 M5 M* v6 U2 i7 ~
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
" k# I$ B8 B" N. r0 e+ {4 K2002: 565-628.
! K7 b% y3 H/ M* i2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ d; U0 z1 t2 R$ {% I
puberty in children with tumours of the suprasellar pineal |
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