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Sexual Precocity in a 16-Month-Old
5 E5 p- {5 M5 g6 v1 KBoy Induced by Indirect Topical
; q( P' x$ x5 S+ I* n u5 G# ^Exposure to Testosterone9 p, B( n4 k' K
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) @4 @( p" l9 }8 j a2 A% N
and Kenneth R. Rettig, MD1) z U- L1 k v4 I V
Clinical Pediatrics$ h$ k; X( k9 y3 X
Volume 46 Number 6$ T% |7 M; n* s. i# d w/ c
July 2007 540-543
/ \: r+ ?. n0 b$ W- S© 2007 Sage Publications
" z! Q6 D' C0 p. ?2 \5 F" P. [$ `% k10.1177/0009922806296651
5 _4 I* M/ Y" \0 ahttp://clp.sagepub.com
) Y# V4 C1 {, `6 T; d Uhosted at
: }8 ]) [6 E) n: w% shttp://online.sagepub.com8 c! A1 {' [* J# K2 y/ {
Precocious puberty in boys, central or peripheral,
2 z/ `7 K6 y5 N% h" t$ I3 N( \& q5 [is a significant concern for physicians. Central
( |, z& f6 p0 Zprecocious puberty (CPP), which is mediated
9 B% q2 {+ m3 f- _+ O$ M; ~% Kthrough the hypothalamic pituitary gonadal axis, has8 P. N* q9 Y# V, {8 `
a higher incidence of organic central nervous system
6 y+ d9 K A G. R* Vlesions in boys.1,2 Virilization in boys, as manifested
2 U3 v, O3 u7 V; V+ b6 n/ k+ N6 q, K fby enlargement of the penis, development of pubic
- \$ b6 W2 a3 o, [! w/ J* bhair, and facial acne without enlargement of testi-( q1 _! b) w! ]
cles, suggests peripheral or pseudopuberty.1-3 We
2 X/ ~4 t6 m3 o3 H7 @report a 16-month-old boy who presented with the
- o4 o# p l4 c+ L* @enlargement of the phallus and pubic hair develop-/ H! e- K* Q4 d) l: C
ment without testicular enlargement, which was due8 I- [! n0 i n6 @
to the unintentional exposure to androgen gel used by
* \# m7 m0 }3 G8 D$ O/ ~* y7 @, b, |* Sthe father. The family initially concealed this infor-& B/ Y5 Y# B$ j' B
mation, resulting in an extensive work-up for this
; b$ L! e4 C2 t) s) Q w+ Ichild. Given the widespread and easy availability of
, b4 i- i. z0 [7 `9 ltestosterone gel and cream, we believe this is proba-
' V0 X* X& o4 Cbly more common than the rare case report in the3 c* y; q. T7 Y& P; H# `
literature.48 j/ R- R: S7 f
Patient Report- D) a: \2 e$ F$ ]1 j- o8 e
A 16-month-old white child was referred to the( a" R b$ u' e4 ~) U' J4 i
endocrine clinic by his pediatrician with the concern
- G' N" m# u: N) [* B7 |of early sexual development. His mother noticed; R! [" B4 c1 h3 b% Q
light colored pubic hair development when he was# Q8 v! o% P) ~$ i2 {$ x6 A
From the 1Division of Pediatric Endocrinology, 2University of2 n% B/ V; J$ X
South Alabama Medical Center, Mobile, Alabama.9 O- I% n( G4 y, O
Address correspondence to: Samar K. Bhowmick, MD, FACE,
* h5 w& z+ r# f$ `Professor of Pediatrics, University of South Alabama, College of. O" M. y; J, Q6 M0 F0 o
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ D) v8 ]6 r, @) ^* {3 `6 ~* m
e-mail: [email protected].
7 I7 b0 K) W8 _about 6 to 7 months old, which progressively became. u1 e3 B. a% s
darker. She was also concerned about the enlarge-
9 ^1 o+ |6 g' _' B+ {$ F% _ment of his penis and frequent erections. The child! q1 T* S' _7 H
was the product of a full-term normal delivery, with
/ P! T# A8 ^) Z: m) m- W$ u! La birth weight of 7 lb 14 oz, and birth length of
- g' ^6 K% i- ]' }# t20 inches. He was breast-fed throughout the first year
9 O2 D' X3 `+ Q8 R5 q* wof life and was still receiving breast milk along with
! j$ h* Q% o" s g9 Ssolid food. He had no hospitalizations or surgery, l% z/ z) A5 K2 F4 K- X
and his psychosocial and psychomotor development5 s8 W" X3 y( R5 p x
was age appropriate.4 U$ R' S( i0 B! r5 F+ y) Q6 f
The family history was remarkable for the father,
9 [% t! U* r) C. J" ^9 Jwho was diagnosed with hypothyroidism at age 16,1 e2 {! w/ R5 M, P7 p
which was treated with thyroxine. The father’s, G, k K2 |3 |
height was 6 feet, and he went through a somewhat f" K, E! A [* g, N8 d2 A
early puberty and had stopped growing by age 14.! ]$ k1 ^" F9 T! P! g
The father denied taking any other medication. The
8 Q; |0 Y' N6 y$ B. T3 cchild’s mother was in good health. Her menarche: C7 ]- Q+ I1 o4 \. J# C
was at 11 years of age, and her height was at 5 feet; ~1 e! J- L7 @; `2 t$ k
5 inches. There was no other family history of pre-: G$ R5 k2 d' h2 A
cocious sexual development in the first-degree rela-! f+ H% _1 ~$ h: q
tives. There were no siblings.
( h6 T$ r# D) \. I) i9 `5 s0 LPhysical Examination
" K% x- k7 ?1 GThe physical examination revealed a very active,) |8 g6 H2 ^% Q, b9 K9 z5 f+ j# y" |
playful, and healthy boy. The vital signs documented/ |- g* n+ j9 ]2 U, j" X
a blood pressure of 85/50 mm Hg, his length was/ E3 E5 ]7 v# y8 z8 c
90 cm (>97th percentile), and his weight was 14.4 kg2 L" z! P! }! h
(also >97th percentile). The observed yearly growth
2 [) D) }" L9 Y5 d: d. H( Qvelocity was 30 cm (12 inches). The examination of
k& ]9 V. V4 M) ^the neck revealed no thyroid enlargement." X+ A/ s! X' d5 p( `/ F% j/ }, o
The genitourinary examination was remarkable for
: L* B* }, y. g8 @enlargement of the penis, with a stretched length of
2 }* A, J K( \. Q8 cm and a width of 2 cm. The glans penis was very well6 U. c4 @) S) J7 |
developed. The pubic hair was Tanner II, mostly around
0 C. V) W% E, Q" ]3 t0 c7 s540( e" i& p0 o# [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ B. z- ?& M( y( r5 [& ]
the base of the phallus and was dark and curled. The( M) h% B8 W5 k- W
testicular volume was prepubertal at 2 mL each.
3 [9 O* w* W; ~0 E& j) f0 T0 qThe skin was moist and smooth and somewhat
) d u! M( L8 coily. No axillary hair was noted. There were no {2 p, t( y# W" _% b1 \
abnormal skin pigmentations or café-au-lait spots.3 h; D4 n" `3 R( M5 Z2 i$ i3 D, {- t
Neurologic evaluation showed deep tendon reflex 2+
# j- P% Q3 r( D2 d2 y- Obilateral and symmetrical. There was no suggestion0 i$ R6 Q' S8 w& d! |2 C3 K* Y6 q1 M! H
of papilledema.
8 }9 x8 l# k# n4 z7 nLaboratory Evaluation" b, ]4 c/ d* i! b/ O* K* Q
The bone age was consistent with 28 months by
3 F& l9 e+ r5 D! C1 F4 V5 f2 Y( m' Jusing the standard of Greulich and Pyle at a chrono-
+ w+ p, ~/ ~* s( j: i# @logic age of 16 months (advanced).5 Chromosomal
2 L i' j+ \9 @karyotype was 46XY. The thyroid function test
9 ~% d) c& k6 Q, v% k$ ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-1 L, s8 Q+ Q: U; e9 T
lating hormone level was 1.3 µIU/mL (both normal).
. h7 A: H% c4 k- _1 G( t4 P8 p/ vThe concentrations of serum electrolytes, blood) f& _0 W: j; g" x
urea nitrogen, creatinine, and calcium all were
; C& R+ T! N: \within normal range for his age. The concentration; w* y6 C U% O5 K' z2 f5 g+ Q* O e
of serum 17-hydroxyprogesterone was 16 ng/dL
. ?. l7 f$ j( M6 N( @(normal, 3 to 90 ng/dL), androstenedione was 20
. d: _8 ?3 h; K2 G, }: S% U5 w4 Png/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% r0 [! N$ H, }( @5 v
terone was 38 ng/dL (normal, 50 to 760 ng/dL),2 ]0 @( i, M! d7 k6 a6 w! b
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
C* M9 l. [" ?" N* p" C49ng/dL), 11-desoxycortisol (specific compound S)
, M% R/ \1 p& z: T& Y0 L: qwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 v. Y5 r( h7 ]5 C7 e
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 l2 K! B. b. V" M1 f7 E6 b. A% y
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),) J! `+ r1 X( D; x! Y7 x0 Z3 [
and β-human chorionic gonadotropin was less than
- M* t; X6 m% [' v0 z9 U5 mIU/mL (normal <5 mIU/mL). Serum follicular
' L9 {7 L! J: F$ Nstimulating hormone and leuteinizing hormone; h, O) J3 F m/ }$ c4 y7 V
concentrations were less than 0.05 mIU/mL
/ q$ P3 J/ x: S: f5 r; r(prepubertal).
) r' \+ l {# @, O: E u/ |The parents were notified about the laboratory
9 _3 b0 s+ J6 I' D% B7 kresults and were informed that all of the tests were
1 ]1 c$ i; [1 C# Hnormal except the testosterone level was high. The
/ r7 C' A8 S& v4 m" jfollow-up visit was arranged within a few weeks to9 h0 X1 V; s( z
obtain testicular and abdominal sonograms; how-4 M( i7 j8 i% u b5 U
ever, the family did not return for 4 months.. Y& g5 C/ U" p) k
Physical examination at this time revealed that the# A- a2 E7 |( |' u" S/ t. p# Z. Y0 H
child had grown 2.5 cm in 4 months and had gained' G( D G$ G) J1 g4 ?3 q
2 kg of weight. Physical examination remained
6 O" ?% P4 X' b/ Q0 F+ N% v) }unchanged. Surprisingly, the pubic hair almost com-4 e" d9 {* C0 V
pletely disappeared except for a few vellous hairs at
5 Q$ F0 C; G/ Z0 O: C+ ~* nthe base of the phallus. Testicular volume was still 2; {/ p! c: S5 d) K- e
mL, and the size of the penis remained unchanged.
5 n: x# M: }- M! U3 F' EThe mother also said that the boy was no longer hav-! y- f! y& a2 z
ing frequent erections.7 q& O" T- L6 I3 s6 p
Both parents were again questioned about use of
" Q7 Z: H2 {+ S7 J* j8 C1 O8 vany ointment/creams that they may have applied to
. }# [. |, ^" ]0 a' s' gthe child’s skin. This time the father admitted the
2 b( Y- \# @' j4 |Topical Testosterone Exposure / Bhowmick et al 541, a# `1 L# e3 S& z$ {
use of testosterone gel twice daily that he was apply-8 N& M( w" r* h6 m; N
ing over his own shoulders, chest, and back area for
5 A* R9 t5 B% Z1 ea year. The father also revealed he was embarrassed
& S: C3 k) k) ]! [' Fto disclose that he was using a testosterone gel pre-2 j$ q5 t, M n8 c2 g8 C t
scribed by his family physician for decreased libido- T# h% H0 \. ]& z# _0 D; a, r
secondary to depression.
- C- F/ T( w$ WThe child slept in the same bed with parents.: }$ v0 ^7 E* t: u1 R; d5 Q
The father would hug the baby and hold him on his
# i/ T4 z0 _" R) echest for a considerable period of time, causing sig-, H, s8 s1 l O, B5 J; n
nificant bare skin contact between baby and father.
, O+ }% X2 \! `* L, l" |0 N# T4 a& rThe father also admitted that after the phone call,1 b: w( c; D: Z A/ _
when he learned the testosterone level in the baby
. e. N/ x4 D3 E. @) swas high, he then read the product information
6 B5 x6 y& }+ t2 z" W0 I3 ?packet and concluded that it was most likely the rea-
2 \/ V; r* ?& C$ h- i( dson for the child’s virilization. At that time, they
7 E: G6 M. c: s0 @decided to put the baby in a separate bed, and the
* @0 [; }( k% S% U" h) c8 | u$ j! h8 vfather was not hugging him with bare skin and had
! u' J/ y+ b7 L/ Z. K0 D: fbeen using protective clothing. A repeat testosterone
1 u. E& F9 W% Y. Htest was ordered, but the family did not go to the
% M8 E; `! m& Zlaboratory to obtain the test.
3 b3 I, k5 K9 f0 CDiscussion! \) Q. w7 T, f6 G1 N8 E5 H
Precocious puberty in boys is defined as secondary& f. H) }- X* x, I: v6 ` C
sexual development before 9 years of age.1,4 I: F, n4 P) H1 s) o
Precocious puberty is termed as central (true) when4 |& _+ w9 v# e K0 E$ a# ]1 r$ @
it is caused by the premature activation of hypo-
& N5 [9 Y7 ~+ }9 d7 [+ b7 Vthalamic pituitary gonadal axis. CPP is more com-
0 p$ j: Z/ ^6 ]' [5 Z, ]3 {8 Gmon in girls than in boys.1,3 Most boys with CPP ^. P6 P. G* Z0 D$ J3 B' J5 C
may have a central nervous system lesion that is
& P( v* P r5 `2 C/ Iresponsible for the early activation of the hypothal-* k' `- G# V" b1 U! c, n7 m& G
amic pituitary gonadal axis.1-3 Thus, greater empha-( `+ U2 z; _% O5 _/ l0 ?' a8 l7 W
sis has been given to neuroradiologic imaging in
, ?& Q. r4 H3 C: F) S3 j4 ?4 @! ]/ A* Yboys with precocious puberty. In addition to viril-
7 V0 ]$ `, n. Y7 R4 b) a- l2 n6 ?ization, the clinical hallmark of CPP is the symmet-9 K( K, N% u$ j F
rical testicular growth secondary to stimulation by
7 t1 r; o0 D* c& Tgonadotropins.1,3# b: f# k/ k, D3 o; g
Gonadotropin-independent peripheral preco-: F7 m. C' D& W1 o! I
cious puberty in boys also results from inappropriate
\/ h# `% J: c1 T9 S" S `/ ^# s) Wandrogenic stimulation from either endogenous or
. z( e0 A' u2 E6 h- [2 X1 sexogenous sources, nonpituitary gonadotropin stim-1 {( w4 o9 G3 @$ Z" W
ulation, and rare activating mutations.3 Virilizing2 _1 m- v9 w! V# R( n
congenital adrenal hyperplasia producing excessive8 H3 H9 |: m7 N6 C! U
adrenal androgens is a common cause of precocious5 i, t) l$ o+ h5 _7 t3 O
puberty in boys.3,4# d! w; `, ?: r/ Z7 a' f; T' J+ O
The most common form of congenital adrenal
% {0 I6 k) D4 w8 |, P' d% Ghyperplasia is the 21-hydroxylase enzyme deficiency.- ^; X% ^& f$ h( c C: i4 a- V9 y& C4 ]( v
The 11-β hydroxylase deficiency may also result in
9 u- B2 U Q4 a3 eexcessive adrenal androgen production, and rarely,. |! k: c: k: x/ _1 e: h
an adrenal tumor may also cause adrenal androgen
; G+ Q; ?, s- G5 Z) c+ n! Eexcess.1,3" A) d, {; J5 V* K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" ?7 m% Y& Q5 j U% |542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 ?& P4 \$ O7 a' V4 w! w @) e, |
A unique entity of male-limited gonadotropin-4 d7 W. @# Z# ^. O5 b/ Z. J2 q
independent precocious puberty, which is also known
; \. D( f/ N U; P: K7 ~as testotoxicosis, may cause precocious puberty at a
$ s! P3 ?/ f, P4 s& }# V9 d5 E" Rvery young age. The physical findings in these boys$ v: T/ Z. n/ B7 B$ j0 N$ W
with this disorder are full pubertal development,+ h3 Y6 `( x0 W$ \: o( f9 a
including bilateral testicular growth, similar to boys
8 T0 y, l8 N# ?6 H. hwith CPP. The gonadotropin levels in this disorder
: y ]4 @4 U0 q Q+ O( a& O" care suppressed to prepubertal levels and do not show
/ Z) r/ `+ f/ g9 F( rpubertal response of gonadotropin after gonadotropin-) b- l1 t4 O2 l
releasing hormone stimulation. This is a sex-linked7 K# [6 I7 Y1 d ` w9 m
autosomal dominant disorder that affects only
; R" [: G/ U" v; Qmales; therefore, other male members of the family
$ p) c7 [% G* Q1 D. o9 }! k: Cmay have similar precocious puberty.3
/ z3 {. J h& I& oIn our patient, physical examination was incon-/ p4 Y. n* b/ t3 Y+ @: O
sistent with true precocious puberty since his testi-
: E' L: F3 A/ J, x$ q8 L, z& ?cles were prepubertal in size. However, testotoxicosis) s, N. G- s! b9 [
was in the differential diagnosis because his father/ m4 J& p S7 B% c
started puberty somewhat early, and occasionally,
3 e. D& k! }$ v+ Ptesticular enlargement is not that evident in the( ^" |& p: L! n7 Z# E* k/ @
beginning of this process.1 In the absence of a neg-
9 E+ s& M# u. R# |& i3 F! lative initial history of androgen exposure, our
: `5 y2 A' |7 E3 O# D/ U2 {biggest concern was virilizing adrenal hyperplasia,
% B. V; H( E! E; n- r! Keither 21-hydroxylase deficiency or 11-β hydroxylase1 M$ l' }0 o& n+ |. A
deficiency. Those diagnoses were excluded by find-4 A0 a$ k8 G+ J4 _
ing the normal level of adrenal steroids.
# m( Z% W3 H/ g% |# L! ^4 xThe diagnosis of exogenous androgens was strongly: L% {/ m' J2 ~3 a' v
suspected in a follow-up visit after 4 months because& B$ v( }/ V" v0 B# t9 H
the physical examination revealed the complete disap-) e; q" A& `, c) z% b, x
pearance of pubic hair, normal growth velocity, and
$ s# i. |, b2 q: cdecreased erections. The father admitted using a testos-: C# C' `3 P6 d4 w( `$ S# k/ E
terone gel, which he concealed at first visit. He was+ T6 O, x2 q; x+ I7 u0 c, D
using it rather frequently, twice a day. The Physicians’0 `% L( u1 c, q: d
Desk Reference, or package insert of this product, gel or
5 i; v, f5 K' N9 S. Kcream, cautions about dermal testosterone transfer to
1 I( G3 ^9 T! t5 munprotected females through direct skin exposure.
E9 m* M5 M0 {; _) N N. @. oSerum testosterone level was found to be 2 times the
' Z' @! w, N8 Ubaseline value in those females who were exposed to2 H% n( l5 y) K; X. M
even 15 minutes of direct skin contact with their male
- g3 H X: G) J0 L; M0 Tpartners.6 However, when a shirt covered the applica-: q: J4 x6 C: Z3 @1 o) J
tion site, this testosterone transfer was prevented.
4 b2 T1 I0 J) {3 V' uOur patient’s testosterone level was 60 ng/mL,4 ]+ i0 h, F( z( @9 t& _
which was clearly high. Some studies suggest that
% F5 n$ ` H5 }0 a2 k4 Gdermal conversion of testosterone to dihydrotestos-
$ m1 m8 o9 d1 Y' n3 t0 j$ h- e# |terone, which is a more potent metabolite, is more% j: o& P8 V' V( C0 \4 F
active in young children exposed to testosterone' g2 H1 w* I4 V% o6 S' M
exogenously7; however, we did not measure a dihy-, t4 [" U5 d) x% ~. k9 B* W
drotestosterone level in our patient. In addition to, C$ Y1 G8 q& c. E
virilization, exposure to exogenous testosterone in
. Y/ V, {: m+ g0 b" |children results in an increase in growth velocity and
/ s7 C! `0 T! T, M1 T+ I# Yadvanced bone age, as seen in our patient.. Q8 _7 [1 N" p# r6 x+ R! n9 B
The long-term effect of androgen exposure during8 A/ I4 \4 v* t. R% ~* L! c: @
early childhood on pubertal development and final0 m' w- n* o5 ~4 r( h& p1 e. ~
adult height are not fully known and always remain! Y2 _% g3 l K' V) G5 A, d5 s3 A
a concern. Children treated with short-term testos-; o, [0 h( b; w5 E! w( u
terone injection or topical androgen may exhibit some9 [! c; J# ?5 [, e- |; }3 r4 s
acceleration of the skeletal maturation; however, after
2 C0 H% b5 {& L, \5 r, G) ^cessation of treatment, the rate of bone maturation: f( ]1 W) Y4 }8 e& C# A" H3 `
decelerates and gradually returns to normal.8,9
|5 {6 _% f4 p+ b" ~% NThere are conflicting reports and controversy+ W' ?0 r' \" }, x2 p6 m0 j
over the effect of early androgen exposure on adult
/ q7 B3 H4 I/ m2 a. V- ~penile length.10,11 Some reports suggest subnormal
* U4 Z% v O7 X- y$ J$ s8 }1 {( Padult penile length, apparently because of downreg-- j/ @5 f* i Q0 O6 Q9 Z- G
ulation of androgen receptor number.10,12 However,
4 N b' K; V% ^9 U( C0 v0 dSutherland et al13 did not find a correlation between" e4 [; r5 n8 W5 Z/ ?+ x
childhood testosterone exposure and reduced adult, \+ O! B, \% N
penile length in clinical studies.9 s% ?; Q# y" H1 Q
Nonetheless, we do not believe our patient is! v; G8 @8 E% P6 o9 w1 z: T
going to experience any of the untoward effects from
9 ]0 g. u3 C5 w/ P2 c, s$ C7 `testosterone exposure as mentioned earlier because
4 O) g! C% S; w- I Gthe exposure was not for a prolonged period of time.( F! y/ J9 F8 p1 L$ c
Although the bone age was advanced at the time of1 ]8 W2 }' p7 K- i& q" U. [# ]
diagnosis, the child had a normal growth velocity at! Y+ \' ^/ t( ^, h h# J
the follow-up visit. It is hoped that his final adult
6 C; g1 \9 Y4 N ~ `; M- yheight will not be affected.9 p+ X0 |- Q6 v* S& ^+ |7 S6 r* ?$ N0 f
Although rarely reported, the widespread avail-, v. S9 D5 h9 x
ability of androgen products in our society may
* e4 D7 K4 p- J+ d" e# Y5 h7 Windeed cause more virilization in male or female1 a+ Z8 |/ P. o
children than one would realize. Exposure to andro-7 B/ [1 c r% H/ ]1 _
gen products must be considered and specific ques-
# g8 ?; x8 B7 |/ i7 W" ~. ytioning about the use of a testosterone product or
2 a" g" p# U) D" s" y/ Egel should be asked of the family members during
& l1 [( D9 ~7 u3 J) e0 L$ t" {the evaluation of any children who present with vir-! j* }9 ]5 Q3 Y9 C% M# Y3 H
ilization or peripheral precocious puberty. The diag-' m- o8 _) G8 ~3 P6 @4 \9 x2 s: x
nosis can be established by just a few tests and by: ]. W7 R" g* P* N; p3 A+ Q
appropriate history. The inability to obtain such a: i/ m% c3 W6 Z$ s
history, or failure to ask the specific questions, may" G% C; |# `- Y2 r9 z. K
result in extensive, unnecessary, and expensive
7 A! x" P" q3 b1 m# pinvestigation. The primary care physician should be2 w" |' q1 P2 y
aware of this fact, because most of these children1 E! `4 s& B6 G3 D- `( m! M
may initially present in their practice. The Physicians’
$ p0 q7 c% Z1 d9 Z7 e! Y; dDesk Reference and package insert should also put a
5 B" I8 @/ h: D1 _& q! ~4 Gwarning about the virilizing effect on a male or" y7 Z9 [1 L, }3 F
female child who might come in contact with some-
# D- s q, v5 |! mone using any of these products., c3 l% G0 A) A; R3 t1 u! I* K5 n
References
& r* C. |* U; n8 _- ^1. Styne DM. The testes: disorder of sexual differentiation! G) _* R7 Y! y/ B6 w- v
and puberty in the male. In: Sperling MA, ed. Pediatric6 f/ j# k7 k, z. T4 q8 o6 Q
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
+ e5 Z8 w- ]% Q Q. w/ o, x2002: 565-628.
0 u5 m- y6 e1 b: s; k5 c2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) D7 S/ v5 ^: G4 f8 ?; ]# l
puberty in children with tumours of the suprasellar pineal |
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