- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:27:02
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old6 V& i1 a3 B' E. [4 X
Boy Induced by Indirect Topical \7 R/ B. `" P u5 S; M3 e4 `1 i
Exposure to Testosterone
7 ~, A- u( u8 V7 H) h/ {) PSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ P# q3 W. }1 r- r0 k$ jand Kenneth R. Rettig, MD1" G# P, M! g! `1 M/ s9 l
Clinical Pediatrics
8 C: G4 M% V; P% Q) |/ LVolume 46 Number 67 x/ H2 c% M, N0 i6 ]* c
July 2007 540-543( f! Y5 z0 g" }3 \
© 2007 Sage Publications2 i1 o& m0 @0 p. k1 p0 r# W
10.1177/0009922806296651# \( w4 _7 \# d9 u+ P/ y" k+ K
http://clp.sagepub.com
- u8 N0 t5 A7 B# {hosted at
5 h9 @7 \; A& ihttp://online.sagepub.com
! M- Z" I8 b8 WPrecocious puberty in boys, central or peripheral,% J ]9 i( c. V
is a significant concern for physicians. Central
( M+ c! x/ @9 k! x( Oprecocious puberty (CPP), which is mediated
3 @% f* Q6 x B! q6 N- W# xthrough the hypothalamic pituitary gonadal axis, has
6 r' D& n$ ^( I; {a higher incidence of organic central nervous system- N4 D) ~7 @0 K. x$ F7 x1 A
lesions in boys.1,2 Virilization in boys, as manifested# J! V$ N: F+ R! h: a. P4 P
by enlargement of the penis, development of pubic
4 N2 Y' m( ~) k, _3 Z/ I- \& ^$ @hair, and facial acne without enlargement of testi-
! w$ |. |1 X) g' @, ]- ^" Wcles, suggests peripheral or pseudopuberty.1-3 We H; E8 t6 W# X- M
report a 16-month-old boy who presented with the" I4 ]9 o; w: C
enlargement of the phallus and pubic hair develop-7 f3 M0 \2 z6 D$ Y. M2 X( G0 c$ W
ment without testicular enlargement, which was due
/ x4 r3 P0 X7 d# p2 Pto the unintentional exposure to androgen gel used by
+ F/ D/ a k8 A/ F1 \' [3 @5 J5 Sthe father. The family initially concealed this infor-
, P: S$ z. A1 Pmation, resulting in an extensive work-up for this A" ?. e: |$ ]0 g5 b E% b! f1 m
child. Given the widespread and easy availability of
$ }9 W- ~) l& e/ ktestosterone gel and cream, we believe this is proba-, C' i) T: z( B1 Y/ ] m
bly more common than the rare case report in the! N+ r7 W; o* b0 `: x
literature.4! H) |0 o2 j4 g
Patient Report7 [% Y% S# c: X( `& M+ C
A 16-month-old white child was referred to the
$ B+ m- Q9 e- Y: W) [3 ^endocrine clinic by his pediatrician with the concern; {. _5 O2 T1 `7 h% y
of early sexual development. His mother noticed
& j7 J2 g7 _( u, v+ T0 @7 _) rlight colored pubic hair development when he was
" c8 Z" f, C' L* _. IFrom the 1Division of Pediatric Endocrinology, 2University of& W; R% s$ }2 S- {# h' N
South Alabama Medical Center, Mobile, Alabama.
4 E+ \9 v4 }9 B: t7 X; L9 ^Address correspondence to: Samar K. Bhowmick, MD, FACE,
0 }# E7 B% [+ H/ I' q* d# [# dProfessor of Pediatrics, University of South Alabama, College of
6 L" l. o+ t( ]+ LMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 K! m. ]1 W7 w5 W4 ]
e-mail: [email protected].. t$ q% t- i: z1 n; W8 L2 o' _/ K
about 6 to 7 months old, which progressively became) ] c: G X6 P
darker. She was also concerned about the enlarge-
. H3 j5 L. K7 Z. Tment of his penis and frequent erections. The child" ^* p* l+ x# \8 l4 d1 m
was the product of a full-term normal delivery, with
4 a4 J6 G) y: R, na birth weight of 7 lb 14 oz, and birth length of
( V1 q! H* [; S7 {" A! n1 e( B, p; ^20 inches. He was breast-fed throughout the first year
) k$ U! d) l, Q; qof life and was still receiving breast milk along with1 I7 F" B6 c' V o1 N2 P- v, j
solid food. He had no hospitalizations or surgery,; | e1 E, F2 h* p7 B4 _6 f" Y
and his psychosocial and psychomotor development
- ?" m5 J2 a3 j. G* E- b' mwas age appropriate., H0 k6 Q% K+ U3 {* ?7 m7 ?- `
The family history was remarkable for the father,+ H& u: Q# D( ^" b/ L
who was diagnosed with hypothyroidism at age 16,
4 a" u i- T! ]0 m( Iwhich was treated with thyroxine. The father’s
+ v3 U$ \4 J& }height was 6 feet, and he went through a somewhat
* B _$ a* c1 Q" t9 Yearly puberty and had stopped growing by age 14.
1 [7 m( s* K6 E8 F& N( `, SThe father denied taking any other medication. The
2 G% |. I5 B( P7 ~( H" E q, \child’s mother was in good health. Her menarche+ p; ^" h0 d8 R1 }$ E e
was at 11 years of age, and her height was at 5 feet9 v6 j. {( H; z/ P8 t9 S$ E7 k
5 inches. There was no other family history of pre-
! R2 e0 m( l0 {, hcocious sexual development in the first-degree rela-
, C. t, n. k" |* _: \* Ctives. There were no siblings.
0 E' G1 N2 v4 h; w. yPhysical Examination8 F1 e, }) n& L( ] W
The physical examination revealed a very active,
( v7 m% o2 K+ B3 P0 \# G6 P- F% xplayful, and healthy boy. The vital signs documented" u h' Z! D. j% e. X) E/ L
a blood pressure of 85/50 mm Hg, his length was% }. @ s3 D7 b6 k& A6 U0 W
90 cm (>97th percentile), and his weight was 14.4 kg! u! U# Q; M' ]% `
(also >97th percentile). The observed yearly growth
, n6 X0 Z+ I5 gvelocity was 30 cm (12 inches). The examination of' Q# ^0 f6 i7 S) e
the neck revealed no thyroid enlargement.
d) a" {: g) \' O1 y. S! k4 eThe genitourinary examination was remarkable for
/ p1 r+ Y) u' l" M# V# denlargement of the penis, with a stretched length of0 S$ ~# e: g" w+ H
8 cm and a width of 2 cm. The glans penis was very well
& T4 e! u3 k' C! L% }; hdeveloped. The pubic hair was Tanner II, mostly around
3 n& D; G; x' Z7 ?. X540/ O" \; w9 v5 @% p7 j7 e
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; X5 N3 |/ \, F1 h. Tthe base of the phallus and was dark and curled. The, s: J2 c5 e! q" ?( R% l# _
testicular volume was prepubertal at 2 mL each.
( F# i; _' h2 @2 b0 T; yThe skin was moist and smooth and somewhat
& c: j' c$ U( R; a: Poily. No axillary hair was noted. There were no$ A: g; v* Q3 r; {
abnormal skin pigmentations or café-au-lait spots.1 u. o( C/ M/ {
Neurologic evaluation showed deep tendon reflex 2+
9 f) M2 f+ f* E. Zbilateral and symmetrical. There was no suggestion
# E2 l' `2 q- sof papilledema.6 u$ b( W+ L+ B0 W! ^
Laboratory Evaluation
9 p; h9 s' A" A! q1 R' L' H; O1 A, SThe bone age was consistent with 28 months by
5 I5 w5 Y& t- n* m4 M! `using the standard of Greulich and Pyle at a chrono-# j) U6 k S; s& N
logic age of 16 months (advanced).5 Chromosomal
( |* Q( A5 a" C, fkaryotype was 46XY. The thyroid function test
7 b0 ?8 z1 x1 f9 \6 Jshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
8 [( D' E6 z" b- [. P3 Elating hormone level was 1.3 µIU/mL (both normal).# v7 x8 b4 {: g A V8 K- S5 K* H+ Q
The concentrations of serum electrolytes, blood
. ?/ ~) j2 v3 g- c& F# a Wurea nitrogen, creatinine, and calcium all were$ N2 P" G# U9 w( p1 R5 @
within normal range for his age. The concentration; Z2 g% F/ W" T; Y: y9 n: m- k
of serum 17-hydroxyprogesterone was 16 ng/dL
* d- N; T0 P p v# P(normal, 3 to 90 ng/dL), androstenedione was 20: `) |4 J) |, d! M
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& H/ p5 N4 n" y. V# L6 a& Sterone was 38 ng/dL (normal, 50 to 760 ng/dL),6 C# A% ?3 F$ L: b+ F' ]& P
desoxycorticosterone was 4.3 ng/dL (normal, 7 to6 o! I. q$ v; E B
49ng/dL), 11-desoxycortisol (specific compound S)
- W9 T+ G2 [& ?& ]3 o' D5 ^+ Nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
! o( H5 l& G8 k0 Z8 [tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 l) ] b" B7 J9 xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
?% t+ ~! Z0 c( `and β-human chorionic gonadotropin was less than
$ B" k# _: c4 O. j' H' y5 mIU/mL (normal <5 mIU/mL). Serum follicular
" g$ d+ q" \; z; p9 sstimulating hormone and leuteinizing hormone8 s& L5 [" n' X( ?, m+ |1 c
concentrations were less than 0.05 mIU/mL+ q2 u/ L: }% Z
(prepubertal).
2 W- u/ e6 [' ^( x4 J4 ~+ R* Q2 pThe parents were notified about the laboratory
" D9 H( D; |' G+ nresults and were informed that all of the tests were
; O0 E" ]. a" z* y8 j) L" cnormal except the testosterone level was high. The
# F' B3 C+ |0 r- m5 E+ |4 B5 x% Hfollow-up visit was arranged within a few weeks to- ^. l- N9 e) P' w; H
obtain testicular and abdominal sonograms; how-4 m+ |6 ~" z4 u0 @' h
ever, the family did not return for 4 months.
$ t3 l+ Z A8 |' A+ }# w5 ^) uPhysical examination at this time revealed that the+ @" q5 V0 |: z' ^$ G
child had grown 2.5 cm in 4 months and had gained
6 m1 _- b& `0 C% r- x. P+ ?2 kg of weight. Physical examination remained& G! w4 m4 M7 G, i
unchanged. Surprisingly, the pubic hair almost com-
, c0 N- O8 h0 ~) O& O4 L* \pletely disappeared except for a few vellous hairs at
/ A. E& m8 x o4 ?1 Q, Dthe base of the phallus. Testicular volume was still 2' Q3 H( ?& ^ _/ m% }3 c
mL, and the size of the penis remained unchanged.' D2 E. J4 H. F" G, U8 a
The mother also said that the boy was no longer hav-
; N6 D6 @2 G0 [4 m2 Ling frequent erections.
3 `; g/ _' T# z* ]Both parents were again questioned about use of
& ?+ V* B Q* Gany ointment/creams that they may have applied to
/ y5 J$ t4 q/ F4 _, y; Dthe child’s skin. This time the father admitted the
* N5 D, M, g) V1 r5 c( C e1 FTopical Testosterone Exposure / Bhowmick et al 541
7 i& U E) J2 t1 z5 ~4 F5 wuse of testosterone gel twice daily that he was apply-
# e- N0 Q4 W- E3 i+ K2 @0 ~ing over his own shoulders, chest, and back area for. Q6 I5 [# g, x0 G9 E7 ]
a year. The father also revealed he was embarrassed
d3 E y0 F, r) Ito disclose that he was using a testosterone gel pre-! ?5 D2 F5 }1 s: p+ c; K, L9 C+ q
scribed by his family physician for decreased libido
7 O: }4 N1 O# I9 F% dsecondary to depression.6 d7 c$ d- C3 j/ j6 G. C' F6 V" o& i6 B
The child slept in the same bed with parents.+ V/ |5 {7 C* U* @
The father would hug the baby and hold him on his* ~6 A. T% _# [' o3 L! G4 W
chest for a considerable period of time, causing sig-
& J* g& \/ j# ^! Z1 W: {+ h* Tnificant bare skin contact between baby and father.: Z7 o( q) O P N$ d3 f
The father also admitted that after the phone call," M5 f2 Q9 p' ]' K) f, p
when he learned the testosterone level in the baby; H7 J: \, _5 r
was high, he then read the product information+ M& X9 a- u4 {3 O( H# \! H
packet and concluded that it was most likely the rea-, ?5 I/ M4 @9 u. ^+ T4 q
son for the child’s virilization. At that time, they
1 w& l J6 s# {% ~decided to put the baby in a separate bed, and the
" N6 q2 s3 U e7 X0 j; Wfather was not hugging him with bare skin and had
% l& z J, y5 s1 Zbeen using protective clothing. A repeat testosterone
7 I5 j8 n4 ]- z& R! Z% Mtest was ordered, but the family did not go to the* {0 _* ~' b2 R I
laboratory to obtain the test.
/ y% @) Y% D. M; n: S% _& R8 [Discussion% Y8 A! T- r: I
Precocious puberty in boys is defined as secondary
9 }& y. s0 ]: r" I5 jsexual development before 9 years of age.1,4% H5 y t; K; b; s' }
Precocious puberty is termed as central (true) when% U# |0 B" T, S+ t& t( e+ y6 a
it is caused by the premature activation of hypo-' ]/ [4 B. c9 U
thalamic pituitary gonadal axis. CPP is more com-
& s% O$ B3 m0 ]9 Vmon in girls than in boys.1,3 Most boys with CPP4 o/ t) t% J2 ^; m! [% V
may have a central nervous system lesion that is$ b1 o! b% ?& j2 S, @7 Z
responsible for the early activation of the hypothal-
5 B2 d: z' B# A' i3 Tamic pituitary gonadal axis.1-3 Thus, greater empha-8 _+ [+ F" C, I) h5 g
sis has been given to neuroradiologic imaging in/ i7 q- R4 r8 Z8 A* L2 H! M% \! s
boys with precocious puberty. In addition to viril-: d8 p- R, P0 G, _' {. G( {
ization, the clinical hallmark of CPP is the symmet-
8 ~, q3 j+ V3 Nrical testicular growth secondary to stimulation by
: P$ z2 F7 w4 e c9 j+ o5 Wgonadotropins.1,3
4 [& g3 `7 ^- o% \2 L: E2 q6 jGonadotropin-independent peripheral preco-
+ T# O1 h, P+ I. L$ \' [- Lcious puberty in boys also results from inappropriate
$ y+ z$ E; t1 l9 ~; Dandrogenic stimulation from either endogenous or# n, R# U" \3 ]6 \% G7 b' x& T
exogenous sources, nonpituitary gonadotropin stim-
; u# {( F- P T8 g" gulation, and rare activating mutations.3 Virilizing$ T9 ~, p& { d d: \' T5 ?" l6 L
congenital adrenal hyperplasia producing excessive) R( E5 \- C( a: t' N8 Q4 s
adrenal androgens is a common cause of precocious
6 t1 _. ?* f' upuberty in boys.3,4
; G Z: {+ ~& D6 T0 \The most common form of congenital adrenal7 d7 b0 Z: L. Q9 T9 R4 d/ c
hyperplasia is the 21-hydroxylase enzyme deficiency.; z# B/ F, s! @# s* M
The 11-β hydroxylase deficiency may also result in8 I2 P/ J0 k" a2 {
excessive adrenal androgen production, and rarely,
0 X' o* U) b: k4 J! b5 Ran adrenal tumor may also cause adrenal androgen: j2 y4 X% e9 D9 V, i+ `! ]
excess.1,3+ w# T( [( d# @8 t4 T1 O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. W6 l* d+ @% B542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, ? l& D1 W/ _/ P4 K: l% T8 vA unique entity of male-limited gonadotropin-1 C0 b! J7 P: F7 s& X' j
independent precocious puberty, which is also known
; G% o! c# l" F4 |: e7 _3 X) ^; ias testotoxicosis, may cause precocious puberty at a
* {# I6 F$ _: r3 P5 D% L- s6 t/ kvery young age. The physical findings in these boys% Z e9 I0 H, P; i8 Q/ ?* ~
with this disorder are full pubertal development,' Z, m) H+ W& ?7 V* Q
including bilateral testicular growth, similar to boys
: i. D' f }& fwith CPP. The gonadotropin levels in this disorder* V2 W* y5 {' p
are suppressed to prepubertal levels and do not show8 I0 ?6 C& e$ a5 L. n% x1 g8 x
pubertal response of gonadotropin after gonadotropin-! v. o# | v+ _: M2 c4 W
releasing hormone stimulation. This is a sex-linked
. S$ Z2 k# w( J( I9 I' hautosomal dominant disorder that affects only
/ X1 Z; ?8 V8 x* W7 Y, H7 n2 Xmales; therefore, other male members of the family3 A9 I, l# Y5 p
may have similar precocious puberty.3
" m; `+ M9 j( S" I. O3 c, o. bIn our patient, physical examination was incon-; \, U- k3 N+ q+ Z- J& r
sistent with true precocious puberty since his testi-" F: n) q. F% P/ O
cles were prepubertal in size. However, testotoxicosis
E" _& j/ Q( Z$ I, b* R5 J- rwas in the differential diagnosis because his father. u3 V7 d V$ [+ V
started puberty somewhat early, and occasionally,) Y& Z1 S6 T5 g+ H3 Q
testicular enlargement is not that evident in the3 e0 y1 [$ A1 w* Q
beginning of this process.1 In the absence of a neg-1 V0 p& {" R4 a$ u& p8 ?
ative initial history of androgen exposure, our
* O5 l% v! a# n5 rbiggest concern was virilizing adrenal hyperplasia,) S y7 [, _/ D
either 21-hydroxylase deficiency or 11-β hydroxylase' E) @ a, o2 {) ?2 J. ?; E z
deficiency. Those diagnoses were excluded by find-
" A: s7 A2 E. Fing the normal level of adrenal steroids.! J M" }/ e. h/ B# @
The diagnosis of exogenous androgens was strongly8 C* E' }& _5 }; V2 I" Z3 `! j8 s5 ?* \
suspected in a follow-up visit after 4 months because2 [) [4 S0 m& k$ U, v
the physical examination revealed the complete disap-' y5 K t$ B- t4 |% g
pearance of pubic hair, normal growth velocity, and
; {, S7 ~* f! Zdecreased erections. The father admitted using a testos-7 m% K% |5 D3 f' r2 Q% b! l
terone gel, which he concealed at first visit. He was
" V! v* z" p* Ousing it rather frequently, twice a day. The Physicians’
0 R& Y0 { \) J7 S3 h$ t; |Desk Reference, or package insert of this product, gel or
: y% X l+ Z- m+ ?; `cream, cautions about dermal testosterone transfer to; _- j7 ]$ T T* M1 C# P# H& x
unprotected females through direct skin exposure.& f9 Y% y0 `! Z# Q9 R, Q p+ |
Serum testosterone level was found to be 2 times the, p9 J4 u$ B. V8 M
baseline value in those females who were exposed to
4 X8 k! H! b9 peven 15 minutes of direct skin contact with their male
; p' b7 V* b% E+ y5 Wpartners.6 However, when a shirt covered the applica-0 T* T% n# E9 l5 P& s5 U
tion site, this testosterone transfer was prevented.
! D' `* I( f' |5 q w, _# TOur patient’s testosterone level was 60 ng/mL,
" q% J! ]/ f& B4 v# H: y8 X d/ Twhich was clearly high. Some studies suggest that- a+ o0 p# F9 x0 T
dermal conversion of testosterone to dihydrotestos-4 C0 f7 v, Q2 P) e2 w- L8 q
terone, which is a more potent metabolite, is more+ y) a D' ~# o, M& e" m% X0 S
active in young children exposed to testosterone
' ^3 m) d+ u2 S' J! ^exogenously7; however, we did not measure a dihy-
" r q$ D/ p" ]" Adrotestosterone level in our patient. In addition to, C& c: Y& u# w0 f1 G+ Z
virilization, exposure to exogenous testosterone in. J( _9 d2 \# a
children results in an increase in growth velocity and# }# T2 q$ H/ s9 L: ]( P3 t7 G
advanced bone age, as seen in our patient.
+ c4 G% x; O; {1 g1 x% qThe long-term effect of androgen exposure during
$ e' q# M3 G o9 m1 g9 \# `; I4 O% Hearly childhood on pubertal development and final
& R! }5 O A& ~; O9 Wadult height are not fully known and always remain2 B* N& l" v, `3 z3 c' O+ b
a concern. Children treated with short-term testos-
0 O; w3 e9 V( v& c" Y7 b, aterone injection or topical androgen may exhibit some! Z# h ~8 q0 k$ g
acceleration of the skeletal maturation; however, after/ d V$ w- I5 P1 a: R
cessation of treatment, the rate of bone maturation
$ r# g9 s, n1 r3 adecelerates and gradually returns to normal.8,9 c7 U& o- d0 i
There are conflicting reports and controversy9 l3 n$ k& r* p
over the effect of early androgen exposure on adult
" v9 `% k$ M* ?3 L) `penile length.10,11 Some reports suggest subnormal
" f. ~7 ]6 r% Nadult penile length, apparently because of downreg-4 }+ F3 l& A* J+ K3 A* x! ?2 w+ g
ulation of androgen receptor number.10,12 However,4 @) d& X+ M% e
Sutherland et al13 did not find a correlation between) O, V* U& a% S1 r2 u6 ^
childhood testosterone exposure and reduced adult
: b! p( _4 B f) H: jpenile length in clinical studies.0 w) Y- _; w! ~2 n4 c0 _: j: X
Nonetheless, we do not believe our patient is0 q7 b L5 `! I, M, Z2 Y
going to experience any of the untoward effects from
, a! `' ^; I4 h$ S" I. |9 jtestosterone exposure as mentioned earlier because: N M5 N6 p6 ~/ S6 o! o" A
the exposure was not for a prolonged period of time.
9 L/ j) }! [7 Z% S7 uAlthough the bone age was advanced at the time of
0 Y( Q: S8 A6 r, C* c7 h. W) Bdiagnosis, the child had a normal growth velocity at
+ }) @0 t/ I* B# u* u* ethe follow-up visit. It is hoped that his final adult
F7 Y3 @5 }- X i9 j; M8 S2 Jheight will not be affected.
3 Z4 [# l5 i3 ^Although rarely reported, the widespread avail-
6 L) _/ P( K' M5 X6 A+ Jability of androgen products in our society may' b5 u( w3 s& P9 N
indeed cause more virilization in male or female/ B7 _9 i+ q4 N( O0 _; k
children than one would realize. Exposure to andro-
2 |% D0 ]% J! P$ igen products must be considered and specific ques-
9 n" N3 j# m& s3 }$ ]0 ^; b5 g6 E/ ~# Xtioning about the use of a testosterone product or
8 D. H4 T" N7 b+ ?2 n3 t3 ]+ E5 ~gel should be asked of the family members during
p3 O6 W" s F8 }- ]' Zthe evaluation of any children who present with vir-
/ I5 q! w7 n( N8 y/ Lilization or peripheral precocious puberty. The diag-
) p" R$ [/ U$ Nnosis can be established by just a few tests and by5 c! A4 f$ h+ i
appropriate history. The inability to obtain such a
6 l1 |2 \' X, p: shistory, or failure to ask the specific questions, may9 F S& g5 @- a9 u6 X
result in extensive, unnecessary, and expensive
# n6 z( h& b5 P6 W: N4 s& cinvestigation. The primary care physician should be& V/ T* @ L( H- f
aware of this fact, because most of these children; o# s* C% ~' J. M$ W$ n2 \# }
may initially present in their practice. The Physicians’. j) w7 j2 c9 W0 K9 W
Desk Reference and package insert should also put a
9 F7 j0 ]/ q% S# O1 {5 _warning about the virilizing effect on a male or
- L- z2 J5 [, Q1 M* |female child who might come in contact with some-
$ w0 S0 c4 j9 g; _( {& K# none using any of these products.: L6 k+ j- n+ ]9 t0 _
References
( G& `+ ~" E) Q4 R& i( m! \, ~2 R1. Styne DM. The testes: disorder of sexual differentiation
* I, @: [9 x% ~, X( d0 z: oand puberty in the male. In: Sperling MA, ed. Pediatric
4 ]5 o1 Y2 Z$ m+ s. P& C L5 Y4 eEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
! u9 H6 e! A2 p3 ?# A0 p1 G2002: 565-628.
5 k/ Q% q; n& E8 S2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
; |0 g% }4 F* wpuberty in children with tumours of the suprasellar pineal |
|