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Sexual Precocity in a 16-Month-Old
8 O S% K# n$ C: u! f6 _7 xBoy Induced by Indirect Topical
" Y/ b- h. u' w0 D) I; V2 jExposure to Testosterone
( l4 B9 @$ F2 |; H, k) S3 [4 ASamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 b3 b. l) N0 S: ~$ zand Kenneth R. Rettig, MD1
: Y2 _4 ?% U" W/ VClinical Pediatrics
6 |" g; T# _0 x, L6 Z8 W& _Volume 46 Number 6
* ]& y) H* r" J7 U7 S+ ~$ T# jJuly 2007 540-543
Y& l; ~1 K) `- J2 k© 2007 Sage Publications
7 I4 ^+ I8 J2 R# E10.1177/0009922806296651
5 V$ u# s7 q9 x, x' {http://clp.sagepub.com8 ~6 J1 c9 S! ^9 M
hosted at2 c/ t8 Z& M; D
http://online.sagepub.com
& ?$ z; P- J4 O- p+ j2 Q/ \5 F( VPrecocious puberty in boys, central or peripheral,2 g0 F/ D8 u! A4 ?( \( [& |: W
is a significant concern for physicians. Central
& U* w3 H, }8 ~$ zprecocious puberty (CPP), which is mediated) P' ?7 I2 E; ?2 ^( C, t
through the hypothalamic pituitary gonadal axis, has$ O$ e! \1 V+ y% p1 ?* ]1 T( }
a higher incidence of organic central nervous system' A2 i- {3 ]4 M, t3 h
lesions in boys.1,2 Virilization in boys, as manifested7 Y: c1 ^! O- t& `% J2 e* R' O
by enlargement of the penis, development of pubic7 c! k: ~! Q4 H$ G# U2 F
hair, and facial acne without enlargement of testi-9 ~; u! D3 B: ?8 R0 W4 A$ R
cles, suggests peripheral or pseudopuberty.1-3 We
0 B4 i: S1 \7 [+ Breport a 16-month-old boy who presented with the
: \9 _2 y( [$ U, L( |; O, t6 r. venlargement of the phallus and pubic hair develop-0 K5 [. v3 W% C: T9 J/ \: s
ment without testicular enlargement, which was due
# N" @7 u1 H) i7 Vto the unintentional exposure to androgen gel used by
+ v' |4 I* B2 k0 Tthe father. The family initially concealed this infor-+ M( j% G6 M$ y5 ^ u* a5 M
mation, resulting in an extensive work-up for this
$ l9 `5 e4 H# z( }% Z" D7 Kchild. Given the widespread and easy availability of
2 v b% \0 t5 L+ n, M, v2 H% atestosterone gel and cream, we believe this is proba- z! ]) A' G5 L4 ^7 T
bly more common than the rare case report in the
2 l6 \& c6 k" b! V. Dliterature.4
4 c1 }# Y1 r. G" |Patient Report
8 x) o8 N# _& C) r! LA 16-month-old white child was referred to the( ]' I2 J/ D1 I% K; o% a. N+ Q
endocrine clinic by his pediatrician with the concern) r% m) Z% Z h7 ?) R4 E$ Y& n
of early sexual development. His mother noticed) a4 _& H( ]2 b) f
light colored pubic hair development when he was& p4 `# y+ m$ c9 i+ G* w" _( b9 t
From the 1Division of Pediatric Endocrinology, 2University of7 D/ F& T w5 A1 w% O2 s( ]
South Alabama Medical Center, Mobile, Alabama.
# V) L( r9 W g, EAddress correspondence to: Samar K. Bhowmick, MD, FACE,5 S8 D- J, E0 F) Z
Professor of Pediatrics, University of South Alabama, College of- \) j- _+ m( Q( @$ V, i W: _
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! ^7 N8 Q7 J, h* O2 R- m
e-mail: [email protected].
+ |+ P- u, M+ G& m I+ A4 Y$ Habout 6 to 7 months old, which progressively became Q0 d) d" g1 s6 J
darker. She was also concerned about the enlarge-
6 X3 L V- N6 h1 H- |/ Sment of his penis and frequent erections. The child
; R& v6 i$ r& a- gwas the product of a full-term normal delivery, with- j& F2 S+ j$ V& Y1 J
a birth weight of 7 lb 14 oz, and birth length of
s, H' R" @; b% [20 inches. He was breast-fed throughout the first year: C1 `% q$ M) r: D) N- }4 I: V- `
of life and was still receiving breast milk along with1 t; k3 r% N3 ^1 j$ L! ~0 ] M* N
solid food. He had no hospitalizations or surgery,; K9 f* ~- s" \3 P7 H4 z1 V! w
and his psychosocial and psychomotor development; t# L7 s5 F+ S7 \( I; j- r* N
was age appropriate.
+ ~* B |/ }! Z5 W8 m, ]The family history was remarkable for the father,
* f; I1 G3 C! L" @who was diagnosed with hypothyroidism at age 16,
3 L3 c# j3 m& P* C( y: U5 O8 H+ Qwhich was treated with thyroxine. The father’s- }2 s6 A( z) Q# `& a- {
height was 6 feet, and he went through a somewhat# g" [' U5 M4 @" L0 T' q9 Y
early puberty and had stopped growing by age 14.
# z$ U! K& V8 { H( S& uThe father denied taking any other medication. The
# W1 B0 [- e- o& ~child’s mother was in good health. Her menarche+ d0 {% J1 E$ g% t/ m8 ]/ f
was at 11 years of age, and her height was at 5 feet
8 l/ J0 F! }* | u9 D5 Z5 inches. There was no other family history of pre-9 G" d( T7 L5 C1 ]4 m# \" X: C
cocious sexual development in the first-degree rela-! }6 Z0 {) J2 l5 n! L3 J
tives. There were no siblings.. h+ y) P; M0 u u6 S3 `2 k* C1 y/ t
Physical Examination4 J% I+ E0 c4 g
The physical examination revealed a very active,4 b8 }2 E& ?# J* q6 v/ Q2 J# g- J
playful, and healthy boy. The vital signs documented7 s' ] A9 C' F- w. \
a blood pressure of 85/50 mm Hg, his length was
, s! ^; t! I$ `1 V90 cm (>97th percentile), and his weight was 14.4 kg
4 t1 |# M0 Y9 i9 K(also >97th percentile). The observed yearly growth
7 h# v* y, {5 N- I- ovelocity was 30 cm (12 inches). The examination of/ s) O; z4 n; f; H2 k
the neck revealed no thyroid enlargement.4 U e$ `% U/ w: }, V
The genitourinary examination was remarkable for
1 S8 S' C+ ?6 y. a5 W2 z: Zenlargement of the penis, with a stretched length of
) x( d i, U7 x1 @, g# o8 cm and a width of 2 cm. The glans penis was very well
K1 P6 u& J2 Jdeveloped. The pubic hair was Tanner II, mostly around
6 E" y& j3 d; `, e5409 q0 ?, T$ v" H6 C" f& V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 h: y6 Y8 g/ @* E" V
the base of the phallus and was dark and curled. The1 \ |6 h1 m e: X' o; S
testicular volume was prepubertal at 2 mL each.
& d$ C7 h' g1 e2 b: |7 MThe skin was moist and smooth and somewhat
' Q) f4 q1 b2 z+ H4 c/ F/ L2 `oily. No axillary hair was noted. There were no
2 M7 \1 _4 s! g; g$ W( N( v. _abnormal skin pigmentations or café-au-lait spots.0 j7 S8 n5 g6 n
Neurologic evaluation showed deep tendon reflex 2+# G) B3 |3 }- t2 {* m
bilateral and symmetrical. There was no suggestion$ d/ \( [( A! P ^$ X: K- u
of papilledema.) G" T1 ~* y; z( d
Laboratory Evaluation1 c6 p+ t9 v) z3 d8 x% S. P/ l
The bone age was consistent with 28 months by; G0 M* y% ]" P1 Z. p ~& H
using the standard of Greulich and Pyle at a chrono-0 _2 ]3 w2 h! _& c" Y5 {& ~1 v
logic age of 16 months (advanced).5 Chromosomal
- J! @ |3 _5 d, h- rkaryotype was 46XY. The thyroid function test
2 T. \. |$ U/ i* |( f2 Dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-: s# a/ S: N$ x: I
lating hormone level was 1.3 µIU/mL (both normal).
: \* g }/ ~- Z3 kThe concentrations of serum electrolytes, blood
4 E: `) N* L0 k# \urea nitrogen, creatinine, and calcium all were
% r$ u# s r. x5 cwithin normal range for his age. The concentration8 E9 n; w0 ?& G3 i' {
of serum 17-hydroxyprogesterone was 16 ng/dL
$ z* l% c; G" n" l! ]" d) n2 L3 T(normal, 3 to 90 ng/dL), androstenedione was 202 }5 z0 }1 L- D7 C5 ^
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-' u! K6 n0 ]& H* @8 b# M
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( I: f2 p# G+ U; Z8 V( d Udesoxycorticosterone was 4.3 ng/dL (normal, 7 to
( ]+ R7 Y- r1 u49ng/dL), 11-desoxycortisol (specific compound S)
- m2 Y7 D' u1 jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 |& N" w: X% E& \: h2 n
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- y# H5 \4 n6 Y+ }& {testosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 O; g0 F! k- _% [+ d" R6 {- B& ~: U, E
and β-human chorionic gonadotropin was less than
$ A% T9 `, y; x: N( s5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 Q( e! o5 w* Q& n- @0 Istimulating hormone and leuteinizing hormone; ?- C, t3 }" H) p; P% Q
concentrations were less than 0.05 mIU/mL. F6 D( Q) l4 K; [% D' n' Z
(prepubertal).2 E7 o$ d) a. D5 S* H% g E8 t; t% ^
The parents were notified about the laboratory) J0 c' q8 w4 U
results and were informed that all of the tests were) G, n! S' [8 C
normal except the testosterone level was high. The+ x1 Z: z1 c3 z
follow-up visit was arranged within a few weeks to
5 N3 _, F# }: L5 m" D8 Aobtain testicular and abdominal sonograms; how-/ v T& H \7 d9 I5 I* [
ever, the family did not return for 4 months.7 l0 g% o* u5 e. O
Physical examination at this time revealed that the+ j/ n) T1 L0 F3 R. ~1 l2 k
child had grown 2.5 cm in 4 months and had gained, ?: Q5 G. _. n& h) ?% ?6 i
2 kg of weight. Physical examination remained& W% m" M* w. b* @% O
unchanged. Surprisingly, the pubic hair almost com-) F. J: O6 S8 R; V4 @
pletely disappeared except for a few vellous hairs at% S9 w* w* o$ F: p& [9 J! B$ R( O
the base of the phallus. Testicular volume was still 2$ }0 i' r/ Z0 v( t1 g6 L
mL, and the size of the penis remained unchanged.' }' q$ ?) n7 j' ~: I. r
The mother also said that the boy was no longer hav-
$ ?& S) S/ _3 g/ T3 Cing frequent erections.1 \+ j0 ~. x4 }5 `
Both parents were again questioned about use of
/ r; c; U. l) Oany ointment/creams that they may have applied to
& }9 E8 u- D2 Ithe child’s skin. This time the father admitted the5 u' P$ {+ K0 V* H0 x
Topical Testosterone Exposure / Bhowmick et al 541
$ K8 V% |( U+ J* M7 }use of testosterone gel twice daily that he was apply-
& {* k' ]; X. u. p$ @ing over his own shoulders, chest, and back area for1 P! o1 |4 l, @% ~: N0 C
a year. The father also revealed he was embarrassed
( y% F; D3 Z4 @4 w; Bto disclose that he was using a testosterone gel pre-" Y4 Y P6 l- H4 I7 Z3 f; o
scribed by his family physician for decreased libido( Y8 Y! m; t' V# J' z) _ y
secondary to depression./ v3 Z* \6 D5 J& L7 V, ^0 i
The child slept in the same bed with parents.
2 [$ O5 n. M* }7 C- C/ M2 iThe father would hug the baby and hold him on his
$ `8 ?6 S/ }+ G3 X* o6 N: Dchest for a considerable period of time, causing sig-
6 z8 s3 C; e4 w' V* Z1 X7 m6 Mnificant bare skin contact between baby and father.
8 K9 R l( R6 Y) V( h1 HThe father also admitted that after the phone call,
* @9 @6 t! T! k# ^) N# W2 f3 bwhen he learned the testosterone level in the baby* \/ A& u# V z
was high, he then read the product information
7 C* y& L) f* P2 X: n& ipacket and concluded that it was most likely the rea-6 d4 O( }2 Z* ~9 Y
son for the child’s virilization. At that time, they
+ O& P5 z$ j) m V9 q* ~$ }decided to put the baby in a separate bed, and the1 n2 C% R m! k7 i: X$ ~% B
father was not hugging him with bare skin and had
5 }$ S* A; E) y! V4 \; p3 Bbeen using protective clothing. A repeat testosterone4 r" @6 ~* p( J. ?$ s2 j
test was ordered, but the family did not go to the
" C& |2 ~( z% dlaboratory to obtain the test.
" l" F8 c. T# B: R: HDiscussion" ~+ T6 x- Z, ^' b* Y; @& q
Precocious puberty in boys is defined as secondary! f, Y( s- N0 B
sexual development before 9 years of age.1,4/ t! @5 }! W! k: d4 [1 a' X, k
Precocious puberty is termed as central (true) when
7 l( M. m$ `4 b0 f& A0 B2 m- @4 ^it is caused by the premature activation of hypo-' a1 Q& m, Y6 }! O. t4 H3 d( m
thalamic pituitary gonadal axis. CPP is more com-
+ ?% L* k* Q1 Y+ e9 Pmon in girls than in boys.1,3 Most boys with CPP
8 e. t: ?/ w- t8 C! k5 [may have a central nervous system lesion that is/ t9 U9 B0 a: Q# e4 R w o4 X
responsible for the early activation of the hypothal-
* _7 O" z' D4 E) U) famic pituitary gonadal axis.1-3 Thus, greater empha-
. g* L- A s- t# H0 A4 v8 |% O* Fsis has been given to neuroradiologic imaging in
; `9 v8 H9 Q- \* Mboys with precocious puberty. In addition to viril-
2 E) l3 l% F) U bization, the clinical hallmark of CPP is the symmet-
9 L# @! V. n' y2 P4 y# Yrical testicular growth secondary to stimulation by. Y! Y- [! m" V1 E9 a. D; `
gonadotropins.1,3
, q7 m8 x- \* ?- h3 H' P1 t. U1 IGonadotropin-independent peripheral preco-* C6 j, ~6 Q' b- K+ t P, @# _: |& h
cious puberty in boys also results from inappropriate
6 }9 O0 _, N, b2 }0 pandrogenic stimulation from either endogenous or( ?$ G/ W( }9 ~9 v: u
exogenous sources, nonpituitary gonadotropin stim-
% P! T6 ~) D3 X. ]0 }6 hulation, and rare activating mutations.3 Virilizing
. @ N" @" |8 Z1 I1 T7 r2 Acongenital adrenal hyperplasia producing excessive9 u# p1 u- p/ _
adrenal androgens is a common cause of precocious9 \3 ?$ Y: ~; b+ r0 p# e
puberty in boys.3,4
, L% g2 J* k1 S, BThe most common form of congenital adrenal( k% ^' q; c, d' f4 F. W/ k
hyperplasia is the 21-hydroxylase enzyme deficiency. g5 ]: o) {, U) R" N
The 11-β hydroxylase deficiency may also result in" h3 d- `1 x! d2 L
excessive adrenal androgen production, and rarely,3 ?5 R' \6 a+ K5 J( h) c% b+ o
an adrenal tumor may also cause adrenal androgen! b, _6 G5 b% S! ^7 R# w( h
excess.1,3
* k0 p( t! @/ g( u7 t5 Aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. ]& @9 H3 T* c( v+ O4 M/ F: y4 [
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
\. N2 X6 k% \7 v2 i# rA unique entity of male-limited gonadotropin-
5 R2 e& |9 B, `9 V2 gindependent precocious puberty, which is also known
( L# l6 r) Q* ^5 Ras testotoxicosis, may cause precocious puberty at a0 A! M5 E# N: m4 W; @) c* ^
very young age. The physical findings in these boys8 M k7 n, ?! C7 l9 r
with this disorder are full pubertal development,% f! T& D+ x, | j. j1 F3 q
including bilateral testicular growth, similar to boys r) f$ u( ?. {
with CPP. The gonadotropin levels in this disorder
: E* H! b7 U' s; e' I% c# b. V6 Dare suppressed to prepubertal levels and do not show3 M) E7 |2 M3 K6 s3 |1 [
pubertal response of gonadotropin after gonadotropin-
# K, `! X2 E( d: r1 q3 W1 V. |releasing hormone stimulation. This is a sex-linked+ j8 h- w' s* j3 L
autosomal dominant disorder that affects only
2 L3 b. r: O* m. ~males; therefore, other male members of the family+ b& r0 T* k; g) n! D0 z8 M
may have similar precocious puberty.3. ?0 w* }6 _$ R: ?
In our patient, physical examination was incon-6 c6 C% n- ]- y4 ?6 ]/ l1 I
sistent with true precocious puberty since his testi-
- M& X" G1 a/ G, w, }8 ^cles were prepubertal in size. However, testotoxicosis
N. Y8 U3 ]: dwas in the differential diagnosis because his father6 I4 D* u \0 a7 Y
started puberty somewhat early, and occasionally,$ h2 N5 b7 O* y& t0 C
testicular enlargement is not that evident in the
: j' z3 f& m$ G4 G* A# r cbeginning of this process.1 In the absence of a neg-
6 _% j! X% i; f! N- q" ?ative initial history of androgen exposure, our
- i1 q# U- K5 {. ?1 j" Gbiggest concern was virilizing adrenal hyperplasia,
2 F/ X3 g Q% M2 ]: jeither 21-hydroxylase deficiency or 11-β hydroxylase* j; e/ Q+ K; e' \
deficiency. Those diagnoses were excluded by find-0 j$ f/ U, Q7 a& a6 @
ing the normal level of adrenal steroids.& E: t d# \1 d4 j g* r4 S8 H
The diagnosis of exogenous androgens was strongly# C6 p: ]1 X( A) }: e+ u
suspected in a follow-up visit after 4 months because: n6 ?0 w$ a; [$ g/ g; E/ Q" o
the physical examination revealed the complete disap-
2 ]( Z( m/ m( F% ~pearance of pubic hair, normal growth velocity, and
6 b! Y3 z, A# h6 G8 E& s5 `decreased erections. The father admitted using a testos-
. R; ~0 G4 d5 o0 ~' wterone gel, which he concealed at first visit. He was+ P; L& Q; {9 E" B. ]) p
using it rather frequently, twice a day. The Physicians’( ]9 f0 t6 U- f
Desk Reference, or package insert of this product, gel or" D, r6 p* z. n' u( @$ e
cream, cautions about dermal testosterone transfer to
/ k$ I* s+ x6 ^8 S# T4 }unprotected females through direct skin exposure.2 s8 J. A" w- h! V! V" C: J: L
Serum testosterone level was found to be 2 times the
; m! p- `2 I, `2 A* Lbaseline value in those females who were exposed to3 a5 ]: S4 [6 D9 v) @7 g8 w
even 15 minutes of direct skin contact with their male
4 P8 {# V+ \! b; @9 ~9 U* L6 fpartners.6 However, when a shirt covered the applica-
3 }, b2 y0 `3 s; t( x1 ltion site, this testosterone transfer was prevented.
~( } x, {7 vOur patient’s testosterone level was 60 ng/mL,7 |; d5 r3 F' i0 ?7 U
which was clearly high. Some studies suggest that2 d( i/ A0 r8 a0 ~, d+ c* `
dermal conversion of testosterone to dihydrotestos-5 Y6 ~0 ?/ c _" W4 i
terone, which is a more potent metabolite, is more
& @4 l2 Y0 h3 y1 }8 _* zactive in young children exposed to testosterone
5 x5 x m3 u% t% l$ Iexogenously7; however, we did not measure a dihy-. z) p7 O% b8 U6 h- m( r
drotestosterone level in our patient. In addition to1 \$ Y* s9 H f) U$ U* _- r
virilization, exposure to exogenous testosterone in8 f/ T; V+ E) n& d6 w$ T! y
children results in an increase in growth velocity and
6 A6 M y$ ]/ a( Radvanced bone age, as seen in our patient. b, {5 F M4 l9 i9 I9 I
The long-term effect of androgen exposure during/ B r9 E9 E. F# U3 z3 J
early childhood on pubertal development and final
9 w+ {, t9 q0 e: k; ?0 v" ~& {5 q' ]adult height are not fully known and always remain
) N, L5 _# q- d% y; _9 K" ]a concern. Children treated with short-term testos-
9 e7 x% ~! ]( D$ dterone injection or topical androgen may exhibit some9 \; g7 F O/ g
acceleration of the skeletal maturation; however, after4 i% A; y' W& K9 m* N) X
cessation of treatment, the rate of bone maturation1 K0 O/ M: a# r) [7 \5 [3 |2 c% @ _
decelerates and gradually returns to normal.8,9+ g- u6 Y( ]6 I" W8 I. B% `
There are conflicting reports and controversy
E) e$ Y9 B5 `. ^0 nover the effect of early androgen exposure on adult% X% s, d& p) |, y; J6 F
penile length.10,11 Some reports suggest subnormal, ?, m; d* g' u9 B" {
adult penile length, apparently because of downreg-8 g: Z( c* k' D2 D; ]
ulation of androgen receptor number.10,12 However,+ Z' j0 O0 @; Z; [& ?6 u0 i0 Q
Sutherland et al13 did not find a correlation between
* f" G1 ]. T4 ?) `5 mchildhood testosterone exposure and reduced adult6 Y# }7 l1 g7 d7 T i
penile length in clinical studies.* D% v) B7 Q# J) b
Nonetheless, we do not believe our patient is* i# V/ `+ j9 C/ ^8 I3 [& H' T2 w
going to experience any of the untoward effects from
6 _. X2 i. x& P2 o0 o3 Xtestosterone exposure as mentioned earlier because9 |# S3 ^( k2 p* |+ b$ ^4 l& ?
the exposure was not for a prolonged period of time.
4 y2 ~: t( m5 b7 \# x/ aAlthough the bone age was advanced at the time of
$ p0 F. k, D2 f& v pdiagnosis, the child had a normal growth velocity at
o3 a# s, b3 e7 b, ^5 u1 U- j) `the follow-up visit. It is hoped that his final adult
1 o- |7 P% I: Q; M9 W0 V3 U# ?height will not be affected.- z8 d9 {& E* S9 z) M6 D8 X) o e- [6 Y
Although rarely reported, the widespread avail-* M; g1 s9 @8 j" A/ {$ i& \5 S, E; N
ability of androgen products in our society may
: w+ a% \ ^# s+ Q4 W% I kindeed cause more virilization in male or female
( r* C$ `/ l# V; qchildren than one would realize. Exposure to andro-) m6 p$ z7 o a
gen products must be considered and specific ques-
( M8 Q& F; _3 ?- P7 ^tioning about the use of a testosterone product or& e, o, @# _3 ~! L* q
gel should be asked of the family members during
$ S& w9 v( c" r( h9 v4 I$ cthe evaluation of any children who present with vir-+ s6 T( q( B/ R& m! T9 w9 [4 n# U
ilization or peripheral precocious puberty. The diag-
1 W. J, ~7 Z" A8 M1 E0 O+ A& enosis can be established by just a few tests and by
9 o% ^6 h2 a) ~9 u( B, V6 _appropriate history. The inability to obtain such a
1 @7 q0 @8 B3 Yhistory, or failure to ask the specific questions, may& d8 A7 V3 Q( B2 d& q
result in extensive, unnecessary, and expensive2 g( D2 S; F$ v9 k& y6 [3 Z. Y3 f
investigation. The primary care physician should be0 Z9 H. c8 r( l+ z- U+ J
aware of this fact, because most of these children
/ {5 i+ L$ a- `3 r1 Xmay initially present in their practice. The Physicians’* {" F9 R" G/ n' E7 n
Desk Reference and package insert should also put a
; T/ O- I; f1 _$ owarning about the virilizing effect on a male or
. v% `6 S' E* y+ w2 s. A3 efemale child who might come in contact with some-
! i! V; O9 b1 ~$ E/ None using any of these products.* e8 L/ p. C/ t) L7 }
References
) h( p. y/ C5 `( a$ J1. Styne DM. The testes: disorder of sexual differentiation& L6 r$ H+ ~. s; f, W& U, n% e
and puberty in the male. In: Sperling MA, ed. Pediatric
3 A. L' }# \" n( DEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 F& X+ P% y' L2 [3 @2 J- t2002: 565-628.
, f1 z2 M' K8 S9 u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% a# Y6 L' d* S7 f; G7 `
puberty in children with tumours of the suprasellar pineal |
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