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Sexual Precocity in a 16-Month-Old' x) N# h* Z0 `6 b& N8 I; g) o. R
Boy Induced by Indirect Topical
, b# C' l' D" @5 ^* K1 S* \Exposure to Testosterone- r7 j. ?5 y: \2 A& }, }
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
% ]* H: y) [0 f5 i$ } fand Kenneth R. Rettig, MD13 y5 c5 h) U/ E/ j4 m% C1 ~. q
Clinical Pediatrics
+ w7 M3 s5 ^, Q! s5 \ a0 GVolume 46 Number 6' Y* j6 L' h4 q( Z) k# f
July 2007 540-543
! f+ ~6 P, M8 t$ ?& `3 {© 2007 Sage Publications
4 ^8 O7 w4 V5 O. w10.1177/0009922806296651
' P" T2 N$ w- M$ M# J- Uhttp://clp.sagepub.com0 u$ Y! \, A* o. n% e2 ?- E. O
hosted at; W. `- O/ e0 S: W% w
http://online.sagepub.com. l3 l1 X$ E4 L9 f! W2 a4 C
Precocious puberty in boys, central or peripheral,6 B I# x+ D* l
is a significant concern for physicians. Central0 i" ?9 q8 k. h- F0 h3 d
precocious puberty (CPP), which is mediated" V; ?8 O/ ], z; Q( }. b/ G( X
through the hypothalamic pituitary gonadal axis, has
$ i8 R; j4 t2 T& Va higher incidence of organic central nervous system9 O+ I$ j8 B1 d& V! `1 z; m
lesions in boys.1,2 Virilization in boys, as manifested
s6 O7 ~; w' P7 X1 H- }by enlargement of the penis, development of pubic
. h: ~" V! e, M3 ehair, and facial acne without enlargement of testi-8 n% j6 m; g4 p* R' m3 `+ E, N3 c
cles, suggests peripheral or pseudopuberty.1-3 We$ y, t; {2 L* x6 V* d
report a 16-month-old boy who presented with the
! w' X4 L: ?5 }3 m: N# {% Renlargement of the phallus and pubic hair develop-4 Y4 H: W8 a. [1 W" t
ment without testicular enlargement, which was due; W4 i9 q* _/ e& i8 U
to the unintentional exposure to androgen gel used by" l6 q% J% p2 W
the father. The family initially concealed this infor-
& m' u8 s1 g8 `6 @mation, resulting in an extensive work-up for this
) g) |, i% }* e/ t+ W) p) schild. Given the widespread and easy availability of3 k2 m; z$ t! u+ Y
testosterone gel and cream, we believe this is proba-
1 T: z; H. p/ L+ Lbly more common than the rare case report in the
. A6 E1 f* V5 vliterature.4
1 `- H' }, A5 P6 l& Q0 J, PPatient Report
- l) X# Z [& s" U7 e0 ~! XA 16-month-old white child was referred to the
' i1 ?. ?2 x* b5 N1 U' x, _) sendocrine clinic by his pediatrician with the concern) F# |. d8 o' f/ C$ t1 [
of early sexual development. His mother noticed
) i, M- x8 M) A2 wlight colored pubic hair development when he was
3 h# v% L8 O% U2 E" UFrom the 1Division of Pediatric Endocrinology, 2University of& p9 f; y0 i6 {5 ]
South Alabama Medical Center, Mobile, Alabama.8 K# O& h, L$ \, i
Address correspondence to: Samar K. Bhowmick, MD, FACE,
# ]. c7 B: B+ X1 B( _ u# wProfessor of Pediatrics, University of South Alabama, College of
3 ~# F* i! h9 b# [$ ?" ~Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ u6 W" o* a j& |% Xe-mail: [email protected].4 n0 m3 R( Q- d- n" {# F1 f
about 6 to 7 months old, which progressively became
D) y$ D u( b$ M4 U/ edarker. She was also concerned about the enlarge-$ j6 g+ }; h0 r7 _
ment of his penis and frequent erections. The child- o3 e$ b" h F& f$ H9 x6 [4 p
was the product of a full-term normal delivery, with
, A. q0 ]: ^: c da birth weight of 7 lb 14 oz, and birth length of- G# \; C, p; a
20 inches. He was breast-fed throughout the first year. b7 K/ H# N, X6 y
of life and was still receiving breast milk along with
( V+ i- P# p6 i3 K7 Qsolid food. He had no hospitalizations or surgery,4 O/ b$ \% Q' B) U3 V7 d/ D5 T+ i
and his psychosocial and psychomotor development
" o; |7 t% A. l0 _was age appropriate.1 S$ G& x \, F1 R
The family history was remarkable for the father,
$ j) f- r$ o! d" b/ nwho was diagnosed with hypothyroidism at age 16,
" @" z& o' y3 W- G# C3 l- bwhich was treated with thyroxine. The father’s* C; C& p. c# y; e9 Y
height was 6 feet, and he went through a somewhat+ ~$ ?. A' A+ P8 r; ]
early puberty and had stopped growing by age 14.
2 [! E: O+ E6 L- ], CThe father denied taking any other medication. The
5 L+ G" _7 I% O# T+ N2 w7 bchild’s mother was in good health. Her menarche# c- f$ j/ w9 P& y# T$ U
was at 11 years of age, and her height was at 5 feet6 s; ?0 J1 W: L H1 u9 A2 S0 P
5 inches. There was no other family history of pre-" n$ u8 C- W/ C5 \5 a9 T8 k. e& n
cocious sexual development in the first-degree rela-
. g4 E+ D9 H t# O$ Ltives. There were no siblings.. [: @4 N2 n0 ?$ }. G- G
Physical Examination5 a( p d5 F$ z' {1 A+ k; B
The physical examination revealed a very active,+ v4 ?8 [8 n1 |' h6 P
playful, and healthy boy. The vital signs documented
- j2 y$ C; Q! K5 o+ k( ^1 c1 I& f( @a blood pressure of 85/50 mm Hg, his length was
, D. \( H0 C/ Z! u' A6 [90 cm (>97th percentile), and his weight was 14.4 kg6 k Z3 o5 r4 W# g8 w( }( L4 s
(also >97th percentile). The observed yearly growth
- j. {% Z' \) y' S# x/ j1 [velocity was 30 cm (12 inches). The examination of- I8 D6 v6 v+ J+ t* B) y% i
the neck revealed no thyroid enlargement.6 Q/ e) k$ U5 b0 Z3 E4 g
The genitourinary examination was remarkable for I1 D7 u, _7 G- d6 E1 O% Z
enlargement of the penis, with a stretched length of
# t( @ }4 U( z) r( T8 cm and a width of 2 cm. The glans penis was very well2 E1 U1 k/ B7 ~ l9 B- B! p f
developed. The pubic hair was Tanner II, mostly around
4 s7 J! Q" S, ~540/ N8 t' a7 K8 @& i, c* W8 j" B6 k
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the base of the phallus and was dark and curled. The+ e* D' U6 }9 P3 i, O
testicular volume was prepubertal at 2 mL each.; a# o* h+ S$ u# v/ S; L9 J/ d( w
The skin was moist and smooth and somewhat
( I0 E7 m' b% y/ E* Eoily. No axillary hair was noted. There were no+ q* @8 F/ u: T+ S6 e0 D8 n
abnormal skin pigmentations or café-au-lait spots.
! x$ c8 H# Q. V& n3 f4 y& ~: xNeurologic evaluation showed deep tendon reflex 2+
$ w% q1 F% l0 P/ T; c3 k( _! ebilateral and symmetrical. There was no suggestion
9 N; Q, h: E8 Xof papilledema.& p- a: V! u$ N/ Y% Q
Laboratory Evaluation
4 C& ?8 c l b2 I& l& HThe bone age was consistent with 28 months by8 G# O1 k' Z& [7 M5 m( i
using the standard of Greulich and Pyle at a chrono-. c' D% V/ y0 S) l5 P
logic age of 16 months (advanced).5 Chromosomal
. s9 \( |: S' }/ p2 D" b' b' Kkaryotype was 46XY. The thyroid function test
+ l0 J( d3 Z, v% }showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. ?) E& q/ E. p% I! N0 Olating hormone level was 1.3 µIU/mL (both normal).
1 j0 E2 k; Y7 Q: @& c v3 VThe concentrations of serum electrolytes, blood& p- y- @" z$ f7 F& _9 A& J
urea nitrogen, creatinine, and calcium all were
1 Z1 e: G( e0 E0 S$ |9 ?( p8 ^, Owithin normal range for his age. The concentration6 z1 y9 L1 O0 e) H: W
of serum 17-hydroxyprogesterone was 16 ng/dL
- c% G: |+ D0 C$ w- c(normal, 3 to 90 ng/dL), androstenedione was 20
W6 ]5 v' c, ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
. y+ C r) q( m" P4 S3 T- {/ }terone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 k* e; C# L/ l- Edesoxycorticosterone was 4.3 ng/dL (normal, 7 to4 y' j, g& l' R6 s
49ng/dL), 11-desoxycortisol (specific compound S). L+ e+ \5 X' ^4 C
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( z% j. Q3 m; G) p0 R' C4 W: z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& B2 o( x$ m! [% I$ W& W6 Ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 i) d- k# X: c; \' l8 v/ @
and β-human chorionic gonadotropin was less than
# T9 t+ y5 S9 O" O9 v4 x: v+ X2 r. M5 mIU/mL (normal <5 mIU/mL). Serum follicular
: x) n( O5 a- g% Y& N2 b* l/ u( M0 \stimulating hormone and leuteinizing hormone
8 N+ S, U. @$ o* Uconcentrations were less than 0.05 mIU/mL/ Z2 e$ Q; l4 U# l
(prepubertal). }6 \! `) Y, }+ c2 }) T
The parents were notified about the laboratory
, i' a% p; y6 F. }results and were informed that all of the tests were
* t; p1 g }( t; `8 hnormal except the testosterone level was high. The
7 y2 e( Z- Q& |; nfollow-up visit was arranged within a few weeks to
* N) w# X' H/ r* y. q6 x$ fobtain testicular and abdominal sonograms; how-
) i1 t: ?8 v3 a" y8 e( wever, the family did not return for 4 months.
/ @7 j) d* r! LPhysical examination at this time revealed that the
# d9 }; R7 Y& @child had grown 2.5 cm in 4 months and had gained, G* `' @8 x# i
2 kg of weight. Physical examination remained' |# p" t4 a, y
unchanged. Surprisingly, the pubic hair almost com-! |* |1 [' |7 Q" M
pletely disappeared except for a few vellous hairs at
6 {" q$ i/ Z' A# S' `. n. uthe base of the phallus. Testicular volume was still 2
1 R9 g2 C8 M0 `& C& [. `* OmL, and the size of the penis remained unchanged.
, x `4 O& T8 L& Q+ {The mother also said that the boy was no longer hav-
C, X; F' a+ B3 C; i2 p6 k0 D1 R8 _ing frequent erections.3 i3 C1 U/ Y9 [- T- q5 @/ [1 c
Both parents were again questioned about use of
: ]7 { }5 }$ A4 @any ointment/creams that they may have applied to+ u6 y; G0 X0 ?( b% x& e# Y, ?
the child’s skin. This time the father admitted the0 M6 k* |+ ~/ K$ j. G8 J
Topical Testosterone Exposure / Bhowmick et al 541
4 p: t, ~1 V5 }# P9 ^& j, W6 Puse of testosterone gel twice daily that he was apply-
# V% w- W6 ~, W e. q5 i1 ^8 \4 N. Aing over his own shoulders, chest, and back area for; e7 {' |/ m g9 M+ a Q9 n
a year. The father also revealed he was embarrassed
+ i/ T0 c. o0 M p) Dto disclose that he was using a testosterone gel pre-
# ^6 l( X5 E; i9 s P2 escribed by his family physician for decreased libido0 F) E# b* \6 Z: e8 r
secondary to depression.( r3 S7 {) V$ B; c! }
The child slept in the same bed with parents.9 @6 l% ?; Q* M1 _$ B; [7 [
The father would hug the baby and hold him on his
( {5 m( Y5 l% _% lchest for a considerable period of time, causing sig-/ K/ \- ]- ~! }
nificant bare skin contact between baby and father.
- P! J1 A/ w6 kThe father also admitted that after the phone call,6 S$ A4 L/ B- Y, B
when he learned the testosterone level in the baby M+ z% ~) ~) c5 g$ b! t# M
was high, he then read the product information" b5 b$ T9 S9 Z$ [" u
packet and concluded that it was most likely the rea-' v2 C" g; P5 B% e3 G1 Z
son for the child’s virilization. At that time, they4 J6 B" B; D4 G$ k e9 M! F
decided to put the baby in a separate bed, and the+ l8 Y% S% g7 [1 K' S- a% `& f
father was not hugging him with bare skin and had9 z0 ~1 v( j/ b4 _1 S2 N
been using protective clothing. A repeat testosterone/ O6 f# g" L2 i; _
test was ordered, but the family did not go to the
- [+ N1 ~9 E! v' ]laboratory to obtain the test.
) _ ^7 q# t& I9 ~6 ?- C& {Discussion/ s( J# `8 b8 h2 ^1 D+ f6 ?0 j# W; l& l
Precocious puberty in boys is defined as secondary' Z5 m: j4 L6 S* N1 t
sexual development before 9 years of age.1,4
' `* Q+ i$ ?6 R* y; sPrecocious puberty is termed as central (true) when3 H) g9 p3 y+ a6 O( X
it is caused by the premature activation of hypo-
" x3 e, U K- y$ W/ D9 F) h+ Uthalamic pituitary gonadal axis. CPP is more com-
* ]9 ~0 @; B9 z% U- E. G3 k+ Imon in girls than in boys.1,3 Most boys with CPP9 S! D. E# X; X' D/ R, U
may have a central nervous system lesion that is
% U7 `7 V" D, Kresponsible for the early activation of the hypothal-9 m; @% J @$ S* v
amic pituitary gonadal axis.1-3 Thus, greater empha-& I5 E& N" ` b
sis has been given to neuroradiologic imaging in
5 O4 q( e7 t2 X* t R+ N5 Cboys with precocious puberty. In addition to viril-0 P" K0 V- b" d3 a
ization, the clinical hallmark of CPP is the symmet-
2 C; i) N" M# S1 drical testicular growth secondary to stimulation by) ~( r$ u- K8 b. L
gonadotropins.1,3' {5 o# k& t4 Y
Gonadotropin-independent peripheral preco-( Z, |, b" _0 ~6 f, ~" m& A
cious puberty in boys also results from inappropriate$ E7 V+ R' X3 ~3 b
androgenic stimulation from either endogenous or
- p8 B3 K- o$ C. S7 S# dexogenous sources, nonpituitary gonadotropin stim-
% D& N6 Z" ~) {' hulation, and rare activating mutations.3 Virilizing
0 u3 \ |5 }$ A. A' H" u5 V8 _congenital adrenal hyperplasia producing excessive; Y1 f8 T2 p. G
adrenal androgens is a common cause of precocious' S3 S2 _/ ]7 _+ }5 h9 K! I! r
puberty in boys.3,4
3 E6 V; J- @9 X+ U7 V, \, dThe most common form of congenital adrenal' R1 t; K8 [* J1 p8 N, D0 d
hyperplasia is the 21-hydroxylase enzyme deficiency.6 k* e& v4 ~5 O. C$ {/ I+ o
The 11-β hydroxylase deficiency may also result in
/ q- s2 M2 N9 V8 R- l; p* F6 L3 Cexcessive adrenal androgen production, and rarely,3 l) L$ u2 ^- e3 Z, y; q) y6 F+ f- G
an adrenal tumor may also cause adrenal androgen* f9 W4 v- O) H: m6 e2 ^ D
excess.1,3) b4 Y* @! E7 t/ w. o
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& [. j. o$ z `# j
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, ~8 O2 Q* q2 t1 @# L& f
A unique entity of male-limited gonadotropin-
! s( h- O/ p$ Lindependent precocious puberty, which is also known
z: j/ N7 _6 O- _. V1 m9 g" E! n/ Eas testotoxicosis, may cause precocious puberty at a! ^3 v: @4 h0 m9 F% | V* N
very young age. The physical findings in these boys
; w/ T$ D" R, v$ B5 d3 ~; P/ @with this disorder are full pubertal development,
+ \8 ]6 R/ m& a# j: M- fincluding bilateral testicular growth, similar to boys' |4 R* S* J2 c! Y1 b- L/ V
with CPP. The gonadotropin levels in this disorder
# D3 v. z5 }5 o( Sare suppressed to prepubertal levels and do not show- T2 L% C/ X7 l8 }4 Y
pubertal response of gonadotropin after gonadotropin-
- z9 m9 O& R/ \9 H$ Vreleasing hormone stimulation. This is a sex-linked4 }4 F3 ^3 |) v
autosomal dominant disorder that affects only* g* T. `1 A6 o6 b: f
males; therefore, other male members of the family% U, s. Q$ {/ r% @6 A, I
may have similar precocious puberty.36 X2 D# P2 z6 Y/ W3 ?" A& y. @9 S
In our patient, physical examination was incon-' G( Z- y1 d+ @% C! c! t# K! {
sistent with true precocious puberty since his testi-
4 ^" Y- ~ W5 M+ j9 N, F; ]; ecles were prepubertal in size. However, testotoxicosis
0 v3 p" d' p( v+ v! _& {' nwas in the differential diagnosis because his father
- N, Y1 R' O4 ~' d9 hstarted puberty somewhat early, and occasionally,
2 q% n x$ H: e, Itesticular enlargement is not that evident in the
/ D. N* `4 T- C6 W7 F+ T6 i pbeginning of this process.1 In the absence of a neg-
/ H! q# i4 a- e! I7 H( k8 z* Gative initial history of androgen exposure, our" [8 `' d5 s3 a" k* _
biggest concern was virilizing adrenal hyperplasia,/ Z5 y& T1 L' G& B
either 21-hydroxylase deficiency or 11-β hydroxylase0 C: t- Q+ P2 i4 ~4 H
deficiency. Those diagnoses were excluded by find-& Y0 c1 |/ t; D. O- r9 H8 Z
ing the normal level of adrenal steroids." {) A6 }- \0 q/ o1 J" L6 V3 g2 ~/ S
The diagnosis of exogenous androgens was strongly
9 D, i- B* ^3 I: q5 i5 asuspected in a follow-up visit after 4 months because
) t* O: y1 i7 b; Jthe physical examination revealed the complete disap-
3 }$ a. b9 J* Epearance of pubic hair, normal growth velocity, and
1 ?1 }3 Q+ k7 m( D1 adecreased erections. The father admitted using a testos-
# o7 T+ \4 l; q# x6 iterone gel, which he concealed at first visit. He was
6 }, d/ i% Q4 O, Gusing it rather frequently, twice a day. The Physicians’8 s# r4 V0 }% q* H% }7 h# G! M% Q
Desk Reference, or package insert of this product, gel or- K; q" r5 f. b% t- Q/ J" _6 n
cream, cautions about dermal testosterone transfer to0 G! h7 x( e, R9 G, u t( A
unprotected females through direct skin exposure.
) m! `8 T! e# R( S* ?/ G& X) M* CSerum testosterone level was found to be 2 times the5 v K' l* v B
baseline value in those females who were exposed to
% D) j8 R$ U* I- u1 s* yeven 15 minutes of direct skin contact with their male! t. t$ h! v5 G \, h9 A! D' v
partners.6 However, when a shirt covered the applica-
: k2 Z* R/ r: T5 C# d2 Qtion site, this testosterone transfer was prevented.
" ?& X, \8 U' N- uOur patient’s testosterone level was 60 ng/mL,
6 U1 g, ]) |+ G( T3 wwhich was clearly high. Some studies suggest that9 m# s3 a. _9 O
dermal conversion of testosterone to dihydrotestos-
. D" t8 F3 s# }terone, which is a more potent metabolite, is more$ y2 d \: @. s7 O* t5 S8 J
active in young children exposed to testosterone4 H# O% E4 \0 I" n3 v! N) {/ P
exogenously7; however, we did not measure a dihy-
' A4 H4 F0 h9 Z2 V- A' W3 Zdrotestosterone level in our patient. In addition to
3 o( q X2 \3 ~& |virilization, exposure to exogenous testosterone in# y; E! t, b" L5 Q
children results in an increase in growth velocity and j! z* q- t" s; l
advanced bone age, as seen in our patient.
- K" e P* D3 yThe long-term effect of androgen exposure during
; M3 t1 A2 H n* r1 @- m* ^- Z6 {5 Zearly childhood on pubertal development and final
. p/ y S; @# S# h" r Jadult height are not fully known and always remain K, L- v: |5 v- N3 i# M
a concern. Children treated with short-term testos-
L4 Y: E5 R2 T6 }terone injection or topical androgen may exhibit some
! ~& O$ {; E* f5 Y" _: }" nacceleration of the skeletal maturation; however, after2 W! r# P, S3 y
cessation of treatment, the rate of bone maturation
% A: i3 R- D) S; z% kdecelerates and gradually returns to normal.8,9! y0 B$ {, D$ h$ [# n2 }4 W
There are conflicting reports and controversy6 B; B% h1 E; R, P( e C; e% Q
over the effect of early androgen exposure on adult! t8 j$ ?4 r2 x
penile length.10,11 Some reports suggest subnormal
3 I' X K+ }, G- K4 @+ @adult penile length, apparently because of downreg-
: }) F4 y, I4 |# Q7 l3 `ulation of androgen receptor number.10,12 However,9 C- V7 Y1 k# O" T, i; P, }
Sutherland et al13 did not find a correlation between
! U( u9 @4 ~/ u8 R! K1 Ochildhood testosterone exposure and reduced adult
: d2 d# ^3 F) f. K4 F7 Epenile length in clinical studies.
+ e3 h. Y$ |* U4 q5 \- ]- PNonetheless, we do not believe our patient is
H3 O/ I" l* m8 D! @2 \: n) {' Y- G7 ^going to experience any of the untoward effects from1 a% e; j m- c( C8 c. H- Z/ F) \0 ?
testosterone exposure as mentioned earlier because
# L# v7 H* _; v# ~+ U) Wthe exposure was not for a prolonged period of time.
; l$ S+ | ?2 j0 g( ^9 QAlthough the bone age was advanced at the time of
" y4 A% J) |3 \, udiagnosis, the child had a normal growth velocity at& T* h6 c- E) | w/ H: R' ^4 o
the follow-up visit. It is hoped that his final adult
1 _ E: a% I: H, Fheight will not be affected.
" B& a( I% [0 i3 H# A7 FAlthough rarely reported, the widespread avail-
( G' }& b1 e. T Nability of androgen products in our society may
8 m8 U# b9 u( B6 Q( V7 q+ n5 U5 ~indeed cause more virilization in male or female3 G' J2 V% v+ E
children than one would realize. Exposure to andro-
6 N( t$ x5 ?1 R. V igen products must be considered and specific ques-
, Z. e' q1 K$ y! W8 vtioning about the use of a testosterone product or7 M9 `& `$ b' e+ E
gel should be asked of the family members during$ ?( ?7 T w* \! Q9 |, c
the evaluation of any children who present with vir-
( z: p1 Y. N9 W5 _( ~6 |3 ?; Ailization or peripheral precocious puberty. The diag-# {3 m" P7 f( r) e) D
nosis can be established by just a few tests and by
( Z3 w m, ^, H% r: Iappropriate history. The inability to obtain such a/ G9 A5 u7 ~2 g4 g: i; d* t
history, or failure to ask the specific questions, may
$ k* G. t( K2 |- G4 Iresult in extensive, unnecessary, and expensive
% V. y6 k4 B! Z2 f5 M0 Tinvestigation. The primary care physician should be G4 i4 r# y1 b# e$ C& y8 W
aware of this fact, because most of these children3 j* g$ d7 ?- y/ w
may initially present in their practice. The Physicians’
. w+ F( B: l( cDesk Reference and package insert should also put a5 F9 A' Y0 U3 m2 g% q2 _0 V2 L
warning about the virilizing effect on a male or2 k7 G' z4 t. d
female child who might come in contact with some-
% ^) U- F+ @ T1 [& i8 Mone using any of these products.
3 W6 a2 ?# y! pReferences5 ]# ^5 V" D' {) {* m+ v4 Y0 j' r
1. Styne DM. The testes: disorder of sexual differentiation
' V5 r0 r7 y' F' dand puberty in the male. In: Sperling MA, ed. Pediatric2 o$ [& [: a" Z% U& s8 `, k
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- \. ~4 Y8 d4 G' G7 a, M* {. u1 r# K2002: 565-628.
& Z0 s( u' T G, [/ X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& E; M D- }7 B6 Epuberty in children with tumours of the suprasellar pineal |
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