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Sexual Precocity in a 16-Month-Old
, ^+ A* j8 A' zBoy Induced by Indirect Topical8 W5 j) i- {, Y/ s& J
Exposure to Testosterone% v; B' d% [' B5 T& T1 D. A0 w. B
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" O* n( Q- b2 k* Z3 f" f( Z' nand Kenneth R. Rettig, MD1
# l6 X$ A& I) D3 G1 pClinical Pediatrics' r, x. [# S v) e0 p n0 `
Volume 46 Number 6( i) V% L& W5 r; M' J \
July 2007 540-5432 M5 |8 p* k5 | u6 K4 ]
© 2007 Sage Publications* v- E" P2 M% k+ a
10.1177/0009922806296651
# q/ G0 ]% O j1 t5 a/ Bhttp://clp.sagepub.com5 h1 `- q7 |3 M7 |! T5 u
hosted at
" Z. c6 E$ {+ U" C/ J! B! a; g4 @3 Chttp://online.sagepub.com
7 {4 k, Q" s* W& N& {5 v$ yPrecocious puberty in boys, central or peripheral,9 B) c/ r" e1 I3 Q
is a significant concern for physicians. Central
) w7 q4 Z6 Y% b* Z. k2 U# eprecocious puberty (CPP), which is mediated) s) x! v. \4 p# Y
through the hypothalamic pituitary gonadal axis, has
) c8 ~5 U+ R9 D0 da higher incidence of organic central nervous system
2 n* o# F. k+ R6 @6 Q3 elesions in boys.1,2 Virilization in boys, as manifested
5 U# E0 [* w$ m2 V* m& L, F0 y4 D& vby enlargement of the penis, development of pubic
( j+ ?; K, u" U1 g2 x; T Z$ M+ [hair, and facial acne without enlargement of testi-6 g% r7 _) c" ]# o
cles, suggests peripheral or pseudopuberty.1-3 We
) |: x! f' Z9 z8 a0 Zreport a 16-month-old boy who presented with the
7 y$ o1 i; g \: ienlargement of the phallus and pubic hair develop-2 b" H& ]4 c( U; W7 G; M4 h$ k
ment without testicular enlargement, which was due- u! O# Z" ?: r& N0 r9 X4 j8 s& h7 G
to the unintentional exposure to androgen gel used by
& x- V8 s! Z0 N! e" `/ _; b2 P1 Y1 U" Sthe father. The family initially concealed this infor-$ i3 B' y) l. N, @( `
mation, resulting in an extensive work-up for this
& U# l7 J8 @/ r. H0 Y& O: Hchild. Given the widespread and easy availability of5 I6 k# k' U% b# m6 q9 s& e) e% G
testosterone gel and cream, we believe this is proba-! w* _$ c! N& l( \
bly more common than the rare case report in the- @2 ~; v2 F$ Z$ q, L$ e
literature.4, x1 H8 A f" D' m2 T
Patient Report0 n& @: `0 o2 K0 d1 G
A 16-month-old white child was referred to the
$ Y) L( i9 d3 C0 `; v6 @endocrine clinic by his pediatrician with the concern4 B2 \4 Q( L7 n T( \3 L
of early sexual development. His mother noticed
; Q) ^. V' J$ e0 L% ^% Jlight colored pubic hair development when he was
: F/ e, z$ `) e1 S% `From the 1Division of Pediatric Endocrinology, 2University of9 ?4 m9 u' w* ?4 x o
South Alabama Medical Center, Mobile, Alabama.
$ z4 i# h! T) p0 @/ E9 v+ x) Z( gAddress correspondence to: Samar K. Bhowmick, MD, FACE,
. j( E4 Y2 g4 T' x$ J# K3 rProfessor of Pediatrics, University of South Alabama, College of& L5 c8 P5 f- F; {% f1 V2 M
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 ~$ P4 o n/ u7 z" w
e-mail: [email protected].
9 A' h m" Z. `8 M: iabout 6 to 7 months old, which progressively became& l$ R4 t4 a. a% w" O
darker. She was also concerned about the enlarge-( b. S \& z6 a, w
ment of his penis and frequent erections. The child
3 W8 e) j; \1 O# L4 B) y& G0 o- uwas the product of a full-term normal delivery, with, }9 i# R% d8 [) I& S2 W9 G: e8 @
a birth weight of 7 lb 14 oz, and birth length of
7 ~. D3 K1 U% T) s0 \7 b4 I: p* f20 inches. He was breast-fed throughout the first year4 n: X" d; m, X$ |* ?0 J( \
of life and was still receiving breast milk along with! W* U. V$ g2 @+ U D+ L
solid food. He had no hospitalizations or surgery,& |& F. Z5 {/ h' z% }5 X
and his psychosocial and psychomotor development. d: \- B7 a- Y! w9 A" C
was age appropriate.
# ^$ M1 `" f8 Q0 M" x2 ]* FThe family history was remarkable for the father,
+ f( q c2 e( q Twho was diagnosed with hypothyroidism at age 16,
1 t6 S2 V8 m t6 c( [$ twhich was treated with thyroxine. The father’s
$ F/ c/ u2 ?$ ^3 Q: y6 Nheight was 6 feet, and he went through a somewhat
4 M# d/ L7 R( h/ Eearly puberty and had stopped growing by age 14.
4 v% A Q C+ ZThe father denied taking any other medication. The. ~& r& `, |6 o: { e, {
child’s mother was in good health. Her menarche. p( ~* z) N+ |6 J L8 i* ^& t3 k
was at 11 years of age, and her height was at 5 feet
8 W9 z" I+ g* T! T! y$ W5 inches. There was no other family history of pre-; A- W2 o8 j. S1 r) x
cocious sexual development in the first-degree rela-
2 h! @4 `$ i2 B3 R9 b5 Ltives. There were no siblings.8 o% J# k' ~, F
Physical Examination; Y" n+ w6 H1 L. d
The physical examination revealed a very active,
8 h# } q9 _: P- h& gplayful, and healthy boy. The vital signs documented7 ^* u2 S1 _5 f3 E9 w
a blood pressure of 85/50 mm Hg, his length was
- r0 g- M' b: O" d90 cm (>97th percentile), and his weight was 14.4 kg
% A* A: ?. k& C- S W2 U: t% @(also >97th percentile). The observed yearly growth$ L. o6 [: w+ b
velocity was 30 cm (12 inches). The examination of; s( a" t3 c, l' X2 P
the neck revealed no thyroid enlargement., b+ i% e5 a4 U+ W, W
The genitourinary examination was remarkable for- O. `* ^8 z& `3 s- r7 _
enlargement of the penis, with a stretched length of
: I0 |* W$ ^# |8 cm and a width of 2 cm. The glans penis was very well7 f) F0 o! V% L2 u2 @! E7 O1 T( W
developed. The pubic hair was Tanner II, mostly around. I& l. P& o; R; \0 P& r& J& C( J2 k
540
" D( w% W9 ]* O7 @at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" f$ l$ O3 z0 F6 ^
the base of the phallus and was dark and curled. The
( @# W# p, r$ D& J: H2 ttesticular volume was prepubertal at 2 mL each.% Q# W4 T. R' e, n8 F- k$ t
The skin was moist and smooth and somewhat
+ b% h) z$ Z: o7 k! q4 ooily. No axillary hair was noted. There were no* J; d# b( T7 o" p$ ]
abnormal skin pigmentations or café-au-lait spots.# E4 g5 }+ |- Z) _' I1 h
Neurologic evaluation showed deep tendon reflex 2+
2 t1 t* \0 m' rbilateral and symmetrical. There was no suggestion
! l; q1 F$ s3 J2 Qof papilledema.
1 l( A6 ]6 k: \! E0 i) _- c5 H1 ^Laboratory Evaluation
0 x7 p( C7 u) a b! l& ~+ ?+ ^The bone age was consistent with 28 months by8 Q4 [1 r, R* o3 _# D+ V7 Z; n F
using the standard of Greulich and Pyle at a chrono-/ g6 ?8 a5 d2 O0 ~
logic age of 16 months (advanced).5 Chromosomal5 O) w2 M, V; b: ?* X
karyotype was 46XY. The thyroid function test
4 C, [" F; J ?$ C/ y6 x3 Zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 l s( H, x/ }" E7 v! m9 r2 B' t: V, |$ Y
lating hormone level was 1.3 µIU/mL (both normal).( \6 ~( z. m% ?$ ]4 n1 U
The concentrations of serum electrolytes, blood
. h2 g0 l+ B r' _3 lurea nitrogen, creatinine, and calcium all were# y8 d& P3 P$ e* Y$ c
within normal range for his age. The concentration
) [6 k4 {/ m( s9 }of serum 17-hydroxyprogesterone was 16 ng/dL! e _* C( n# O: ]) g
(normal, 3 to 90 ng/dL), androstenedione was 20
9 ?9 z; h- ~7 Kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ o( E8 O/ a/ P8 `* O+ v/ j; Fterone was 38 ng/dL (normal, 50 to 760 ng/dL),
5 e9 s/ [! H* pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ M* a1 f/ H3 I5 p) B49ng/dL), 11-desoxycortisol (specific compound S)7 K- t: H6 U- Q1 [5 o
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) ?0 j0 K) r! ]6 v, f
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 t" f6 v" u) V* f2 @: }! d
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
2 Y$ C: S9 @, {and β-human chorionic gonadotropin was less than! h. U1 ^3 y- T- M1 f$ L/ v
5 mIU/mL (normal <5 mIU/mL). Serum follicular G4 Q5 h) j$ y1 C7 i. O4 Q
stimulating hormone and leuteinizing hormone" ?/ C, G# e3 u) y9 U9 y
concentrations were less than 0.05 mIU/mL
s, z) I9 K- z0 u9 a) v9 o/ e(prepubertal).0 s( d+ i0 e+ X0 D
The parents were notified about the laboratory2 I5 F+ K5 p2 n0 `! Y5 o
results and were informed that all of the tests were
. t2 J. G" D6 q8 d/ r, h' jnormal except the testosterone level was high. The) S# g) j- Y- h! Q+ N% J; l% T5 K
follow-up visit was arranged within a few weeks to9 b; l3 A2 }( x) `) H# j
obtain testicular and abdominal sonograms; how-& ~7 q/ _9 k9 m( }5 o. @
ever, the family did not return for 4 months.
1 P: H8 l6 j* n5 |) [Physical examination at this time revealed that the
- N3 W- M$ E7 G- cchild had grown 2.5 cm in 4 months and had gained4 h: O) p% ^% ?- X- H
2 kg of weight. Physical examination remained- E, n3 @' P3 L6 k: O% @+ l
unchanged. Surprisingly, the pubic hair almost com-
- ^/ N% \% Y0 L& q9 z1 q( w) rpletely disappeared except for a few vellous hairs at/ m0 ^9 k; P" U3 W
the base of the phallus. Testicular volume was still 2) N. M9 f0 n! L3 R# l* d
mL, and the size of the penis remained unchanged.
5 `) S' ?( \) s+ {- [The mother also said that the boy was no longer hav-6 K( z' z' }( ]7 h0 v( j
ing frequent erections.% s6 Y6 Z% R! y2 _& }; P8 E. {
Both parents were again questioned about use of
8 W+ ~& W( }4 z& {any ointment/creams that they may have applied to, H! k; v" E& z
the child’s skin. This time the father admitted the* J5 f4 t# Y8 @ ?9 T9 F
Topical Testosterone Exposure / Bhowmick et al 541
8 v3 b& l4 j: Duse of testosterone gel twice daily that he was apply-7 V' I5 v& ], }& {, l
ing over his own shoulders, chest, and back area for4 P, e5 K/ i6 r1 |
a year. The father also revealed he was embarrassed
+ x H( V {/ zto disclose that he was using a testosterone gel pre-
, t$ k0 A: G. ~! ~6 [& \( cscribed by his family physician for decreased libido% d. P* v" ]. S6 b, g
secondary to depression.
7 R5 g b: x5 T, [4 n* kThe child slept in the same bed with parents." q9 L/ y8 i; X0 L$ d' ^
The father would hug the baby and hold him on his' J" }* M, M& X7 f, g7 Z
chest for a considerable period of time, causing sig-9 o( j7 B! b' p+ g# M
nificant bare skin contact between baby and father.
) G, @0 O6 L) ~* W3 V' U0 tThe father also admitted that after the phone call,
+ D; L. R) }7 B: Y" Q" L! \when he learned the testosterone level in the baby2 y) s2 H7 H8 ^( C7 u+ ?
was high, he then read the product information
8 Q- l- `# M2 L/ Npacket and concluded that it was most likely the rea-
6 m' C( p& F0 M9 r: J* J4 Fson for the child’s virilization. At that time, they( C( } }3 }# n9 g2 G6 @, X+ n
decided to put the baby in a separate bed, and the
K* ]5 L* w0 N& k3 rfather was not hugging him with bare skin and had
( g- N+ p- G- f- g7 Nbeen using protective clothing. A repeat testosterone+ y$ E# l. A3 h
test was ordered, but the family did not go to the
$ t- ?. \) K5 K. a( p5 H, O, Q( Vlaboratory to obtain the test.
0 g" h+ m% x; K9 e7 v) fDiscussion" R6 j& }0 L% \& F; l
Precocious puberty in boys is defined as secondary1 u- J# x- {4 L1 {8 e) N
sexual development before 9 years of age.1,45 z$ S9 g6 _# H0 e6 b
Precocious puberty is termed as central (true) when7 j# t0 W' o( s/ Z. ]
it is caused by the premature activation of hypo-# d" A1 W; @8 Z2 F2 p& O
thalamic pituitary gonadal axis. CPP is more com-& g7 p2 a! H: z
mon in girls than in boys.1,3 Most boys with CPP% O9 b! R p/ J6 ~8 n6 s" C! @
may have a central nervous system lesion that is: r% h# ]- ^" N" D: g0 Y/ S4 y, c
responsible for the early activation of the hypothal-
3 a: w/ g+ y, n3 R5 q& Ramic pituitary gonadal axis.1-3 Thus, greater empha-
( q7 k) @% M ksis has been given to neuroradiologic imaging in
" X8 w5 x1 [- mboys with precocious puberty. In addition to viril-
9 g2 e9 ]$ t' V" ]9 p, Bization, the clinical hallmark of CPP is the symmet-
4 |4 k$ w9 p' U* ]- }6 U+ B( \7 Trical testicular growth secondary to stimulation by5 a" @6 k6 v) X2 I
gonadotropins.1,3/ z! n0 \ V! k% F+ c6 Q
Gonadotropin-independent peripheral preco-( K B! ?+ _) u" o b
cious puberty in boys also results from inappropriate
5 r' A" U5 m/ ~4 M2 r' Nandrogenic stimulation from either endogenous or' J* u! Q' R' `( S
exogenous sources, nonpituitary gonadotropin stim-' D0 A/ t1 F: r) ^3 M; y
ulation, and rare activating mutations.3 Virilizing
5 R6 t$ b& [9 [$ S6 G& ycongenital adrenal hyperplasia producing excessive8 h# i8 ^/ J2 ^
adrenal androgens is a common cause of precocious
. N* h. m5 j' V7 V6 kpuberty in boys.3,4% T- s6 E5 U% o' B7 L: H5 E
The most common form of congenital adrenal
" A- g- _7 T) C6 c& n" dhyperplasia is the 21-hydroxylase enzyme deficiency.
' E: [' z& F) X7 ?7 g1 ~1 HThe 11-β hydroxylase deficiency may also result in0 |& B; e/ @- i8 e6 F. y
excessive adrenal androgen production, and rarely,$ r* [3 g: R& ^
an adrenal tumor may also cause adrenal androgen d3 q, L$ O4 O2 L8 U
excess.1,3
% e r* F& a' N7 Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 M" K0 l0 u# N' z7 }7 _6 K
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, H9 T- o# W T. j5 |
A unique entity of male-limited gonadotropin-& v0 Q5 G$ i: C) F4 H- [# K
independent precocious puberty, which is also known9 k! u4 _6 U6 z* }/ `3 R- H
as testotoxicosis, may cause precocious puberty at a
6 q6 X" P9 Z' W( h% d! d4 L* Vvery young age. The physical findings in these boys# h" A7 v% W0 p) c: A
with this disorder are full pubertal development,
+ H4 J, ^/ ~# R& D/ \. q1 oincluding bilateral testicular growth, similar to boys
" y7 M4 g7 M" U% I3 f1 _with CPP. The gonadotropin levels in this disorder3 L/ }5 }: t3 v+ `3 D! f
are suppressed to prepubertal levels and do not show, q) L4 s4 M A& Q" i; {
pubertal response of gonadotropin after gonadotropin-
/ x0 L V. x( c/ sreleasing hormone stimulation. This is a sex-linked
9 z7 x, ~3 | qautosomal dominant disorder that affects only9 @9 q, J: k6 O0 f3 p! m( V8 m
males; therefore, other male members of the family
# U+ t1 o# \( \3 m! D U; b* Jmay have similar precocious puberty.3- j) s9 v1 B$ y4 P' O0 ], a: o
In our patient, physical examination was incon-$ P9 x7 @ g4 a% b
sistent with true precocious puberty since his testi-1 B" d& I" I6 z8 c* O$ ^, d
cles were prepubertal in size. However, testotoxicosis/ m2 A4 [5 X: G! w$ r. o. Z# U: v
was in the differential diagnosis because his father
9 ?* f) v; a( d& ]# B; tstarted puberty somewhat early, and occasionally,
$ N5 Y0 E5 U% p" E6 K% ~testicular enlargement is not that evident in the
$ E% V! U' Z4 ~. k+ e8 H, Vbeginning of this process.1 In the absence of a neg-' D3 E7 p! \2 B2 _, h
ative initial history of androgen exposure, our
, \3 [. H% K- O" N$ o7 c, e3 o/ kbiggest concern was virilizing adrenal hyperplasia,! x, u, `& p0 ?& b3 I/ I; m" D
either 21-hydroxylase deficiency or 11-β hydroxylase
; Y6 q8 J' Y- J7 {0 S \5 Cdeficiency. Those diagnoses were excluded by find-
- [( C0 b# F3 v i+ \& ging the normal level of adrenal steroids.
$ s5 v" k4 d" G% R! X1 C: YThe diagnosis of exogenous androgens was strongly0 A& r; s: s9 z" V, t5 ~7 ?
suspected in a follow-up visit after 4 months because
$ i2 F; V2 q. @$ Y, u2 F1 Tthe physical examination revealed the complete disap-+ C m! S9 F- S! J& ^
pearance of pubic hair, normal growth velocity, and; a$ N( L2 u( |% x' d& P% a* a7 ?
decreased erections. The father admitted using a testos-
( q, ~! \ a4 {$ S. @9 U7 o( l2 Vterone gel, which he concealed at first visit. He was
: a( E$ }) [# x+ i# A/ susing it rather frequently, twice a day. The Physicians’6 j4 O6 l3 a4 g# u! `- j3 c
Desk Reference, or package insert of this product, gel or
6 E6 ]+ s, N& a# w5 ~$ X4 ?& kcream, cautions about dermal testosterone transfer to8 Q- s7 q4 Y: j
unprotected females through direct skin exposure.- q/ s9 S7 P( X$ v) l" X) N
Serum testosterone level was found to be 2 times the
& @- R5 @. O' |; A2 g8 q) ebaseline value in those females who were exposed to
, T: d, [8 A3 N3 Ieven 15 minutes of direct skin contact with their male
' g$ y8 \( R% a) e" @partners.6 However, when a shirt covered the applica-
5 G, _6 w$ d L' X8 S3 dtion site, this testosterone transfer was prevented.
6 r, e" W3 ^: Y9 dOur patient’s testosterone level was 60 ng/mL,- Z4 y6 `5 g; |! O4 `
which was clearly high. Some studies suggest that4 B$ P4 P1 ^- j* Z: Z" S
dermal conversion of testosterone to dihydrotestos-
% [- r, G4 s* f8 _3 {terone, which is a more potent metabolite, is more
4 b: R) ~. s6 Y1 T% factive in young children exposed to testosterone& O7 R& S" j3 }' e! ^: B6 P
exogenously7; however, we did not measure a dihy-
. L2 I; a8 y# ]5 L$ vdrotestosterone level in our patient. In addition to
$ q! f8 W) H) l/ r- p( H. k5 wvirilization, exposure to exogenous testosterone in: @) g* a5 f8 V3 S( s
children results in an increase in growth velocity and
7 x" \, O @" q' a5 w* {advanced bone age, as seen in our patient.0 V! E9 i. U0 m' v w6 o
The long-term effect of androgen exposure during
; G* |. t) L7 \ \! W$ E/ @early childhood on pubertal development and final4 K+ {! S2 r* k* |
adult height are not fully known and always remain7 R- b! e! `; a+ S9 R# U4 @' l! Z( T
a concern. Children treated with short-term testos-# l8 f' r: ]- w4 a# Q
terone injection or topical androgen may exhibit some
# R( F# I& ~" _& F9 H1 ~0 M( _acceleration of the skeletal maturation; however, after6 T( W+ A0 l. O; r: |
cessation of treatment, the rate of bone maturation0 y" k! t1 ^8 W& J' k6 t
decelerates and gradually returns to normal.8,9, f( x R$ e7 g* G! C! f) Z' F
There are conflicting reports and controversy
! V' ]: a- N% w l- Oover the effect of early androgen exposure on adult5 t) f) |3 o5 t: V [: s
penile length.10,11 Some reports suggest subnormal" T: Q. K% N3 ^& v
adult penile length, apparently because of downreg-$ G i0 b* S9 S# v. I# ?. U s
ulation of androgen receptor number.10,12 However,0 ~" v% ?' r0 R$ [. M
Sutherland et al13 did not find a correlation between
7 Y6 w+ K* `% Q# y1 mchildhood testosterone exposure and reduced adult/ Y3 {. Y9 P1 T. Z
penile length in clinical studies.
* _* a! _8 m4 }2 i6 _: aNonetheless, we do not believe our patient is1 x# l; z6 U, C' Z/ k6 n: P
going to experience any of the untoward effects from; [7 V$ _+ g) x- X% Y9 Q
testosterone exposure as mentioned earlier because
! }6 c% U7 O, [4 ]2 ?the exposure was not for a prolonged period of time.1 H X% `% K$ t7 c
Although the bone age was advanced at the time of
+ ~5 g9 O) ]7 `0 n0 kdiagnosis, the child had a normal growth velocity at) p) S, {/ r& U# d4 A1 ?
the follow-up visit. It is hoped that his final adult- i$ @7 t, f1 ]: r$ o2 c) I
height will not be affected.
( w& V( A6 w, _Although rarely reported, the widespread avail-" w: ~1 B' M6 c- ?% V6 c$ z! O
ability of androgen products in our society may- r' I- F' Z( @4 K, ]( p# v( K
indeed cause more virilization in male or female; b* |* @8 l3 j: F6 f9 f; X
children than one would realize. Exposure to andro-
" t! b/ F* j q' k: J6 R6 y! G" E* igen products must be considered and specific ques-
( T2 t2 P) Y2 y+ E$ t. [4 _% ^tioning about the use of a testosterone product or7 m8 L# Q y- w4 i: \5 }. m
gel should be asked of the family members during& w6 o" @" Q5 a" g8 m. \
the evaluation of any children who present with vir-
6 }! l% o6 v9 D( @. C% ?2 u& uilization or peripheral precocious puberty. The diag-9 w2 l$ k9 K- h Z: K9 R
nosis can be established by just a few tests and by, A) r6 W8 h1 @7 i0 E
appropriate history. The inability to obtain such a
( e: X5 o4 O5 O! ]1 chistory, or failure to ask the specific questions, may
8 Y+ m s: N3 D. |8 C) `- O# X6 Aresult in extensive, unnecessary, and expensive
. x7 O# V4 ?1 y. J9 G* Q* O6 ginvestigation. The primary care physician should be
( R1 Q; @2 v; g- y% z, haware of this fact, because most of these children* X; x+ q6 D5 K) Q# e" [! `
may initially present in their practice. The Physicians’$ Q1 K& [% B" w( C/ q+ W6 Z0 X
Desk Reference and package insert should also put a
( C- k. V; i9 ]( A5 Swarning about the virilizing effect on a male or
, b; Z* s: C* l& g+ `female child who might come in contact with some-
" |+ G# [! s" e/ L. [3 G8 E; H4 M: Eone using any of these products.6 }2 S% _ x9 O8 c6 r
References
' Z8 a+ A- B4 D7 `, {8 i1. Styne DM. The testes: disorder of sexual differentiation
' P; a# @: ^$ F% Zand puberty in the male. In: Sperling MA, ed. Pediatric* C# {& ]* T( [& ~2 `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
" G0 ~* Y$ q, H# V2002: 565-628.
* s( C5 @* f2 ~% H1 h1 }2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
: c& h1 F9 L5 ]( Qpuberty in children with tumours of the suprasellar pineal |
|