- 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-Old
9 v$ d& ^9 X' f! }Boy Induced by Indirect Topical9 E+ i5 ~( ]9 F0 r3 f, A' i0 R
Exposure to Testosterone
2 J/ ]- O9 y% p- W* ZSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
K; B9 T( W5 Yand Kenneth R. Rettig, MD1& @0 Y7 X2 G% d0 Q1 K9 {
Clinical Pediatrics H- [1 G$ v( p* M! @
Volume 46 Number 6
" s1 x, l# o1 ~) N$ T) kJuly 2007 540-543. r6 r% O/ ?# w4 x1 F. @
© 2007 Sage Publications$ ], r- Q: O7 a% E% E8 J4 N
10.1177/0009922806296651
- r/ m: v$ h3 J G$ bhttp://clp.sagepub.com+ [5 e: L( d/ ~5 Q: g T9 B
hosted at
) q1 U" T8 G& W+ d6 phttp://online.sagepub.com$ f# w" C2 v8 b' O
Precocious puberty in boys, central or peripheral,, R) b% L4 q# \/ [4 E K
is a significant concern for physicians. Central7 g9 z$ W2 ^5 j
precocious puberty (CPP), which is mediated; A, ?) X) _; o Q: m: t! Q' }4 u
through the hypothalamic pituitary gonadal axis, has
4 H; n* q; }' J0 E! Y1 P8 Sa higher incidence of organic central nervous system
4 t+ s- c# M4 \, glesions in boys.1,2 Virilization in boys, as manifested0 B# x4 X5 N) m/ u1 I3 J1 j0 D
by enlargement of the penis, development of pubic* L' k; I4 ]3 K% E* X
hair, and facial acne without enlargement of testi-4 w1 d9 z4 z* e7 ~! e% J9 O J
cles, suggests peripheral or pseudopuberty.1-3 We
/ v2 G* ] C7 I$ R: e( a, D5 T5 freport a 16-month-old boy who presented with the
; M* S) H0 D' _0 @. X" U' tenlargement of the phallus and pubic hair develop-
5 F5 M2 }2 Y2 S- Tment without testicular enlargement, which was due
) A, T5 D- c; P/ uto the unintentional exposure to androgen gel used by' ^* ?: n, K9 V; I
the father. The family initially concealed this infor-0 V( b3 h: S5 c2 w$ r7 T' g
mation, resulting in an extensive work-up for this% j& D, S6 {4 ], R( r, F L
child. Given the widespread and easy availability of1 J5 @3 N' U& N& Y' f
testosterone gel and cream, we believe this is proba- s1 F( C3 w4 ?' J* c' ~/ g/ t+ f
bly more common than the rare case report in the j. k1 o! m6 [( q3 `
literature.42 O8 Y; b& _ `: r
Patient Report
S( _" l4 V% q+ x# b8 V/ tA 16-month-old white child was referred to the, M/ a% D) ?- y/ x. D
endocrine clinic by his pediatrician with the concern
2 w: f/ a/ Q2 @* e5 c/ I' X8 s/ Wof early sexual development. His mother noticed' F, |: s h5 ~$ H2 r# C
light colored pubic hair development when he was; v$ [/ {; |, {+ o: x% R5 |
From the 1Division of Pediatric Endocrinology, 2University of
- I% j, v! _2 i% O8 k% _0 @7 USouth Alabama Medical Center, Mobile, Alabama.3 M2 c2 S2 B( d( z$ i: e K9 @8 S
Address correspondence to: Samar K. Bhowmick, MD, FACE,. e9 {, c# f7 b7 s% ~1 W
Professor of Pediatrics, University of South Alabama, College of m+ O8 ?( a. a. }% m$ w) B
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- b, d7 u- Y W1 `* A4 U% x& v
e-mail: [email protected].4 c; u; ~# K) L4 L" a, o3 _3 {
about 6 to 7 months old, which progressively became; p: ]* N& m" H5 t. Z
darker. She was also concerned about the enlarge-% [: u4 U& L$ T5 F, F
ment of his penis and frequent erections. The child
; L% R! B1 D0 a9 d+ a8 Swas the product of a full-term normal delivery, with/ s6 g' Q# C X- r; u
a birth weight of 7 lb 14 oz, and birth length of
. u" t4 O7 p4 c: c) ]3 p: j* Q" J6 N( B20 inches. He was breast-fed throughout the first year
( }' ?* m8 r8 e. i; B; z/ W$ i1 gof life and was still receiving breast milk along with
6 Q6 [% w+ l- _; `solid food. He had no hospitalizations or surgery,8 i# n5 ?: T: r( F9 x, a
and his psychosocial and psychomotor development, o. q2 d! `4 {: B- s5 d& Z/ k1 ]; T3 {
was age appropriate.8 }% r8 M& l# q# R% X: @
The family history was remarkable for the father,- z5 p% v, w1 c& O+ b' r5 O- o
who was diagnosed with hypothyroidism at age 16,
- ^1 \4 I9 L/ Xwhich was treated with thyroxine. The father’s( H4 q t5 c+ V
height was 6 feet, and he went through a somewhat
5 A4 Y% Y8 ^5 x9 r1 O5 _early puberty and had stopped growing by age 14.
. Q% j( n9 q# K0 c% vThe father denied taking any other medication. The
6 G+ W' E1 i9 b, t3 gchild’s mother was in good health. Her menarche7 w$ X( M1 J6 k' Z: k% e) S1 A+ n+ J
was at 11 years of age, and her height was at 5 feet M8 c6 B( N7 E! l
5 inches. There was no other family history of pre-
: |' V( K9 o$ d4 R" l ^cocious sexual development in the first-degree rela-2 @ x) O$ b" l
tives. There were no siblings." |& \. ^" e% s. O3 p: o L& t9 G
Physical Examination
6 ~. n0 G1 B9 i& QThe physical examination revealed a very active," s& \( Q6 L+ \8 r
playful, and healthy boy. The vital signs documented! G# E7 p8 W4 l5 @9 t. M
a blood pressure of 85/50 mm Hg, his length was2 k9 n9 N8 m; t8 V: C9 f3 c% ^
90 cm (>97th percentile), and his weight was 14.4 kg7 r( t/ H& t) P( Z9 R- w
(also >97th percentile). The observed yearly growth
9 P9 x! Y' F, Z* L' |; b& J* Pvelocity was 30 cm (12 inches). The examination of: s+ {" s! s, x7 J( ^& I/ d. Q
the neck revealed no thyroid enlargement.! b" n( S# z# I4 K0 w6 a) p
The genitourinary examination was remarkable for
" v% ?5 a' J7 y5 {3 R- senlargement of the penis, with a stretched length of
4 r% Y, v) d1 c8 s# Z8 cm and a width of 2 cm. The glans penis was very well5 I7 T) X9 P7 e
developed. The pubic hair was Tanner II, mostly around
6 e7 t8 \. F. w% A$ x540
, P& v! x( Z5 u% aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" T( i' y( V, t0 R2 F' _0 w; Gthe base of the phallus and was dark and curled. The
4 ^/ ]- b# z8 F/ M6 S- X2 Otesticular volume was prepubertal at 2 mL each.
/ C* A) w. a8 Y$ u7 x% K6 oThe skin was moist and smooth and somewhat
1 ]6 s$ ^( z3 w+ Hoily. No axillary hair was noted. There were no+ ~, q$ V; P8 P$ R. {" X; \
abnormal skin pigmentations or café-au-lait spots.
0 R4 j4 Z5 m m, R5 v4 I+ k5 U7 yNeurologic evaluation showed deep tendon reflex 2+
6 |5 m) ~# y* c& pbilateral and symmetrical. There was no suggestion
/ p( m3 ^& j# d( Gof papilledema.
' ]( E7 Z# R0 oLaboratory Evaluation
2 A: L5 y8 |) M v* T9 ]The bone age was consistent with 28 months by
1 U+ E: A0 y6 K9 z" Musing the standard of Greulich and Pyle at a chrono-1 G3 `2 [& q* N. F! s
logic age of 16 months (advanced).5 Chromosomal8 T$ P2 ]( @# [5 a0 ^
karyotype was 46XY. The thyroid function test; ?% ]4 o8 `5 {" I1 Y1 ?" V6 X: p
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. e0 u! }0 s* ]! P3 r' Llating hormone level was 1.3 µIU/mL (both normal).0 ^, N6 R( D8 Q+ v) W4 z' }( e1 L
The concentrations of serum electrolytes, blood
1 j0 W1 y- [3 murea nitrogen, creatinine, and calcium all were/ z# m. W0 a. J: d s
within normal range for his age. The concentration
! Y5 c' R. s: D9 c& Aof serum 17-hydroxyprogesterone was 16 ng/dL
4 x* h7 o9 t& U" }! _5 U2 G+ H3 \(normal, 3 to 90 ng/dL), androstenedione was 20% J; Y: N0 Q6 h& ?# n3 s
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% C: u8 [+ T, K5 I* v- c) @& m
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
4 h4 W: E, L. H- Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to
! G5 @; j1 `& A$ b# V+ [8 y49ng/dL), 11-desoxycortisol (specific compound S)3 m% e5 R- D9 w/ C( D- u- O
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-1 ~. ]- U3 V# l, r# h
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 E! {6 b- H4 f% p* V$ q5 b% y- X
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
K$ C1 G% c4 @- O% Q- c, ]and β-human chorionic gonadotropin was less than" B5 w. |5 B2 w: n9 ?
5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 [3 a2 c+ j% P# f1 G2 R; [stimulating hormone and leuteinizing hormone
$ f* k' t1 @9 O% @' o b2 i Wconcentrations were less than 0.05 mIU/mL
3 w; ]8 u: @! h3 Q% ?- B- ~(prepubertal).
5 y% A+ l/ m+ s: @The parents were notified about the laboratory
! [+ R* U8 b( g1 v" A, ~results and were informed that all of the tests were
- @2 u j6 n& `9 I$ Jnormal except the testosterone level was high. The; m, \, m* v1 I& J1 ]/ C! S
follow-up visit was arranged within a few weeks to- v9 X$ D5 `1 F' o. |$ Q
obtain testicular and abdominal sonograms; how-( Z: ~. V! p" A+ k
ever, the family did not return for 4 months." E" \/ X" O# n( @9 ^
Physical examination at this time revealed that the% p3 g" N2 L7 o% i7 I, t% w0 |
child had grown 2.5 cm in 4 months and had gained7 J% n% `. C: A2 e6 x- B! t' C+ Y
2 kg of weight. Physical examination remained
" D8 {$ f4 n' ^. m6 j4 E4 wunchanged. Surprisingly, the pubic hair almost com-
5 w* h! \. s9 x- y1 q- Zpletely disappeared except for a few vellous hairs at
3 J4 D3 r3 c, Athe base of the phallus. Testicular volume was still 22 V8 R4 S( |' o0 t; G* O6 W6 p$ C! s
mL, and the size of the penis remained unchanged., W: k9 c( E" a9 Y
The mother also said that the boy was no longer hav-
- G. G0 f P% i. {, ling frequent erections.
* \6 |' J" l7 a" [5 r( gBoth parents were again questioned about use of! {0 N* Q( e" u) s; O4 H- L
any ointment/creams that they may have applied to
1 r( A3 c) T) B: Ithe child’s skin. This time the father admitted the
3 M3 }$ ~& x1 C/ ETopical Testosterone Exposure / Bhowmick et al 541
' R' ]2 ^' [) I+ F+ d& Z' suse of testosterone gel twice daily that he was apply-
/ O8 z+ \( {* M& W* j! E. uing over his own shoulders, chest, and back area for2 H8 Q# d% R$ l8 B
a year. The father also revealed he was embarrassed5 w$ C$ m- i, {( C* u
to disclose that he was using a testosterone gel pre-" {; T4 S# t* [5 M6 W
scribed by his family physician for decreased libido
s0 m7 l, D2 P6 F" W+ a$ M. v: s7 t- r3 zsecondary to depression.! h; V1 S2 ?4 e& h H! L
The child slept in the same bed with parents.
" G# |+ ~8 z' kThe father would hug the baby and hold him on his
' @5 u+ ~" C6 y9 ~chest for a considerable period of time, causing sig-! l7 q# s/ [/ s0 I/ O! J) z& X
nificant bare skin contact between baby and father.
+ q X5 a* Y3 v6 j- w# n, {The father also admitted that after the phone call,
' g8 P# U, A6 [ t9 Pwhen he learned the testosterone level in the baby! U' b! E; M4 F0 W' X, M( i D
was high, he then read the product information
% R Y6 l5 {; N5 |packet and concluded that it was most likely the rea-
0 i& F2 x0 h6 j( q {son for the child’s virilization. At that time, they& [7 Q. [" D" d
decided to put the baby in a separate bed, and the
: T- l* L# S0 F, L0 v- s* Ffather was not hugging him with bare skin and had; N) n3 C$ @5 d) E9 v
been using protective clothing. A repeat testosterone
! w0 M; @' G% r" F" G* xtest was ordered, but the family did not go to the6 n3 z5 _0 R9 Q3 e+ ^5 C5 N
laboratory to obtain the test.. H! v$ Y/ ^5 O6 v
Discussion
7 x. A. Y# M; U$ ]( F, s' EPrecocious puberty in boys is defined as secondary( v, R4 _- {0 H$ R1 n
sexual development before 9 years of age.1,4
$ r" n0 V. D3 Z1 Q, A4 k6 \Precocious puberty is termed as central (true) when
- h; T6 g' A; }1 z& L$ qit is caused by the premature activation of hypo-
: K0 \: B1 |1 H3 E! q3 Nthalamic pituitary gonadal axis. CPP is more com-3 b6 ]% a7 z+ v5 P5 I* K
mon in girls than in boys.1,3 Most boys with CPP3 N) }5 Z8 y0 ~# w( T
may have a central nervous system lesion that is$ Q# L8 i- ?6 D' v2 c, w
responsible for the early activation of the hypothal-
$ t/ o* @: Z4 o/ y; gamic pituitary gonadal axis.1-3 Thus, greater empha-
^8 ~) x- [% }' o6 W' ?' v0 esis has been given to neuroradiologic imaging in& g$ N% t: A; m9 O% |
boys with precocious puberty. In addition to viril-
; c2 r7 I. G5 O9 q( Hization, the clinical hallmark of CPP is the symmet-
5 W/ Y& A' n. w; X( `6 U B( Orical testicular growth secondary to stimulation by# G; a& a# z3 i/ l
gonadotropins.1,3/ h( F7 Q# p j* \0 X, ~# A* `
Gonadotropin-independent peripheral preco-: J* Y5 V5 L- x V
cious puberty in boys also results from inappropriate: s/ W# k5 |7 D! g$ ]& u$ i8 r6 h/ l
androgenic stimulation from either endogenous or F4 L% Y8 P$ U1 N5 ~( p0 R
exogenous sources, nonpituitary gonadotropin stim-
- L: h( s5 Z& Y8 b) a' [0 Culation, and rare activating mutations.3 Virilizing
, q1 Y$ {! J/ K( `congenital adrenal hyperplasia producing excessive" d k/ J. C: M0 F8 i7 d4 T
adrenal androgens is a common cause of precocious9 Y2 u6 Y" g w5 ?) P; u! N
puberty in boys.3,4$ y9 k1 K# L' f
The most common form of congenital adrenal
& x+ o" G$ }" Khyperplasia is the 21-hydroxylase enzyme deficiency.# @+ H* T6 s, ?8 L
The 11-β hydroxylase deficiency may also result in
( a( {/ M4 G7 D+ f o; t) `excessive adrenal androgen production, and rarely,
0 n2 k( `' |- {- O) @8 X4 Tan adrenal tumor may also cause adrenal androgen
' }1 s; e, \* d) h% Texcess.1,3 D+ a4 s7 w6 ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. b/ \- |' A) {- d8 w) U
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, n) d! f8 C( t j- Q% O
A unique entity of male-limited gonadotropin-
$ \7 A) B1 \: o; ?8 N1 U: R! U. H3 ?independent precocious puberty, which is also known4 a f! }. q, a& E, L7 b- P
as testotoxicosis, may cause precocious puberty at a
0 n# F3 Q* P+ y1 {& d9 _6 ^) [9 fvery young age. The physical findings in these boys
: i/ {* k3 @0 r+ _* @& q5 k: _with this disorder are full pubertal development,! S# C- h$ w) d! B2 G1 r+ U
including bilateral testicular growth, similar to boys
6 [# E/ {- k8 \# xwith CPP. The gonadotropin levels in this disorder
# O+ y/ p, [ W( Mare suppressed to prepubertal levels and do not show' v& x$ w$ P: e B
pubertal response of gonadotropin after gonadotropin-
' d, s( a; |5 f- ?( B; s y' `releasing hormone stimulation. This is a sex-linked: z+ i; X/ |) t; O, ?1 u
autosomal dominant disorder that affects only! `+ } @; L& c @0 K
males; therefore, other male members of the family
. W% v" c) g/ u* [4 Wmay have similar precocious puberty.3) u+ f# e. Z+ [+ T
In our patient, physical examination was incon-
5 m' S; E8 b0 V# a+ Y7 _sistent with true precocious puberty since his testi-
; M$ m% m7 N1 Kcles were prepubertal in size. However, testotoxicosis5 `1 T, u" O4 {* P* d
was in the differential diagnosis because his father. u. a5 }3 O( f' n9 X& N
started puberty somewhat early, and occasionally,5 O" e% ^+ O6 a( ~. y
testicular enlargement is not that evident in the$ q3 I* ^$ b* r; N
beginning of this process.1 In the absence of a neg-: I, Z7 m' V& g( M3 [5 M+ |! v
ative initial history of androgen exposure, our4 o0 x4 t4 J3 \! Q; l8 M
biggest concern was virilizing adrenal hyperplasia,1 s+ |- A+ O; H% p
either 21-hydroxylase deficiency or 11-β hydroxylase) m: g( E' a# F5 V* u) V
deficiency. Those diagnoses were excluded by find-& ^% K1 F: J, I* c @ o- i
ing the normal level of adrenal steroids.5 Y" j' W) W( P2 Q) l
The diagnosis of exogenous androgens was strongly
) L. L3 {2 V4 [: _4 o* ksuspected in a follow-up visit after 4 months because4 S8 f; g0 `1 u& r/ Y# a) ^
the physical examination revealed the complete disap-
4 Q# _9 I' ]- U& w4 M! y( V& c/ Ipearance of pubic hair, normal growth velocity, and" o7 x* r- p M. T" l: J6 Y0 g
decreased erections. The father admitted using a testos-
# a4 U2 c/ [8 a. ?: l: N# fterone gel, which he concealed at first visit. He was% u$ ~. E- P7 W! b* x- s# q: B o
using it rather frequently, twice a day. The Physicians’
7 O6 `0 X9 l/ J& N% RDesk Reference, or package insert of this product, gel or
# k; R% V5 g" _5 j8 }cream, cautions about dermal testosterone transfer to
, Z# x6 p. k! o. f( V1 xunprotected females through direct skin exposure.0 y$ m, e: w- ]2 Q. ]4 ?! i8 n
Serum testosterone level was found to be 2 times the% u* D" M* @ E Q
baseline value in those females who were exposed to5 F% |3 I+ m( V3 L) Q
even 15 minutes of direct skin contact with their male6 C9 S6 o$ Q5 Q
partners.6 However, when a shirt covered the applica-
) U/ @$ V- m$ _7 otion site, this testosterone transfer was prevented.4 m2 b# F: G7 f) l
Our patient’s testosterone level was 60 ng/mL,
7 l U+ r& B6 G& rwhich was clearly high. Some studies suggest that
& u4 s# g. L4 K3 }dermal conversion of testosterone to dihydrotestos-
* ^6 g% E9 P9 {1 Aterone, which is a more potent metabolite, is more
% Y8 g. F* X* Lactive in young children exposed to testosterone
# H: |0 y. `5 E5 `exogenously7; however, we did not measure a dihy-/ s+ C: w: [6 H2 q3 C
drotestosterone level in our patient. In addition to$ Z9 B* j+ s9 I& r& F! _
virilization, exposure to exogenous testosterone in
1 ~$ U$ T; w, ^& S$ M Pchildren results in an increase in growth velocity and6 |' M7 h$ G i/ x0 D
advanced bone age, as seen in our patient.
) r$ N) C t: QThe long-term effect of androgen exposure during
3 B7 e8 N5 m, w& c6 c9 h2 `early childhood on pubertal development and final( `0 a$ e i3 H
adult height are not fully known and always remain
$ z+ k( W6 j, H% I7 Aa concern. Children treated with short-term testos-. M }; ~2 T* T1 r/ r& x+ f4 F( f
terone injection or topical androgen may exhibit some
3 ^9 d5 _' F `" x# W1 L; Lacceleration of the skeletal maturation; however, after$ r3 Z% z; U% z* {
cessation of treatment, the rate of bone maturation
' b- m* d- G% hdecelerates and gradually returns to normal.8,94 H: L( \- |1 L$ O9 p
There are conflicting reports and controversy
( M+ W* N+ J& U" vover the effect of early androgen exposure on adult0 U/ a8 C, x: x9 y4 \
penile length.10,11 Some reports suggest subnormal; u+ N* Q" K( G {+ ~7 K
adult penile length, apparently because of downreg-
0 b' L$ E2 a! G. [0 ?ulation of androgen receptor number.10,12 However,
2 g& V4 i1 h8 ]5 x5 H( F/ Q. LSutherland et al13 did not find a correlation between! V. ?& U' E2 A$ P$ Y
childhood testosterone exposure and reduced adult
) B s6 o2 G0 s W1 C9 @penile length in clinical studies.0 U/ Q8 _* L; ^% S* L- y/ j
Nonetheless, we do not believe our patient is% z; U2 W( Q3 m# D! H' |
going to experience any of the untoward effects from6 D; ~0 |0 K; t3 |8 H0 U0 C1 ?
testosterone exposure as mentioned earlier because q3 g0 ]% ~6 h3 f8 ?
the exposure was not for a prolonged period of time.
, {3 c' N: m3 p* G: CAlthough the bone age was advanced at the time of
}' j% l. c$ g* Mdiagnosis, the child had a normal growth velocity at3 O) y8 Y; u/ U5 M) \" n
the follow-up visit. It is hoped that his final adult
- b, w% h8 O3 w* B9 N9 Theight will not be affected.
% v5 [, I9 t5 e( T9 R! ?Although rarely reported, the widespread avail-4 x" v; b2 l! C- {/ B$ ~) D' Z+ X, n
ability of androgen products in our society may5 c- }5 D' X% p* c! h
indeed cause more virilization in male or female& p' M& S; C$ X$ J2 o) U
children than one would realize. Exposure to andro-) h2 _, D3 ]2 `% Z: w9 F7 q
gen products must be considered and specific ques-; ?* P* l, E# E) U3 P
tioning about the use of a testosterone product or1 H" \6 l: w* p5 v
gel should be asked of the family members during
) O6 c# N6 P3 `- lthe evaluation of any children who present with vir-2 o% h4 a8 g6 F. [
ilization or peripheral precocious puberty. The diag-0 U9 v, N- A- ]- p$ }! i
nosis can be established by just a few tests and by" s, a+ ]8 l1 `! n& R
appropriate history. The inability to obtain such a
' h6 S$ J! j% ]& P! E$ e' y4 ~history, or failure to ask the specific questions, may" O# e$ ~) ~. j1 d* y
result in extensive, unnecessary, and expensive
# K N9 D* s& L1 ]. C9 n0 g; @investigation. The primary care physician should be
" n% {& o9 u1 q0 e( R4 aaware of this fact, because most of these children7 N; C% ^% B4 Z, j' g5 }6 A0 t
may initially present in their practice. The Physicians’
4 u# N9 g3 E: F! o5 NDesk Reference and package insert should also put a
h9 f# C; r# xwarning about the virilizing effect on a male or
5 s( }5 }& s; X. |6 Z( K% ~female child who might come in contact with some-/ m9 {/ @) y& `: a9 r: z5 Y
one using any of these products.. @3 Q6 g0 z. C! W" [* K
References9 P/ Q' r3 ^' o: B3 Q
1. Styne DM. The testes: disorder of sexual differentiation- Q3 h/ Y( }* f: h3 z
and puberty in the male. In: Sperling MA, ed. Pediatric& p, q" H4 D. y, }% l! M! U! u
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
5 ^. x9 x9 y$ }- f; ^2002: 565-628.
4 N5 V$ [- P7 i8 T" ~+ Z0 q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 v3 [1 O9 X4 O- T3 l) {puberty in children with tumours of the suprasellar pineal |
|