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Sexual Precocity in a 16-Month-Old7 j9 m+ W/ x/ J: a! s
Boy Induced by Indirect Topical" D$ j6 c/ F( x1 Q5 C6 t& P
Exposure to Testosterone
r6 m. K- c4 W5 F! {Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- d& n r2 ?3 Nand Kenneth R. Rettig, MD1# @4 T- }* t2 [1 o: `3 L* O# c
Clinical Pediatrics
+ V! _, y/ U* X0 b( x4 AVolume 46 Number 6
3 }$ F4 K) M6 ?4 @0 ]* d BJuly 2007 540-543 b5 K( z8 k R
© 2007 Sage Publications
4 {; O G/ _ Y$ v7 \5 f10.1177/0009922806296651. S& ~0 D1 G. O" T* E
http://clp.sagepub.com
: ], q( o* V% v; e% ?4 A) p. Lhosted at2 Q7 i; e- Z% W, s% v
http://online.sagepub.com
, n9 D, i- J0 C$ BPrecocious puberty in boys, central or peripheral,# j1 x5 r6 J1 r0 }: x
is a significant concern for physicians. Central; e; ]3 F Q3 w$ M/ A, O
precocious puberty (CPP), which is mediated
/ J7 @% Q1 g! ~4 Z8 [0 L$ r, Wthrough the hypothalamic pituitary gonadal axis, has
( i; c0 R* t+ M, na higher incidence of organic central nervous system7 H! M" U( P1 O* s% P
lesions in boys.1,2 Virilization in boys, as manifested; r0 \1 d+ Z" c: S
by enlargement of the penis, development of pubic
v/ [ a7 ]3 \( x) Q2 Q9 Yhair, and facial acne without enlargement of testi-
+ @5 R$ q$ A6 rcles, suggests peripheral or pseudopuberty.1-3 We
6 t4 @. r# ]0 A& i- ereport a 16-month-old boy who presented with the7 t* U; w4 g' O- ]& g9 X
enlargement of the phallus and pubic hair develop-+ |# C4 ]2 D) l; Q
ment without testicular enlargement, which was due# B2 O2 ?8 |( c7 K! e7 A
to the unintentional exposure to androgen gel used by4 x5 _% Y# m5 R6 o! w0 b' k1 p
the father. The family initially concealed this infor-
3 X8 \( H. _7 s5 _$ G9 w0 {3 fmation, resulting in an extensive work-up for this
* u( J9 Q, p/ y Y( F- Tchild. Given the widespread and easy availability of4 W, m+ T P2 ]
testosterone gel and cream, we believe this is proba-
8 c' J# f. N1 r; W7 n, O! dbly more common than the rare case report in the
5 X/ f, C+ @3 B8 P* _2 `7 Mliterature.4' K q8 S0 m* v
Patient Report3 V* o. o4 ^" H' [
A 16-month-old white child was referred to the
* ]$ H4 k- o% w% }/ i. aendocrine clinic by his pediatrician with the concern
3 e; W2 D! J$ k( ~+ N Lof early sexual development. His mother noticed
$ x# a/ v; c1 W i& K& J' mlight colored pubic hair development when he was
: _' }* R( h; x; p, Z+ X) NFrom the 1Division of Pediatric Endocrinology, 2University of9 I" K8 P4 C$ t! c3 N) ?% l- b
South Alabama Medical Center, Mobile, Alabama.1 u% s' O4 l5 D2 @) v
Address correspondence to: Samar K. Bhowmick, MD, FACE,. L# B' _, U/ h, r9 ^: z, c/ v' }
Professor of Pediatrics, University of South Alabama, College of
4 X4 B5 w: B/ X9 w& RMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;, A: G* t) m9 k
e-mail: [email protected].7 O5 p U8 l) ?; X* m9 o
about 6 to 7 months old, which progressively became* d- F& O7 H1 {9 v7 O/ |
darker. She was also concerned about the enlarge-7 s7 U$ R7 |" y, I
ment of his penis and frequent erections. The child# `) O9 D3 r/ G; H
was the product of a full-term normal delivery, with
% l7 f9 k. {5 w0 |! m5 I/ ]- |a birth weight of 7 lb 14 oz, and birth length of& i) \" ^9 F I/ b
20 inches. He was breast-fed throughout the first year# M4 ]: A! Z2 a$ B; w) I: E
of life and was still receiving breast milk along with
- V& ?' M4 Z. q1 b& Ssolid food. He had no hospitalizations or surgery,5 N. V4 N/ {% [( `" D8 D: h
and his psychosocial and psychomotor development# k) m8 A& i& |- N* d, e& g
was age appropriate.. W$ t% a( s D. N" l6 N
The family history was remarkable for the father,7 \, u4 _; o z; E5 g8 S; B
who was diagnosed with hypothyroidism at age 16,$ x/ [2 s: v: E+ c2 v
which was treated with thyroxine. The father’s
( s' _% @) `/ b6 oheight was 6 feet, and he went through a somewhat
0 {: N. B3 L+ a, ~9 f7 l" t, Vearly puberty and had stopped growing by age 14.7 u: G; [7 q6 ]- y
The father denied taking any other medication. The
1 P$ f3 |: U- i9 H; Wchild’s mother was in good health. Her menarche" D. v: d e: n, y) v( |
was at 11 years of age, and her height was at 5 feet7 L% o/ f" s) E |# j" I" E5 d, e& X
5 inches. There was no other family history of pre-
) |) e% \1 G$ \/ l5 y+ Xcocious sexual development in the first-degree rela-; \, y# R( e$ E4 y2 ~9 w7 _
tives. There were no siblings.
8 X4 g/ V9 U+ ^0 PPhysical Examination
" ]) k3 R+ r) Z8 lThe physical examination revealed a very active,) r1 N, O/ b0 ]/ ?0 f6 n0 a
playful, and healthy boy. The vital signs documented w3 g$ s, |" ?4 H) a. ?/ o; Y! v
a blood pressure of 85/50 mm Hg, his length was3 p. B6 ?: s5 C% ~1 d, k$ {
90 cm (>97th percentile), and his weight was 14.4 kg
2 s- E0 F) N4 K+ Y3 d T(also >97th percentile). The observed yearly growth) y- o9 @9 R$ M! K
velocity was 30 cm (12 inches). The examination of
1 a0 I: Q t. b, l) u9 R. M& q& \- sthe neck revealed no thyroid enlargement.6 j, J* ?1 O, e% M' q" ? [# B, H* g
The genitourinary examination was remarkable for
( }5 S& v( y/ Q* |* N7 \enlargement of the penis, with a stretched length of
$ E6 @5 R- }, ^6 }8 cm and a width of 2 cm. The glans penis was very well
) @" i' U: _" X3 h+ L- K4 H/ l, Jdeveloped. The pubic hair was Tanner II, mostly around7 J1 T# w! Q- E4 R9 ?' t: Y
540
$ Y, C' `: V0 b+ wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. F7 R: X: u2 o' p- N, |
the base of the phallus and was dark and curled. The
+ k& ?) A7 U* |8 utesticular volume was prepubertal at 2 mL each.' \- u6 r8 _4 {
The skin was moist and smooth and somewhat9 d6 I! w: Y0 F2 _3 n" V) L
oily. No axillary hair was noted. There were no
% x6 s& E5 d/ I* P# [% G( Xabnormal skin pigmentations or café-au-lait spots.
9 B# c) S& U: z9 wNeurologic evaluation showed deep tendon reflex 2+
7 i) k) W8 v& O7 N) ~7 ^bilateral and symmetrical. There was no suggestion
, z9 c. A9 w1 Vof papilledema.
5 u0 M$ V& `0 D1 t- S+ a8 fLaboratory Evaluation5 g; T9 @! |5 e# r3 V5 t; \
The bone age was consistent with 28 months by
. e% l/ `. c y' U7 H) v4 p( Zusing the standard of Greulich and Pyle at a chrono-: s2 a) i9 d9 x+ j! N
logic age of 16 months (advanced).5 Chromosomal! T, m, p- H/ Q7 K
karyotype was 46XY. The thyroid function test
8 f+ j& `# l& d- G3 d6 e+ Bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
( q8 F5 h+ ~0 Klating hormone level was 1.3 µIU/mL (both normal).
4 R0 t2 Z4 D) t2 e8 L( x) }( mThe concentrations of serum electrolytes, blood1 Z1 T8 d _, H7 v
urea nitrogen, creatinine, and calcium all were
0 H/ r w$ j7 z. Zwithin normal range for his age. The concentration
6 C0 l8 [' n* ^& Jof serum 17-hydroxyprogesterone was 16 ng/dL
! x0 h6 `3 W8 |5 |- d0 `+ f(normal, 3 to 90 ng/dL), androstenedione was 20
e% N8 ~1 L( u2 I. V5 B/ P* |ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-4 m P) ]- s, }% D6 e$ D; [
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
! Y2 }- D' ~% \' m0 u+ V- C. q1 Bdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ K" Q J& r! |2 }49ng/dL), 11-desoxycortisol (specific compound S)
+ f5 S; o B" A& X) [+ Hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: b' I1 E- m% Z+ n& g1 w
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total3 O1 P4 ]2 e# ^5 p0 k# v1 `7 M
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 j) P% k. y" ?
and β-human chorionic gonadotropin was less than
0 u+ u }& N" t$ y5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 a' o* Z8 E- x* E. `2 T9 k% estimulating hormone and leuteinizing hormone
2 j6 c+ E3 A2 M a; U8 Fconcentrations were less than 0.05 mIU/mL
" M$ x9 F$ p; {. r3 F# Z& b(prepubertal).
* ?: u. ?3 K- X& W1 r# n4 {; uThe parents were notified about the laboratory
( S+ Z H4 D( g. g2 Hresults and were informed that all of the tests were
7 s' E" {" n4 R* g7 K- F% \) wnormal except the testosterone level was high. The
0 f; w5 Q6 }$ Z* j/ tfollow-up visit was arranged within a few weeks to( v- y; M3 V1 V% z' x
obtain testicular and abdominal sonograms; how-
2 C4 A: b+ Q; R1 n: c" r ]# lever, the family did not return for 4 months.( k" r6 U+ ~& T: \ P
Physical examination at this time revealed that the" z) j' V5 M- U1 q2 Z
child had grown 2.5 cm in 4 months and had gained- ~2 Y {& R ]) f" l
2 kg of weight. Physical examination remained2 K P) J/ |, z; ]. r
unchanged. Surprisingly, the pubic hair almost com-7 y# U; f1 K8 V
pletely disappeared except for a few vellous hairs at( K P5 _ X) g4 \5 q+ ?% B- _2 c
the base of the phallus. Testicular volume was still 2! t) R0 ^* ]; @ {2 P$ i
mL, and the size of the penis remained unchanged." Y! d/ S, G5 {9 X/ H2 M: m
The mother also said that the boy was no longer hav-1 ?" i4 M! d* d" D
ing frequent erections. b0 n M9 E( h; ]
Both parents were again questioned about use of" W# U' X1 A2 l ^
any ointment/creams that they may have applied to
2 P9 h0 o5 @2 ^3 O, X0 D. wthe child’s skin. This time the father admitted the
4 C5 M1 M7 R9 G9 B4 T; kTopical Testosterone Exposure / Bhowmick et al 541* Z* |$ f% D$ d0 |+ Q
use of testosterone gel twice daily that he was apply-3 w7 I& Z# E8 Q, m5 Z2 x& z- O
ing over his own shoulders, chest, and back area for
( ]* e, |( o0 a# xa year. The father also revealed he was embarrassed/ }$ v6 k7 d; }& _3 \
to disclose that he was using a testosterone gel pre-5 s- |' i: e% k0 F
scribed by his family physician for decreased libido8 E! m) f/ @/ h
secondary to depression.! r! `. u5 ]: O% o- [% V* |' n! u6 G& u$ s
The child slept in the same bed with parents.6 a6 C0 o) x; N) k) s
The father would hug the baby and hold him on his! L( R0 P2 h2 v7 E
chest for a considerable period of time, causing sig-
6 f4 L [5 i3 \! |/ A0 Vnificant bare skin contact between baby and father.6 P" W" ^" ] ?* I4 b1 O7 R
The father also admitted that after the phone call, s$ f: Z5 E! d P) j3 R7 n
when he learned the testosterone level in the baby2 s, Q5 P8 ~2 X5 ?1 Q/ U
was high, he then read the product information" }* v' C7 _$ w, w3 z# B# w. u
packet and concluded that it was most likely the rea-
( u: t1 H; q+ W R% T- z( Fson for the child’s virilization. At that time, they
2 c% h; E6 w( B( Zdecided to put the baby in a separate bed, and the
5 p& V1 I$ s- u1 u- }father was not hugging him with bare skin and had0 a- ^2 |- \; q+ U) L- i- [; }# T6 `
been using protective clothing. A repeat testosterone
$ c% ^, t: f5 O8 `test was ordered, but the family did not go to the. z4 u4 q, E7 ^ V/ _" N1 d; M
laboratory to obtain the test.. _* f! Z1 `- h5 o# J# g
Discussion* v' B. p% Q' U* R6 \5 [8 ]
Precocious puberty in boys is defined as secondary
F, ^- `2 z2 o, ysexual development before 9 years of age.1,4& a6 z0 H4 G6 K- K! k
Precocious puberty is termed as central (true) when
9 T8 a: [3 Y1 E+ _2 \it is caused by the premature activation of hypo-) E- g% k8 z6 H. N* v
thalamic pituitary gonadal axis. CPP is more com-/ z+ B% C: l J" i7 m9 b+ `
mon in girls than in boys.1,3 Most boys with CPP* t o1 `+ R6 S1 o7 m
may have a central nervous system lesion that is
: O9 V) o2 j4 j! t, cresponsible for the early activation of the hypothal-
( {" ]( g7 S% p8 eamic pituitary gonadal axis.1-3 Thus, greater empha-3 s) x7 O2 _9 T+ w& t+ }' ~4 }
sis has been given to neuroradiologic imaging in% {- I4 [9 A6 I" U; X
boys with precocious puberty. In addition to viril-
7 c" Q2 I6 b ^ x2 I& o& D$ Fization, the clinical hallmark of CPP is the symmet-5 b) l1 S! T4 \' l1 H" Y" s R
rical testicular growth secondary to stimulation by9 ^( q! O: v: U1 v9 Q/ C
gonadotropins.1,3
5 T+ g( l& W6 X. g" p; X6 rGonadotropin-independent peripheral preco-, s& I, P# L0 B3 s% K) J6 }4 V
cious puberty in boys also results from inappropriate* [) s+ E! t% h: w& e3 h
androgenic stimulation from either endogenous or% K; d* P, I5 _& K5 j
exogenous sources, nonpituitary gonadotropin stim-
2 d5 I& R- d. f: Z/ eulation, and rare activating mutations.3 Virilizing' `- R. ^4 r6 g3 `7 H
congenital adrenal hyperplasia producing excessive& p l- m2 |1 ~2 a. y
adrenal androgens is a common cause of precocious
: @' u2 G' p, y1 O. `9 Q$ ~puberty in boys.3,4% I) J, r1 ^0 G
The most common form of congenital adrenal
, I0 q# [$ @* _- v0 X( Nhyperplasia is the 21-hydroxylase enzyme deficiency.+ w( v9 e* D2 `
The 11-β hydroxylase deficiency may also result in
" h% w% I# d0 N; Eexcessive adrenal androgen production, and rarely,
* Y- _, K8 ~1 ian adrenal tumor may also cause adrenal androgen$ {6 q4 q; I/ }4 F( ^, \9 b$ p
excess.1,3! `1 V3 z! s6 S5 g( C+ o# M' V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 l3 J9 I5 w5 k- f) f
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, C" d" T! A/ Y: uA unique entity of male-limited gonadotropin-
3 K3 d, K6 v) z) e. iindependent precocious puberty, which is also known3 F) ?+ M8 Y# U/ i( J- f) U
as testotoxicosis, may cause precocious puberty at a
# {! x0 Z1 U, X" O7 F' e; `very young age. The physical findings in these boys
9 e% F0 ^& K1 [/ g( `1 w5 A6 d4 [ ywith this disorder are full pubertal development,& {6 O- {* F2 m, l
including bilateral testicular growth, similar to boys/ K# w7 S* r5 u1 o) R8 I+ G
with CPP. The gonadotropin levels in this disorder7 y! v0 W' E/ {; W2 ]# f3 n
are suppressed to prepubertal levels and do not show+ [8 q" O4 c/ b9 G' h- n* L J/ M) m7 \
pubertal response of gonadotropin after gonadotropin-
( J1 b0 ~& Z/ n* ]% H2 i$ c: Vreleasing hormone stimulation. This is a sex-linked; b: R; Q2 R, }& v: h, x
autosomal dominant disorder that affects only
; Z1 D: m( @! _8 C* D8 z& u/ @males; therefore, other male members of the family0 g+ R& S. B7 P$ H, T
may have similar precocious puberty.3& v& _9 W) @: q& p8 Z
In our patient, physical examination was incon-$ y4 M8 o$ ?4 a; f. i' p' @: {3 }+ \
sistent with true precocious puberty since his testi-- e. y, z! K% h% u! j2 [
cles were prepubertal in size. However, testotoxicosis
7 P+ J# O( Z& g6 M; ywas in the differential diagnosis because his father! X$ V$ K: }8 I, g: T, u, |8 h
started puberty somewhat early, and occasionally,) W* l4 n; L' v/ H2 A0 Z
testicular enlargement is not that evident in the8 R \6 p4 x& W) Y# D& }; \' G% m
beginning of this process.1 In the absence of a neg-
" X! v! C3 d5 `( ]9 @ative initial history of androgen exposure, our* I+ A* x3 `& H+ O. ]( B( G
biggest concern was virilizing adrenal hyperplasia,
P2 a% B% A) g2 x3 f) o9 a" M4 Peither 21-hydroxylase deficiency or 11-β hydroxylase
. t) S( h2 Z/ \- Mdeficiency. Those diagnoses were excluded by find-
+ a; R0 Z; y- R( }0 W2 k2 cing the normal level of adrenal steroids.5 R6 {* R5 X4 z$ _; q
The diagnosis of exogenous androgens was strongly
) i9 m2 v6 _& N3 ~) Msuspected in a follow-up visit after 4 months because
9 C% g5 g/ g) R. kthe physical examination revealed the complete disap-
# N2 {2 v7 i Apearance of pubic hair, normal growth velocity, and ]# t" @; [3 h7 ]1 [, e
decreased erections. The father admitted using a testos-
+ n% a" Y* y ]% m6 _8 N3 _' y# rterone gel, which he concealed at first visit. He was! E; h1 \; Q" F* [% p- _
using it rather frequently, twice a day. The Physicians’
; W5 U! g# I! Q7 x3 W9 q' c( \Desk Reference, or package insert of this product, gel or. k% b' A* ^; V) I3 E: m
cream, cautions about dermal testosterone transfer to
4 O" [/ ?0 ]3 M4 j# ?9 r/ U3 g' ounprotected females through direct skin exposure.
7 T- W1 b9 W9 oSerum testosterone level was found to be 2 times the- R$ f/ M4 J8 l2 [% |% {+ v% ~
baseline value in those females who were exposed to7 T% m: E2 r, k9 F4 M
even 15 minutes of direct skin contact with their male" _& l7 ~) q* r! l
partners.6 However, when a shirt covered the applica-% f0 m0 R2 f# [4 _! L. K; |
tion site, this testosterone transfer was prevented.
* |2 h3 Z1 j& W8 }Our patient’s testosterone level was 60 ng/mL,9 M3 N1 ?0 n7 v, W0 U) f
which was clearly high. Some studies suggest that' |' n* g2 f+ o# I
dermal conversion of testosterone to dihydrotestos-
' h4 x7 R9 h, {- c7 ^terone, which is a more potent metabolite, is more
7 R# Z& ]4 g4 G5 t1 ractive in young children exposed to testosterone
! N; @ M: b% ^7 c! U8 wexogenously7; however, we did not measure a dihy-" a) i4 V' X; k* Y
drotestosterone level in our patient. In addition to
: c6 @* d% ]0 q# u$ {6 n( Hvirilization, exposure to exogenous testosterone in
! S- y3 a. s9 |0 Mchildren results in an increase in growth velocity and3 a" c4 F7 {! o+ C% |6 {, s
advanced bone age, as seen in our patient.. a. d2 e) k: T$ Q- t* f5 Q6 [
The long-term effect of androgen exposure during" G; i$ L9 e( s* ?" n. s5 e. A0 m
early childhood on pubertal development and final O6 l! `6 e- `' P
adult height are not fully known and always remain; P# L- |. |% Y$ u
a concern. Children treated with short-term testos-7 L7 Y* b$ T" w/ A; I3 V- e8 s
terone injection or topical androgen may exhibit some6 ]9 a5 b& Q% H! y
acceleration of the skeletal maturation; however, after3 T4 `1 Z0 ?- @& K
cessation of treatment, the rate of bone maturation
! M4 V+ Y4 B8 K0 Cdecelerates and gradually returns to normal.8,9
( s7 {$ r3 c% X0 e) ?There are conflicting reports and controversy* F; O( ^ O; o$ l2 E/ T T" `
over the effect of early androgen exposure on adult0 S0 l- C$ `9 ~
penile length.10,11 Some reports suggest subnormal
4 o' Y# x: t/ y5 Fadult penile length, apparently because of downreg-, ~' F" ^" [! X4 ?% N
ulation of androgen receptor number.10,12 However,) Z( V& Q5 l9 b+ G) Y
Sutherland et al13 did not find a correlation between
+ B% a$ o6 c+ i6 R" b2 J) v! t- R8 rchildhood testosterone exposure and reduced adult
. e5 u2 ~, N* h1 d! Y$ V- {' Dpenile length in clinical studies.
8 l7 i$ `7 v, |8 j) S* mNonetheless, we do not believe our patient is0 z2 A$ i ?) `' g9 `. Q
going to experience any of the untoward effects from+ o' J& }( `9 ?. M+ @
testosterone exposure as mentioned earlier because9 x, X+ [& z6 ^$ S6 O
the exposure was not for a prolonged period of time.
3 |! ?2 w2 L0 x, V ^$ dAlthough the bone age was advanced at the time of( G, v2 H% d% }5 D1 @+ Q: B
diagnosis, the child had a normal growth velocity at
8 H! H0 L9 M% l+ y+ R1 Tthe follow-up visit. It is hoped that his final adult
8 M6 X/ x* U7 @& I* _" X% [3 Qheight will not be affected.1 V5 M$ r x Y( d, T& X0 P
Although rarely reported, the widespread avail-
9 n( {3 r9 V5 g3 @5 _9 f1 Z# R$ ~) Lability of androgen products in our society may
, S' u3 ?! y. D4 }% u: Oindeed cause more virilization in male or female7 |# C' b- n7 b7 K
children than one would realize. Exposure to andro-
6 k4 g- A' |' j. Y$ Wgen products must be considered and specific ques-# S$ R) ~9 |9 v6 |1 Z
tioning about the use of a testosterone product or/ a% \) T( }! Y" D
gel should be asked of the family members during1 v" e0 u4 H* j/ z! [
the evaluation of any children who present with vir-" u7 [. \! C% \2 o# E
ilization or peripheral precocious puberty. The diag-) U8 P+ g$ u* T$ {3 r: U) C
nosis can be established by just a few tests and by
% @$ K( [ }5 n4 `, ^+ J% [appropriate history. The inability to obtain such a$ q& q( p+ `0 q9 \5 U; V
history, or failure to ask the specific questions, may- v6 B& L2 @- z O" E; U4 K g
result in extensive, unnecessary, and expensive
) w# |# ]) Q. o: e+ D, tinvestigation. The primary care physician should be' W+ ~% F" F1 f! X U" {8 x
aware of this fact, because most of these children
8 O) D+ }2 \& m0 Z- h# p, X/ g- bmay initially present in their practice. The Physicians’: x% c* g; p$ P! F/ h' s4 v
Desk Reference and package insert should also put a: g* F+ ^' r M3 c
warning about the virilizing effect on a male or( B' e/ y* A1 }7 i
female child who might come in contact with some-3 S% l, @7 {) a) Q$ S3 _ w3 z
one using any of these products.
4 E9 X# b9 ^/ D4 MReferences) X( C; V' m+ O w: x8 |$ ?
1. Styne DM. The testes: disorder of sexual differentiation
! X9 z% r; k! f0 J3 M, wand puberty in the male. In: Sperling MA, ed. Pediatric& w6 _3 ?" s* U( ?+ {3 x/ g
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& _) Z, {1 e9 b$ }: L, |5 y5 E
2002: 565-628., f& g) N0 f% x" }" X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious/ H+ a5 ^* I+ R/ L
puberty in children with tumours of the suprasellar pineal |
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