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Sexual Precocity in a 16-Month-Old
! y0 M/ w8 B7 \( C8 v, fBoy Induced by Indirect Topical
0 t( C5 `1 F8 oExposure to Testosterone
0 J' m0 h% E$ m7 B; _9 q1 VSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ K, E- f; g5 E) B r
and Kenneth R. Rettig, MD1
; }4 P/ X- c1 ?" U3 [Clinical Pediatrics% Z- {& y1 h) S$ w1 G: R, v
Volume 46 Number 6
, j( ~/ r3 D. F8 S) x5 v6 c- jJuly 2007 540-543
0 Z3 O- P* X, ]0 t$ T© 2007 Sage Publications6 s( J5 @0 E' X8 @6 x6 o# |
10.1177/0009922806296651
, n7 a, W: ?7 D+ b: _' \( yhttp://clp.sagepub.com
) G' O# i+ {$ U9 {; nhosted at
* P; a8 c5 p }http://online.sagepub.com! V) Y/ ?/ I! @) D/ |7 A
Precocious puberty in boys, central or peripheral,
' D+ E) i, B, n |0 Pis a significant concern for physicians. Central9 \1 M5 g1 u1 G/ T9 I
precocious puberty (CPP), which is mediated
( l( H4 r- _' I r/ s7 a4 Z4 Q6 Hthrough the hypothalamic pituitary gonadal axis, has& J3 j2 e% y. I/ l+ [; }. w( }
a higher incidence of organic central nervous system
! e0 I, e/ n& j& y5 v/ rlesions in boys.1,2 Virilization in boys, as manifested
) Z2 u2 y; G* r- J$ p K' f+ ?by enlargement of the penis, development of pubic
. t9 M5 c; |5 r% shair, and facial acne without enlargement of testi- H) r+ J! [/ ?- l3 \* |* b
cles, suggests peripheral or pseudopuberty.1-3 We
/ {+ ?5 b. `# W4 t" |# O7 mreport a 16-month-old boy who presented with the
+ H+ ^: Z S# menlargement of the phallus and pubic hair develop-
0 S" z/ D3 V' o# e3 O+ x: yment without testicular enlargement, which was due, ^3 O% y1 ~) U6 l
to the unintentional exposure to androgen gel used by
6 Y9 ?4 p! g) S' L; |& `$ C- }the father. The family initially concealed this infor-4 w7 V+ u7 C# m
mation, resulting in an extensive work-up for this
+ ^ z2 [5 v, L$ r* l1 ychild. Given the widespread and easy availability of
' |9 I" C2 M V+ T9 F, Ttestosterone gel and cream, we believe this is proba-5 B3 m4 \4 { g8 X
bly more common than the rare case report in the
4 E' y" B) e- j* Cliterature.40 U6 a( D* V- Z' H$ m8 o
Patient Report
' E/ F2 f: d" s: pA 16-month-old white child was referred to the
/ x" _$ [" A( {9 {& vendocrine clinic by his pediatrician with the concern& K5 [7 M1 e+ |9 z8 _
of early sexual development. His mother noticed
" |0 @" Q8 A; B# Z& P+ I dlight colored pubic hair development when he was
. S0 p- P( i2 I" WFrom the 1Division of Pediatric Endocrinology, 2University of; u' z& d& y8 H: H
South Alabama Medical Center, Mobile, Alabama.8 n* U' x& t$ t) @) p6 K% S- G0 X9 z
Address correspondence to: Samar K. Bhowmick, MD, FACE,
( ` Y' h W% r( X& F- HProfessor of Pediatrics, University of South Alabama, College of
4 g( t2 \% H9 w8 s7 i m, W BMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 j1 P7 Q9 u9 z: I
e-mail: [email protected].: B9 Q& @5 a# ]- Q, H
about 6 to 7 months old, which progressively became
8 }8 _2 b" F; u1 I. P& Y% }6 G$ T& P, [" tdarker. She was also concerned about the enlarge-
3 k+ D1 l6 m \0 ament of his penis and frequent erections. The child
; f5 n/ v; @" ]+ ?# _was the product of a full-term normal delivery, with
3 U/ S/ Q2 ^% |! z# ~+ ha birth weight of 7 lb 14 oz, and birth length of
5 n6 E0 b" e6 H% ^) h5 q. j20 inches. He was breast-fed throughout the first year- `* K$ |+ W) V: W1 [- }" I3 L
of life and was still receiving breast milk along with: }- Q8 j; g. _
solid food. He had no hospitalizations or surgery,$ T4 _* R$ @4 o9 W
and his psychosocial and psychomotor development
+ G8 C6 ?- z8 y' hwas age appropriate.% c7 `9 b3 M$ M
The family history was remarkable for the father,
. ?4 i0 V5 ?- G3 Uwho was diagnosed with hypothyroidism at age 16," \& U& g$ z' w5 c) J3 W2 y
which was treated with thyroxine. The father’s+ j- w3 m; Y8 y- m: a9 f9 ?. j
height was 6 feet, and he went through a somewhat" o9 Z e+ e1 z; J5 z- i3 h
early puberty and had stopped growing by age 14.+ O9 }6 K/ w' j; G# K# V
The father denied taking any other medication. The
4 _3 Y& J5 n. W! B( [child’s mother was in good health. Her menarche2 r, |. e# {3 O) u$ ?
was at 11 years of age, and her height was at 5 feet: l* t t7 J A1 b1 J2 p; v
5 inches. There was no other family history of pre-7 w+ v3 m+ f7 T9 }6 {0 m
cocious sexual development in the first-degree rela-
; T5 R: X! W3 w. u( E5 r9 z/ Ttives. There were no siblings.
+ C y% B1 U! a; v/ F4 @Physical Examination
! r6 D: z! b4 UThe physical examination revealed a very active,
- h0 l" Z7 w5 [ U, Jplayful, and healthy boy. The vital signs documented& V7 ?" c0 c8 t- d
a blood pressure of 85/50 mm Hg, his length was
1 [; F; ~* {9 ]* f; t90 cm (>97th percentile), and his weight was 14.4 kg- j3 E; C9 T$ `% V2 U
(also >97th percentile). The observed yearly growth
, L0 H, Z) K& y- k, ]5 G+ o% zvelocity was 30 cm (12 inches). The examination of. k: b6 @, {* Q, w. T* Q$ F
the neck revealed no thyroid enlargement.: O! n1 M. h8 f- h' ?' i0 `
The genitourinary examination was remarkable for7 b) z6 K( S0 d4 d2 i; E6 x8 J
enlargement of the penis, with a stretched length of. R6 Y) H& {) X% K0 F d6 `4 f
8 cm and a width of 2 cm. The glans penis was very well
9 j$ S+ |8 v+ B W( \3 xdeveloped. The pubic hair was Tanner II, mostly around
$ F5 a7 D4 l9 |( v, h4 H$ G5407 g* @9 J6 P0 B) t0 E' I
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the base of the phallus and was dark and curled. The
( |4 f1 O* ]: \1 P' f* L! {testicular volume was prepubertal at 2 mL each.8 h( j* u: w5 @0 k) q& J/ y
The skin was moist and smooth and somewhat
- F4 H3 R( w* @( V/ p4 }6 z' y0 Aoily. No axillary hair was noted. There were no: H4 |% w( f5 @ P7 q
abnormal skin pigmentations or café-au-lait spots.4 j: A& \' i! K/ F4 R% B
Neurologic evaluation showed deep tendon reflex 2+! i) J+ t8 M/ S2 m( D/ y( E& s: T
bilateral and symmetrical. There was no suggestion
0 y1 K! {, |- H( l* {8 I$ ~; q7 }of papilledema.1 v; k# b- C0 k( J8 q8 Z
Laboratory Evaluation5 `" D! w8 [' t$ |# \0 m
The bone age was consistent with 28 months by: d) b: ?' n+ ]1 W; D, ~7 e! l# O% |
using the standard of Greulich and Pyle at a chrono-- Y. B- q" [, U" J# m5 R
logic age of 16 months (advanced).5 Chromosomal6 V9 G) A& l& C+ L
karyotype was 46XY. The thyroid function test
! s' w" c6 T2 z8 [) C0 w Fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 V" `( }# m8 N& O) B: xlating hormone level was 1.3 µIU/mL (both normal).; c4 `7 x: p5 x. J0 {2 J; Y
The concentrations of serum electrolytes, blood
0 A8 e6 h1 u# i7 R w# [0 surea nitrogen, creatinine, and calcium all were3 n1 E! ]1 A8 i# F+ N9 C
within normal range for his age. The concentration
3 E* l+ |. ?( a' f/ R7 gof serum 17-hydroxyprogesterone was 16 ng/dL- r( {5 U( ]( T$ h N7 d9 n! y
(normal, 3 to 90 ng/dL), androstenedione was 20: D) s6 B* t* ^2 D5 J# d6 a+ n, H
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 {4 Z2 a' U" j7 i) X7 M7 p
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; W! c4 ~ B0 d2 `3 e+ I
desoxycorticosterone was 4.3 ng/dL (normal, 7 to1 Q- ?0 V7 [3 [3 D% c
49ng/dL), 11-desoxycortisol (specific compound S)
# m. M+ P' J! d* G5 R2 J U% Swas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 r% t& d/ F- ^5 S4 D& Ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 J( }2 @! Z5 p0 y4 h4 Stestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! j4 A! c) f" _' R& Pand β-human chorionic gonadotropin was less than
6 Q7 Q0 i9 g% ^5 mIU/mL (normal <5 mIU/mL). Serum follicular
& O8 d: E- Z2 Z( C; b ]stimulating hormone and leuteinizing hormone
8 V) u# i- U2 m" F7 J) ^5 |concentrations were less than 0.05 mIU/mL
$ I" h9 `( H/ V: u n(prepubertal).
3 x( m4 B4 u$ K) d) W) C1 SThe parents were notified about the laboratory
+ H( W! f4 D- W+ A7 fresults and were informed that all of the tests were
8 ^- e; x# k& W' x1 rnormal except the testosterone level was high. The U+ U0 P1 {1 b. c# R" w
follow-up visit was arranged within a few weeks to+ R4 ]0 v# B) P7 c" u
obtain testicular and abdominal sonograms; how-) z- ]4 x% `* z9 z6 w
ever, the family did not return for 4 months.
+ z& s L3 p4 _3 N1 p) CPhysical examination at this time revealed that the: J3 t, n2 z: U9 R6 N
child had grown 2.5 cm in 4 months and had gained; }9 g& \" N0 i: p
2 kg of weight. Physical examination remained
/ S% G9 d; d2 r/ Z6 t; Vunchanged. Surprisingly, the pubic hair almost com-
- U( K4 ]; O* ]' Qpletely disappeared except for a few vellous hairs at
5 R2 L. ]$ f+ fthe base of the phallus. Testicular volume was still 27 A2 B5 ^. _& f
mL, and the size of the penis remained unchanged.
, e; w& P" R! }2 U$ A. Y3 D3 @) ?2 {The mother also said that the boy was no longer hav-
5 f( A3 h+ ~- P# ]- N0 V# Fing frequent erections.3 w L3 }( W+ L0 Q
Both parents were again questioned about use of" h1 j% b: _3 j) f8 m- e" c4 H% w
any ointment/creams that they may have applied to& h6 D, Z D) B# ^! L/ n5 A# o
the child’s skin. This time the father admitted the6 @( ?$ z1 L# U0 y3 ~! U5 v' |
Topical Testosterone Exposure / Bhowmick et al 541 B1 W) ]! N- }7 A0 R
use of testosterone gel twice daily that he was apply-" b h Q$ k5 N) Q9 v$ q! Z
ing over his own shoulders, chest, and back area for
' ]: V6 {% @! R: H+ n+ Ma year. The father also revealed he was embarrassed
' h; b, W" Z' Rto disclose that he was using a testosterone gel pre-
1 r$ v4 A( m! w( W0 ?scribed by his family physician for decreased libido
0 A& W! ?: U- C& N, Ysecondary to depression.5 ]4 y0 W4 c' _; J0 O
The child slept in the same bed with parents.. }8 _- S* r: K9 t' |$ Q, a
The father would hug the baby and hold him on his9 C% x' X0 ^. l# j4 u# N
chest for a considerable period of time, causing sig-
# |- n" ]- y$ s; X; C& I: z" ynificant bare skin contact between baby and father.
" v$ W/ j k( k# c4 p1 M$ PThe father also admitted that after the phone call,3 [% m0 |* l W/ V
when he learned the testosterone level in the baby. [4 ~4 {: F# U8 i% F: W
was high, he then read the product information
* ~1 t3 B: q0 Y4 ypacket and concluded that it was most likely the rea-: U- B0 k. D) y5 R7 C
son for the child’s virilization. At that time, they, m, P2 O( O6 Y7 l
decided to put the baby in a separate bed, and the0 G9 M$ P0 v+ }
father was not hugging him with bare skin and had. `8 o4 e( h& {. F6 I5 n1 i" |. o+ y) d
been using protective clothing. A repeat testosterone0 l1 p C" `0 h2 u5 x# i
test was ordered, but the family did not go to the, x ]' @! [# E2 A: Y& V9 m2 x6 b
laboratory to obtain the test.
! W! E E; g# u1 k% E1 \& ?Discussion
) b/ f, m" Z$ F. uPrecocious puberty in boys is defined as secondary
1 V4 N% [9 l: n" N4 s3 ^sexual development before 9 years of age.1,4+ p' L% r7 s' D1 k$ [: N# ?2 ]8 j
Precocious puberty is termed as central (true) when
% u3 W" v9 O9 a1 B6 ?4 q4 fit is caused by the premature activation of hypo-. D0 s5 {; o" h8 C
thalamic pituitary gonadal axis. CPP is more com-
5 Y8 O d# t% Y8 w2 Bmon in girls than in boys.1,3 Most boys with CPP) i7 u' H# I( w4 Y4 t( Q. ?3 F
may have a central nervous system lesion that is" F7 s. M9 z0 {0 ]( @9 c! C
responsible for the early activation of the hypothal-; _8 ^+ S% K. t7 \' m3 U& \, L
amic pituitary gonadal axis.1-3 Thus, greater empha-
' _7 k, F, K& D2 [1 Fsis has been given to neuroradiologic imaging in
4 H$ J8 j* _6 o; Y+ \boys with precocious puberty. In addition to viril-
) H5 h' e C' g- w& V8 Qization, the clinical hallmark of CPP is the symmet-5 t6 w) k( p# A
rical testicular growth secondary to stimulation by( B" C5 N" M n* G, N
gonadotropins.1,37 _4 w$ s$ B& D! ~- E5 Q
Gonadotropin-independent peripheral preco-8 x# B7 b$ o- {( b% X
cious puberty in boys also results from inappropriate' S2 z/ ^* n6 Z
androgenic stimulation from either endogenous or
4 Y- s A$ X, i' mexogenous sources, nonpituitary gonadotropin stim-) {4 S/ m* H$ y/ k5 e0 k: S
ulation, and rare activating mutations.3 Virilizing1 o @/ N" U' T' p* p
congenital adrenal hyperplasia producing excessive
0 b, o/ y, X3 {adrenal androgens is a common cause of precocious
% O: p! Q$ w( g8 ypuberty in boys.3,4. h I( A6 p1 |+ c+ X* S
The most common form of congenital adrenal# X6 x% o+ r/ S/ ]& R1 H
hyperplasia is the 21-hydroxylase enzyme deficiency., Y1 E; m7 l: y! d, Q1 B1 v
The 11-β hydroxylase deficiency may also result in0 Z& @5 l2 J9 L5 z
excessive adrenal androgen production, and rarely,
2 c& l, g% \1 L' h" y# \an adrenal tumor may also cause adrenal androgen
% D- l- h8 e( n& n$ A/ Cexcess.1,3+ z2 P; N2 V3 ?0 H: y+ v7 ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: d( q9 Q, u9 h- E; F$ W: f
542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 Y: Y1 Z9 k, I
A unique entity of male-limited gonadotropin-$ D0 v/ m$ W" }1 a, Q0 R
independent precocious puberty, which is also known
, [% @% O. h$ E: m$ zas testotoxicosis, may cause precocious puberty at a
- z3 e7 z# W) T$ Z5 {very young age. The physical findings in these boys' T8 A1 i$ F% z: x
with this disorder are full pubertal development, F) j' V5 A' K* ]& ?
including bilateral testicular growth, similar to boys% ]' f6 B8 a s( X4 m1 n( m- l
with CPP. The gonadotropin levels in this disorder9 j' {# @$ U- Z& O
are suppressed to prepubertal levels and do not show
( [% j- O* [2 H2 O4 ?5 U x* Dpubertal response of gonadotropin after gonadotropin- B, u! k/ ?4 [
releasing hormone stimulation. This is a sex-linked; W; m7 r6 `0 E D
autosomal dominant disorder that affects only
9 {( P. R$ x' i% C* pmales; therefore, other male members of the family
* X" [2 t1 y+ ]- tmay have similar precocious puberty.3 a' O( `" a1 |- {" _) K2 Q
In our patient, physical examination was incon-6 b: z, G! X4 `& u. r4 Y
sistent with true precocious puberty since his testi- J7 P8 b8 c% f1 c+ }0 [0 r% @- x4 J
cles were prepubertal in size. However, testotoxicosis9 {/ l o$ R7 z$ I2 r+ {: L% S7 s
was in the differential diagnosis because his father
+ Z1 c& ?# A9 M0 jstarted puberty somewhat early, and occasionally,2 F( { ~- D7 ?8 {$ ?& B
testicular enlargement is not that evident in the
3 o: c5 b+ T. S' A: [8 H' Z* Ybeginning of this process.1 In the absence of a neg-; D3 R. T- R! f7 _1 q5 i! s
ative initial history of androgen exposure, our* |! S0 u+ l& c8 D& b7 o: T
biggest concern was virilizing adrenal hyperplasia,
% |( B, E( |. d* E( N7 _2 ~either 21-hydroxylase deficiency or 11-β hydroxylase5 C$ r! v' }" ?1 R2 ^6 x( U
deficiency. Those diagnoses were excluded by find-' N8 K" O( n; T9 k4 F- W6 M
ing the normal level of adrenal steroids.! W& K+ M( d1 A7 c ]3 I
The diagnosis of exogenous androgens was strongly0 Q9 v& a- N: R( Y( e7 j) F% m
suspected in a follow-up visit after 4 months because
/ |* d! B& q2 M) P! B. |0 a! lthe physical examination revealed the complete disap-
" ?0 y1 l, n7 npearance of pubic hair, normal growth velocity, and
: B9 O1 f# f" _* w0 ]# hdecreased erections. The father admitted using a testos-
) z7 m! [% k) A5 z0 X' Hterone gel, which he concealed at first visit. He was
/ n+ N; Q6 i+ U! e: v5 \( Busing it rather frequently, twice a day. The Physicians’! p- X1 |+ u% C3 L8 t
Desk Reference, or package insert of this product, gel or9 c+ O4 T6 E" R; H k
cream, cautions about dermal testosterone transfer to
4 u- m- W5 g1 c/ E- C: Q2 [unprotected females through direct skin exposure.+ b& _2 Y- R- X7 I# V4 i) x9 L, r
Serum testosterone level was found to be 2 times the7 x* @8 ]; a" u- v! H* X% M6 z
baseline value in those females who were exposed to, Z; d, ]7 `7 F
even 15 minutes of direct skin contact with their male
! l8 i7 o6 d$ E2 I" C' L/ Tpartners.6 However, when a shirt covered the applica-; i o* X' b9 N/ j2 M: H: _2 S) E
tion site, this testosterone transfer was prevented.7 O7 r! ?- m) E+ w
Our patient’s testosterone level was 60 ng/mL,
6 l7 J! T$ A1 |which was clearly high. Some studies suggest that
2 J+ A- P- y8 C6 Zdermal conversion of testosterone to dihydrotestos-' f$ T* {; z) f$ x
terone, which is a more potent metabolite, is more0 H, G' T# t' q2 E' m2 a
active in young children exposed to testosterone
/ [( F, K, x: z% p+ lexogenously7; however, we did not measure a dihy-
I, L& u: y7 T- Ndrotestosterone level in our patient. In addition to
5 t1 t8 ?) S" i* ivirilization, exposure to exogenous testosterone in; K$ `# t% b1 c
children results in an increase in growth velocity and8 U: i, n- _4 s2 E) L
advanced bone age, as seen in our patient.
( {. p5 J% q7 b& J. C/ O4 ]The long-term effect of androgen exposure during% v' O7 p, K n' y2 q
early childhood on pubertal development and final* R1 d1 O# b5 a; |9 Q% H) n2 ?
adult height are not fully known and always remain# B7 L* L3 i! W4 r5 w/ g& D& P
a concern. Children treated with short-term testos-& K) t, F$ K1 }% R
terone injection or topical androgen may exhibit some
/ p- u1 _* r' j" B# z7 qacceleration of the skeletal maturation; however, after1 C0 r3 l7 z+ e9 i. l
cessation of treatment, the rate of bone maturation
/ s* x% ]7 l$ U4 L, S# qdecelerates and gradually returns to normal.8,91 D( L' a+ Q3 w% n9 L, }2 k. ^% O
There are conflicting reports and controversy1 c9 U# v; r/ b# r) w9 K3 O' L
over the effect of early androgen exposure on adult
5 U+ R/ X" r' Qpenile length.10,11 Some reports suggest subnormal* r: p$ V4 N; r. b/ I
adult penile length, apparently because of downreg-
1 K5 L& G$ v/ x7 C5 W1 t# Yulation of androgen receptor number.10,12 However,
* n* }9 e6 E: `* X- g, WSutherland et al13 did not find a correlation between
, Y9 \& R3 w" p" _# \) ]4 D+ r- ochildhood testosterone exposure and reduced adult1 B" h! E+ }, N. S8 A. m
penile length in clinical studies.
' O0 T+ ~' r8 B$ G# w' DNonetheless, we do not believe our patient is" T' b; s; V2 \0 p1 q8 o' n) g
going to experience any of the untoward effects from6 o% H$ Q( ^( [& Y4 {8 [
testosterone exposure as mentioned earlier because) ]0 I! t+ N# d0 |6 |2 t3 _# e
the exposure was not for a prolonged period of time.& {5 ?8 V8 M6 o; u+ `! v
Although the bone age was advanced at the time of* t; R8 f0 ], s" U, w$ y
diagnosis, the child had a normal growth velocity at% c$ @+ F9 i5 E9 U* }/ N
the follow-up visit. It is hoped that his final adult
2 U& d$ o1 j, r2 ?9 pheight will not be affected. n1 y* U% Y$ v" Y
Although rarely reported, the widespread avail-
% A+ L, P/ Z" |0 Q' Xability of androgen products in our society may2 c3 d" x% K9 R
indeed cause more virilization in male or female
$ s7 q3 ?. C; Q2 _" Q$ J. ychildren than one would realize. Exposure to andro-
. L! r7 h! l E9 \7 mgen products must be considered and specific ques-
3 ~' Z ~& v5 [7 xtioning about the use of a testosterone product or0 M$ ^/ {, R& ]' H+ `
gel should be asked of the family members during! \7 Q3 N9 S0 v9 X
the evaluation of any children who present with vir-, H/ w. {9 Q' u+ y. j' I
ilization or peripheral precocious puberty. The diag-" c1 G/ H- Y q( e+ f0 l4 [4 l/ |, X
nosis can be established by just a few tests and by
4 j' c) r8 k+ l9 Gappropriate history. The inability to obtain such a
7 p4 x' Y0 ~$ e- @. ~6 X8 nhistory, or failure to ask the specific questions, may! A) n% m5 \( s- s
result in extensive, unnecessary, and expensive9 A8 D7 e. e+ S6 g. ]
investigation. The primary care physician should be/ v0 N: }# N6 h0 S6 e& T
aware of this fact, because most of these children2 e' a# P; c$ y$ Z; X. P% `5 f& K
may initially present in their practice. The Physicians’# z+ z+ E- b4 c; O9 [2 \
Desk Reference and package insert should also put a, i/ c! {* A0 F9 M7 E
warning about the virilizing effect on a male or0 p8 h$ i6 e% m( B( y, p4 ^: X- v
female child who might come in contact with some-
0 ~. a6 Y' B& ?* zone using any of these products.5 n+ Y9 r& m/ ^9 e
References% s! s% U9 z a
1. Styne DM. The testes: disorder of sexual differentiation
, Y/ g" m$ q# n# T) _and puberty in the male. In: Sperling MA, ed. Pediatric% ^' |7 J9 @0 z: ^& c8 o6 z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;0 S" u% p+ }( E/ j6 H/ u
2002: 565-628. I5 z* d/ A. z$ }1 s' I( O0 h
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 c2 e! ?7 m" p; Z( @; |$ v5 R% a5 E
puberty in children with tumours of the suprasellar pineal |
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