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Sexual Precocity in a 16-Month-Old
3 C3 B# d* V9 KBoy Induced by Indirect Topical$ y. J2 F5 g2 m5 w- @
Exposure to Testosterone+ Z0 H3 f8 M' V4 w7 q$ ~6 G9 B
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. ^5 d+ ?* b. |' F1 c% [
and Kenneth R. Rettig, MD1
& o+ O( j/ N* l* `Clinical Pediatrics
7 p1 k& v% D- a) v. TVolume 46 Number 6* ^9 \, ?9 B, r/ m, K, R* L
July 2007 540-543
8 z* m- B, r. O! W2 ?" ~© 2007 Sage Publications7 @ k# }) u0 G. \4 f- h
10.1177/0009922806296651" F1 ~. Q. f% K8 h' N
http://clp.sagepub.com8 ~. S: y+ K r1 S$ V+ A- B
hosted at
# ?. {: Y( k* q/ Chttp://online.sagepub.com
# e: b3 K1 s' n( ePrecocious puberty in boys, central or peripheral,
! U4 q' V6 Q8 l, K$ g- ^- |, A2 Tis a significant concern for physicians. Central& A! w( _9 o. Q* l6 @, \3 \
precocious puberty (CPP), which is mediated
) r+ e& I- E7 A; U! m; Y5 |through the hypothalamic pituitary gonadal axis, has
7 p+ G4 w }& z+ s) K8 aa higher incidence of organic central nervous system
! t8 w3 k3 K8 ^1 o# V8 ilesions in boys.1,2 Virilization in boys, as manifested( h0 D9 F" X9 @5 f
by enlargement of the penis, development of pubic) C) h( n ?" H( Q1 S
hair, and facial acne without enlargement of testi-
; ^" \, R: b d8 k8 a2 xcles, suggests peripheral or pseudopuberty.1-3 We
t6 F; Y3 k+ m% n5 r% Breport a 16-month-old boy who presented with the
* p% v3 K( s8 Z8 I: menlargement of the phallus and pubic hair develop-) F: W6 q+ Z: q/ H
ment without testicular enlargement, which was due
, O- i7 |) ]9 {: s$ O' K3 `to the unintentional exposure to androgen gel used by
0 y! G2 {8 B+ N- w5 s. {the father. The family initially concealed this infor-1 o5 @0 @$ P) z* E/ F" B
mation, resulting in an extensive work-up for this$ V3 ?' L8 C o/ G9 q D
child. Given the widespread and easy availability of+ x* ]5 `( N) b3 K
testosterone gel and cream, we believe this is proba-
; N, g7 d+ Y( F% K0 G" ^ |% gbly more common than the rare case report in the
1 f; x6 ]: K, z8 _ ~literature.4 j% P! U. W8 `2 E! H
Patient Report
: [) H7 H" b7 C3 h) W: Z5 L' p+ dA 16-month-old white child was referred to the
' A# w" p% ]0 s X3 {+ Pendocrine clinic by his pediatrician with the concern
4 y. ?+ |$ X. C7 z7 @of early sexual development. His mother noticed( _+ H; ^5 P0 P1 _
light colored pubic hair development when he was: \* f% ?; p" B. r
From the 1Division of Pediatric Endocrinology, 2University of( ?% h+ D X+ g2 H& w
South Alabama Medical Center, Mobile, Alabama.8 ?$ R3 c! f% k E
Address correspondence to: Samar K. Bhowmick, MD, FACE,8 H) U3 f+ ?3 _) Y' [. p
Professor of Pediatrics, University of South Alabama, College of3 Z2 e F! `/ T/ R1 i3 E
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 Q: r( N8 W! \e-mail: [email protected].
+ {+ ?& K/ Y+ C* e* B0 c$ r/ ^# }( I2 V) babout 6 to 7 months old, which progressively became( K& p* s) U& z
darker. She was also concerned about the enlarge-6 U5 R- S+ @/ s ^4 t9 b% L3 l p/ ?
ment of his penis and frequent erections. The child
- N3 n, A' g+ @9 Iwas the product of a full-term normal delivery, with
: @2 {9 A' N: h1 ^6 s+ ka birth weight of 7 lb 14 oz, and birth length of
, m9 m" y$ B& |# Y* z/ J8 Y( u# @8 G20 inches. He was breast-fed throughout the first year
: ? b+ P- e9 u( P' Y# Mof life and was still receiving breast milk along with
, ]1 Z7 q: G; u0 V! Y. @solid food. He had no hospitalizations or surgery,- r" I: z8 O R% |- V
and his psychosocial and psychomotor development5 R. [; d. f2 O! x
was age appropriate.) [3 h% Z$ s2 l- {5 i/ _0 }- r
The family history was remarkable for the father,
. t* V4 @! V- X5 p8 M5 S& |who was diagnosed with hypothyroidism at age 16,
( ?3 Z. K" O- j9 a8 d# kwhich was treated with thyroxine. The father’s
3 \! h: E" T3 R% b$ \$ Eheight was 6 feet, and he went through a somewhat
* F% _# r9 w$ M, \early puberty and had stopped growing by age 14.
" a6 R' _* f" t% p7 J+ j: zThe father denied taking any other medication. The
2 b4 f9 a0 U; q& o1 `child’s mother was in good health. Her menarche
1 Y$ ~( C& k3 e9 xwas at 11 years of age, and her height was at 5 feet8 C. x% {6 |8 D( v# D
5 inches. There was no other family history of pre-
" O$ C; a- J$ D& |) ycocious sexual development in the first-degree rela-! y1 w% V) j4 \3 B u* ]
tives. There were no siblings.
/ h, V# L5 P2 E& \: m9 oPhysical Examination
0 i, s: F; L# ^' qThe physical examination revealed a very active,7 x/ G8 k# \' N7 W. _- K" v1 B
playful, and healthy boy. The vital signs documented
2 \7 p2 R" y! g1 s* P4 b4 l9 Ka blood pressure of 85/50 mm Hg, his length was9 h0 T( `# B; A+ D
90 cm (>97th percentile), and his weight was 14.4 kg
" l7 w* z! T" W, p% f# ?(also >97th percentile). The observed yearly growth c5 A9 o8 d( w# A1 v- \8 B
velocity was 30 cm (12 inches). The examination of
* P* Y8 U) X& ^+ ^8 L7 ~6 p; ethe neck revealed no thyroid enlargement.
$ n$ L0 x' q+ j" S+ Z1 f: PThe genitourinary examination was remarkable for
& C/ V0 q* x R3 ^enlargement of the penis, with a stretched length of
0 J9 P" @4 \' ~! f3 b/ t5 Q8 cm and a width of 2 cm. The glans penis was very well( E4 j0 \, U4 o$ q
developed. The pubic hair was Tanner II, mostly around
; ~6 l/ k! ~ g' l0 s2 b8 o540- b+ k6 ?$ W) y4 L! ?+ \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: ]2 |! n/ a5 w# O* ]4 c& x
the base of the phallus and was dark and curled. The2 `# B$ u6 }& } T; o
testicular volume was prepubertal at 2 mL each.
4 V0 ~% O0 u0 dThe skin was moist and smooth and somewhat
, ?7 j' M5 l: M7 P8 M: C" woily. No axillary hair was noted. There were no
5 p B ^1 h: J6 ?abnormal skin pigmentations or café-au-lait spots.
% {: {# l7 M$ m' g2 GNeurologic evaluation showed deep tendon reflex 2+$ K" |$ I( m- o/ b
bilateral and symmetrical. There was no suggestion
+ a1 T7 N5 `1 g2 sof papilledema.% n3 s/ O1 G1 ]% H L6 p& U/ j
Laboratory Evaluation5 ~9 ?1 r6 M& _/ r
The bone age was consistent with 28 months by
4 z7 ~, e1 u4 S1 gusing the standard of Greulich and Pyle at a chrono-
7 b0 `. q% `' O+ B; Q4 k; ?9 ylogic age of 16 months (advanced).5 Chromosomal
. n: H0 n% L5 z# Z" ], ]karyotype was 46XY. The thyroid function test
# m7 B8 N8 E+ a. O" b4 [$ xshowed a free T4 of 1.69 ng/dL, and thyroid stimu-" J, _6 ]6 U- E3 c# q4 k& }
lating hormone level was 1.3 µIU/mL (both normal).
% v) ^. n% K' {+ r6 X- wThe concentrations of serum electrolytes, blood% \3 x( Y# u' s! ~6 _# a, l
urea nitrogen, creatinine, and calcium all were
+ g# x' k/ L1 w, R* p( V# p! qwithin normal range for his age. The concentration0 Q* Y; ^) I9 u# d% u
of serum 17-hydroxyprogesterone was 16 ng/dL. s" L' z" H, S0 b& Q5 x- U5 ]
(normal, 3 to 90 ng/dL), androstenedione was 200 I5 z- K/ {9 r% n1 f; ~" o) V
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* ]2 K; r) E) {, C, ?
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
- Z9 [% Y" K7 w6 A4 cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
( ~9 k- O: |- o3 B49ng/dL), 11-desoxycortisol (specific compound S)' @. S! G$ f; a, E9 A% S+ l6 I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 x% G, U! ^% Qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. x. p/ }& a1 Y; z. K# W
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; c/ N. c: y- B$ ~6 b1 ~and β-human chorionic gonadotropin was less than
! f8 v! h0 O0 q2 [6 j5 mIU/mL (normal <5 mIU/mL). Serum follicular
% h" o; O* l& Z" J' ]8 Hstimulating hormone and leuteinizing hormone
+ r- ]* C$ I: |$ h- econcentrations were less than 0.05 mIU/mL. C, i, i: g+ H& ~
(prepubertal).
# }* u7 s* Q0 WThe parents were notified about the laboratory# u4 F" Z% ^' b, j8 [ C( |9 k# ~
results and were informed that all of the tests were
6 M$ R- \# C: e7 n4 k# snormal except the testosterone level was high. The! a9 S8 R0 v! j+ H8 c6 q0 U
follow-up visit was arranged within a few weeks to
2 {7 ?2 o8 {& g& E/ V& xobtain testicular and abdominal sonograms; how-# v _$ @. E% `. F
ever, the family did not return for 4 months.( S' ~9 H7 T- h5 _+ D/ j6 t
Physical examination at this time revealed that the
4 ?( i& N5 Y. u( H9 M% C7 U; hchild had grown 2.5 cm in 4 months and had gained2 m( N1 h& |* `% \) q3 B
2 kg of weight. Physical examination remained# D6 K; t* v- O$ i' v
unchanged. Surprisingly, the pubic hair almost com-
9 y. B$ `' j& i* y& \pletely disappeared except for a few vellous hairs at! S& i/ H4 G7 M2 e/ J' ^$ C) [
the base of the phallus. Testicular volume was still 2& l% C% u% S6 o# M' o& q* E
mL, and the size of the penis remained unchanged.
( E4 `+ ^1 H& BThe mother also said that the boy was no longer hav-
# ~) ^4 Z- o8 n: k7 ving frequent erections.
0 t l+ h6 r7 h) I/ R YBoth parents were again questioned about use of; g. ]8 q0 q2 c
any ointment/creams that they may have applied to
- A% _: h4 W1 l$ K6 p3 d6 t6 tthe child’s skin. This time the father admitted the
# m% A* \1 r7 ?9 u8 k; bTopical Testosterone Exposure / Bhowmick et al 541
9 u- V% L `3 v7 Huse of testosterone gel twice daily that he was apply-
4 g% }! ]: `/ k( i" i1 Uing over his own shoulders, chest, and back area for; C6 K) r% p8 K# [6 _* j
a year. The father also revealed he was embarrassed" Z6 n4 L8 {# ?% s5 t7 q! ~
to disclose that he was using a testosterone gel pre-
9 j" c4 q( E+ F' |2 l' z4 ~scribed by his family physician for decreased libido$ `5 C1 f( W6 [% Q& S2 }" Y& H
secondary to depression.
+ ~4 [1 i; I1 z/ u1 k) cThe child slept in the same bed with parents.
) O3 S: ]: G1 wThe father would hug the baby and hold him on his" C. @* b0 j+ e }* [8 B' z
chest for a considerable period of time, causing sig-
2 H6 E6 F, R( m( M% Snificant bare skin contact between baby and father.9 g( _7 ?) M5 F
The father also admitted that after the phone call,: T2 G: n9 J3 o1 C6 @3 r
when he learned the testosterone level in the baby' f/ U3 s- j& l+ O/ x( a$ M$ W$ h
was high, he then read the product information
9 w, T1 q0 t) H& J9 Z% zpacket and concluded that it was most likely the rea-$ W; \8 C2 t! @. T% q4 {2 v5 s
son for the child’s virilization. At that time, they
* J6 a2 A" c* y2 Pdecided to put the baby in a separate bed, and the
) E9 v3 ?, \3 m6 C" J6 j* pfather was not hugging him with bare skin and had
' o" p3 L9 G( X9 y( {" B4 a( Bbeen using protective clothing. A repeat testosterone y% V% \% q5 ?! G" @
test was ordered, but the family did not go to the& p+ R3 D4 V6 Q% s2 W8 }* z5 S
laboratory to obtain the test.+ E% V- d8 Z& k7 ?1 @
Discussion$ v9 j2 ?4 V8 t9 {. T7 k' m
Precocious puberty in boys is defined as secondary
) c1 E. @7 H! q+ B rsexual development before 9 years of age.1,4
$ i2 N7 M2 h* z9 NPrecocious puberty is termed as central (true) when
& D- `3 ]+ j" m! Lit is caused by the premature activation of hypo- w5 h" o5 |; E: ]" ~* H0 F* ~
thalamic pituitary gonadal axis. CPP is more com-
' \1 w" W% X7 k) [( Umon in girls than in boys.1,3 Most boys with CPP
6 B' A: Y5 _1 h A3 F: n$ rmay have a central nervous system lesion that is, W0 E3 w( E' c' [& K
responsible for the early activation of the hypothal-
$ [8 d) n+ `! P/ T# a/ h9 ]amic pituitary gonadal axis.1-3 Thus, greater empha-; O5 h7 Q/ Q) ]+ m% f
sis has been given to neuroradiologic imaging in
' y$ Q# S, x# f" J& eboys with precocious puberty. In addition to viril-. A- p n: Q0 C. e" s( F" ]
ization, the clinical hallmark of CPP is the symmet-5 q+ f0 F2 H/ q
rical testicular growth secondary to stimulation by* b- R: W9 {, C9 _% g( _2 G+ R' v
gonadotropins.1,3
; t2 p- v* K% x! E+ o' y: i1 r+ G1 mGonadotropin-independent peripheral preco-. A4 ]+ ^' P h; j" ], A
cious puberty in boys also results from inappropriate6 v: ^# w9 o6 \0 U( @$ D
androgenic stimulation from either endogenous or, Z4 e) ^8 e( }8 b* k! f
exogenous sources, nonpituitary gonadotropin stim-
, I3 W& H( g, L* M4 E! julation, and rare activating mutations.3 Virilizing4 S. b, U3 I+ F! ]# ]
congenital adrenal hyperplasia producing excessive" Z; G8 u# g ?6 ?! }0 G
adrenal androgens is a common cause of precocious
' K$ Z1 P+ D- \8 t0 {puberty in boys.3,4
$ |: M7 s2 z( a: }. f2 ^, S0 rThe most common form of congenital adrenal
- Z$ u7 E3 Y3 l' O6 c! whyperplasia is the 21-hydroxylase enzyme deficiency.0 K; g. q: f" @* `! l( p- X# x
The 11-β hydroxylase deficiency may also result in
) ]( z5 E7 ^' E5 l6 Yexcessive adrenal androgen production, and rarely,' ?4 i, `3 I" r, W: R
an adrenal tumor may also cause adrenal androgen1 H$ u0 x; U6 P& B
excess.1,3% S I% x/ z4 ]) f. e) X/ M
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& L b, e& \ ] M3 `9 l542 Clinical Pediatrics / Vol. 46, No. 6, July 2007+ k! ]* c4 O) c) ^
A unique entity of male-limited gonadotropin-
# R K3 p: y" t# v, Sindependent precocious puberty, which is also known9 A+ N5 O1 H" c0 u
as testotoxicosis, may cause precocious puberty at a
5 b, g! {' T2 U& c/ w6 }0 d, g; y0 Nvery young age. The physical findings in these boys
9 t& j% |: A7 A* _with this disorder are full pubertal development,. d5 Q7 R9 }9 p, E3 U. o
including bilateral testicular growth, similar to boys. z3 D: l6 e- K ^
with CPP. The gonadotropin levels in this disorder
/ k" o. C9 s$ I1 z3 y+ o" l- Eare suppressed to prepubertal levels and do not show n( U1 t, X& w0 D
pubertal response of gonadotropin after gonadotropin-1 @! U4 Z- ?7 w: E7 a, v
releasing hormone stimulation. This is a sex-linked" }* R/ w! @" |. d0 X8 F
autosomal dominant disorder that affects only
8 L" H+ f. _" L \+ X+ nmales; therefore, other male members of the family* b) n& n, y5 P8 w- P3 j
may have similar precocious puberty.3
* n- m- S# [( Q6 A9 GIn our patient, physical examination was incon-
. O5 a: D! C3 e; b. P( k! n" Hsistent with true precocious puberty since his testi-: K3 {2 B8 O# z
cles were prepubertal in size. However, testotoxicosis ~- b/ X% f8 m* U# O
was in the differential diagnosis because his father. B6 ?3 @ G/ m- I
started puberty somewhat early, and occasionally,
/ d8 X1 v+ K, ^/ i, Ptesticular enlargement is not that evident in the
5 h3 M2 @( @( {beginning of this process.1 In the absence of a neg-" T. t1 k/ M7 A# S+ u9 J
ative initial history of androgen exposure, our* o5 o+ @, M+ j! F. i
biggest concern was virilizing adrenal hyperplasia,
# w& Q3 J# l! Z) p; Q# ~. _either 21-hydroxylase deficiency or 11-β hydroxylase
8 @7 ~$ M0 s2 }8 Tdeficiency. Those diagnoses were excluded by find-( f* p7 D6 h* v/ ?( j% p
ing the normal level of adrenal steroids.; c" B1 t* N- T+ e q `2 l
The diagnosis of exogenous androgens was strongly
% a. e5 U! X$ x* xsuspected in a follow-up visit after 4 months because) I, b/ T5 W( j6 m
the physical examination revealed the complete disap-
: V4 D. t2 s) h5 `pearance of pubic hair, normal growth velocity, and
( i, \6 c. p( D! O, ldecreased erections. The father admitted using a testos-, X5 O: W0 E5 P' w
terone gel, which he concealed at first visit. He was: ]3 N! q, r: O. h, E+ [# k: ]
using it rather frequently, twice a day. The Physicians’
}. F" B4 ^6 [ }& t: K% f1 xDesk Reference, or package insert of this product, gel or: ]: L4 t: M E: R |
cream, cautions about dermal testosterone transfer to
' X5 y$ {& P) U ]( b7 ^& |unprotected females through direct skin exposure.8 O6 A5 G( F/ f. X6 P7 d
Serum testosterone level was found to be 2 times the
4 [$ w7 y2 n" W7 A* J1 J- u, dbaseline value in those females who were exposed to
) J8 L( u$ X* @* Peven 15 minutes of direct skin contact with their male
$ p u) Q7 F! l2 `( ?partners.6 However, when a shirt covered the applica-9 X: s' u4 `0 u% r, B0 l
tion site, this testosterone transfer was prevented.+ R8 C$ G: h0 j
Our patient’s testosterone level was 60 ng/mL,$ f+ [2 T7 N) ^' E( e" {
which was clearly high. Some studies suggest that; J- X! D5 g+ B8 l" ]) f7 A9 o5 H; s
dermal conversion of testosterone to dihydrotestos-
4 c9 e: |& n3 c, I% d+ {: p* Zterone, which is a more potent metabolite, is more# g" S/ k) B( {
active in young children exposed to testosterone$ V7 c! J1 a) [
exogenously7; however, we did not measure a dihy-( [6 F4 ^2 J1 w8 W& {% k
drotestosterone level in our patient. In addition to
6 O2 A7 C6 ~( ?9 Pvirilization, exposure to exogenous testosterone in
$ E9 q; z5 D3 v6 V! c* ~' S+ ochildren results in an increase in growth velocity and* ?8 A! o2 b) e2 E; q
advanced bone age, as seen in our patient.% s! P1 Y- l( E' X2 o
The long-term effect of androgen exposure during
9 b3 E4 Q I4 z8 Q) K! ?# Vearly childhood on pubertal development and final4 p8 ^7 C" Z; n+ E7 C" n
adult height are not fully known and always remain
. V+ o+ n6 ^2 wa concern. Children treated with short-term testos-
2 k) k6 x" T. f/ ^, x0 c wterone injection or topical androgen may exhibit some
& N7 t/ E3 l. i$ K7 ]3 iacceleration of the skeletal maturation; however, after
; G0 R" I" `- R( _cessation of treatment, the rate of bone maturation4 ~" d( I' Y4 }. z
decelerates and gradually returns to normal.8,9/ U$ x! p( e+ F6 m) M
There are conflicting reports and controversy2 a- t0 f' f$ ]; X2 N p: B
over the effect of early androgen exposure on adult9 _, `# ~- c9 O1 P1 \$ b: }/ m
penile length.10,11 Some reports suggest subnormal& K( ~- o4 p: t/ [9 a0 b8 `
adult penile length, apparently because of downreg-; ~0 d8 A( r$ p+ n \/ x
ulation of androgen receptor number.10,12 However,0 s0 ^( s+ R* M" J0 e) E, v
Sutherland et al13 did not find a correlation between C' T- C i. `
childhood testosterone exposure and reduced adult- b) }( k o, z2 Z
penile length in clinical studies.4 b1 e7 {8 j8 D9 b. i
Nonetheless, we do not believe our patient is: T6 ^8 I4 |3 t2 U2 d
going to experience any of the untoward effects from+ ~" {! u$ b5 O
testosterone exposure as mentioned earlier because- ?8 ~8 z: J/ P/ e& G2 m2 M! A+ ^
the exposure was not for a prolonged period of time.- k" a# A3 b0 v9 |
Although the bone age was advanced at the time of
; p$ o( k4 O2 S& i6 Fdiagnosis, the child had a normal growth velocity at$ v0 n$ Z; a0 q" q8 ~5 m1 N# m
the follow-up visit. It is hoped that his final adult
% {9 e, G8 }# ~8 k5 {, Y, T9 lheight will not be affected., a7 o% q `4 j" @, R
Although rarely reported, the widespread avail-
/ Y8 T: O2 ^4 Pability of androgen products in our society may' ~/ T& A: ?- A# C. e* j& N8 x' i
indeed cause more virilization in male or female* `9 o2 I8 Q+ ~- N; C
children than one would realize. Exposure to andro-8 j% `$ j& K9 F' H4 x
gen products must be considered and specific ques-
9 F/ }9 A3 x1 D/ Ptioning about the use of a testosterone product or1 |5 R6 P+ Q: t' J" U% X
gel should be asked of the family members during
, z* ~$ n) T: c: C8 ?! s }the evaluation of any children who present with vir-; H* Z L' l- }5 |6 Y% d
ilization or peripheral precocious puberty. The diag-5 v# s. c* Y1 L7 y' X' G
nosis can be established by just a few tests and by, Z: ~% Z* A! x) K4 g5 r7 f j- R
appropriate history. The inability to obtain such a1 a* u+ B) m7 [6 C- N' g. H$ ]
history, or failure to ask the specific questions, may
+ L4 I/ W6 q3 r. J* ~result in extensive, unnecessary, and expensive2 c/ k# u9 a9 r. w
investigation. The primary care physician should be2 e8 j" o- }& E# i* r! q7 n; I( O
aware of this fact, because most of these children) s; J4 o9 \8 G4 u6 L$ {: W
may initially present in their practice. The Physicians’
* n* f) d6 X! r8 ?( s0 ]! H& O- ?Desk Reference and package insert should also put a7 H8 Z! W2 k3 E1 o8 R
warning about the virilizing effect on a male or
8 M# v% l/ e, N: h% \! S+ Tfemale child who might come in contact with some-
5 @6 X: L: o$ ?4 r! Z) Lone using any of these products. Y7 L2 y5 |& b3 n. T: W
References
% [. s' y- s8 s. P0 y, _% ]1. Styne DM. The testes: disorder of sexual differentiation
6 b+ J/ U/ R; ]9 k2 o$ tand puberty in the male. In: Sperling MA, ed. Pediatric" _) H+ H7 }7 b* p) ^
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 \- K8 w9 p, t2002: 565-628.- x& ~& t- w& g! A) {
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious6 @6 ] c" G$ U" \$ R# s
puberty in children with tumours of the suprasellar pineal |
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