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Sexual Precocity in a 16-Month-Old' @( P1 m0 g) |* ~4 i
Boy Induced by Indirect Topical0 J. g1 X" R. a! y* j: u5 R' H# i6 L
Exposure to Testosterone
( D U/ T9 F. uSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; D# S( z/ N. b$ u3 M) d* o' Qand Kenneth R. Rettig, MD1
8 n1 J C; x' s0 qClinical Pediatrics
/ H5 W; o9 R# uVolume 46 Number 6
) f5 f/ O$ s/ x; mJuly 2007 540-543( j1 C. U" w8 w8 r' `" C j
© 2007 Sage Publications
X5 |( g* W. {# y10.1177/0009922806296651
8 z5 [ A4 D$ q8 i% i- X: Jhttp://clp.sagepub.com* }$ ~- v' z) q$ l z2 P
hosted at2 ~4 {4 _* _" A
http://online.sagepub.com! s3 `$ P7 G/ N
Precocious puberty in boys, central or peripheral,: }7 n- H3 Q8 \4 L0 X
is a significant concern for physicians. Central" H( S" Q; _! J' {
precocious puberty (CPP), which is mediated
0 t0 V5 }2 J6 H3 k9 ~: I d1 o- _& e3 Zthrough the hypothalamic pituitary gonadal axis, has. [& `( g1 g& v: }, J+ Q9 a$ g7 N7 l
a higher incidence of organic central nervous system
; x! {4 t; ~2 u9 E, y2 h/ W; M" Clesions in boys.1,2 Virilization in boys, as manifested
+ F' J' P f9 j7 o0 t! Hby enlargement of the penis, development of pubic6 {4 X' _$ z b+ j2 ]8 [) m
hair, and facial acne without enlargement of testi-
# @+ z; m2 K" Ecles, suggests peripheral or pseudopuberty.1-3 We
4 S* e4 r5 ?( w2 s1 }4 z) Q1 m( ^report a 16-month-old boy who presented with the
, T# x; T- b, H) A3 [/ }" |enlargement of the phallus and pubic hair develop-
, h5 P3 M0 w" a( s4 D! S, b+ f) m% Tment without testicular enlargement, which was due
* v: X# @1 M4 Y Ito the unintentional exposure to androgen gel used by% z4 T% z: F& ]% @ I* s5 f
the father. The family initially concealed this infor-0 y3 ] ]) i3 F a
mation, resulting in an extensive work-up for this9 }, _7 ]8 ~1 v# U4 K" }+ @
child. Given the widespread and easy availability of
6 v# k- i% u& c9 m% ^1 P- Ltestosterone gel and cream, we believe this is proba-. s. J$ e" s5 q( @) l) c- a% M
bly more common than the rare case report in the3 d2 f) O) J! B* h) A$ ~3 f$ h u9 L
literature.4
% h- a! [* o0 ~" @6 ZPatient Report
9 A4 l) U( `) i+ \; ^; TA 16-month-old white child was referred to the8 c& }& N% y) n+ V+ g
endocrine clinic by his pediatrician with the concern! |- Q' i# F! S5 T9 W9 \- U* L
of early sexual development. His mother noticed
, p( {3 }& T0 o2 zlight colored pubic hair development when he was
) n5 w: e4 P O+ `' V1 O$ y! _* SFrom the 1Division of Pediatric Endocrinology, 2University of- i7 c/ i- T4 y+ _3 c/ a V
South Alabama Medical Center, Mobile, Alabama.
# Z& e _4 m1 f/ v9 m. dAddress correspondence to: Samar K. Bhowmick, MD, FACE,4 F+ ^5 ?6 t$ x( N
Professor of Pediatrics, University of South Alabama, College of
* q5 q% N" q$ M8 W( l) y& W7 ?Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;! u+ J9 y+ f8 S0 D$ R
e-mail: [email protected].
. t# a, c6 [8 k: W8 m( Uabout 6 to 7 months old, which progressively became
9 T' ~* f- |3 C z1 I& c6 Wdarker. She was also concerned about the enlarge-
2 \) y; ^1 ^( Q. l2 N! ~3 A: ument of his penis and frequent erections. The child6 U: ?2 K9 G/ p
was the product of a full-term normal delivery, with
2 [0 O& Q! M2 d0 Q/ B+ Z8 x* ya birth weight of 7 lb 14 oz, and birth length of
8 {% h+ X& b) K. o5 }5 K20 inches. He was breast-fed throughout the first year
* B1 D ]) E, L7 d! `of life and was still receiving breast milk along with
4 [4 X, c/ [( |: P/ u esolid food. He had no hospitalizations or surgery,
: X" H+ X' x3 c0 R7 K# c! ^& x1 Z# band his psychosocial and psychomotor development5 f4 A9 {* O p' z7 A, Z) c# U
was age appropriate.
. z( X. B# _" A- t; MThe family history was remarkable for the father,
+ L. H( ]+ r1 l% N! xwho was diagnosed with hypothyroidism at age 16,
$ h9 Y; C) q0 I. X# {which was treated with thyroxine. The father’s
) [$ x# W7 Q7 U: i; Y# N, sheight was 6 feet, and he went through a somewhat
8 _+ t7 p( p) J% l- [$ t( kearly puberty and had stopped growing by age 14.
" W d7 b% F+ N3 X2 H3 M4 v5 b/ R3 HThe father denied taking any other medication. The
" P) y7 R/ p0 n0 ~+ Q" \5 X! |9 Mchild’s mother was in good health. Her menarche! E1 l7 R0 V0 Y
was at 11 years of age, and her height was at 5 feet
$ \% E/ x; w4 B! i5 inches. There was no other family history of pre-5 d7 C; s. q3 ^- C
cocious sexual development in the first-degree rela-2 b4 s. y' J: K3 ^! Y
tives. There were no siblings.0 u# `; `* l$ _& q5 L, o
Physical Examination! P5 S; ]2 N$ ~: \& K7 }
The physical examination revealed a very active,! r: o. K. A- i. `3 I% y4 m
playful, and healthy boy. The vital signs documented
/ a6 d! [9 k9 t# G3 ]- xa blood pressure of 85/50 mm Hg, his length was& {, y6 D/ w/ a% R
90 cm (>97th percentile), and his weight was 14.4 kg
i* c$ F; x- o3 i9 F4 |(also >97th percentile). The observed yearly growth- C" u C6 h* l: E9 Q
velocity was 30 cm (12 inches). The examination of" u/ M9 W( i' H. b& h7 R9 W$ v
the neck revealed no thyroid enlargement.5 S9 ]2 s) \6 f( i, p- c9 h$ y6 p6 Y4 }
The genitourinary examination was remarkable for
( }7 o" E2 E7 E& \; I. g' renlargement of the penis, with a stretched length of0 H$ q' `- p9 K0 z+ B
8 cm and a width of 2 cm. The glans penis was very well* d0 F. J! @$ I/ O
developed. The pubic hair was Tanner II, mostly around7 }/ W S" @3 h) g3 m
5406 J) r! p! G! u$ X A4 W8 K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 n3 \) n- [# T; o* h1 \& u$ `* U
the base of the phallus and was dark and curled. The
, R% t& Y- U o. i( Rtesticular volume was prepubertal at 2 mL each.
# d- a7 n) f8 FThe skin was moist and smooth and somewhat
) T: U% C f1 @, h8 X) r0 O0 _' uoily. No axillary hair was noted. There were no: j4 A" i/ t# p
abnormal skin pigmentations or café-au-lait spots.
+ M$ @" C# g, `Neurologic evaluation showed deep tendon reflex 2+9 H6 ?$ ^# i; ~) V( N% F6 Q
bilateral and symmetrical. There was no suggestion) r9 [! _* U# _
of papilledema.6 }% e% |. `9 m4 Z
Laboratory Evaluation
* h, t( J2 ?+ G( T8 p+ u/ PThe bone age was consistent with 28 months by, @7 g) m. F* J5 ~1 g3 y" ?; @
using the standard of Greulich and Pyle at a chrono-
+ g* e7 L" L) plogic age of 16 months (advanced).5 Chromosomal
3 U5 z+ A9 ~ b+ f" z3 {7 m1 ]karyotype was 46XY. The thyroid function test
3 Z1 l4 c* }1 d& T+ _' F# [- ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-" x; s/ I" k1 {, j
lating hormone level was 1.3 µIU/mL (both normal).
{" i% J5 X% i/ t1 BThe concentrations of serum electrolytes, blood0 b, y3 |1 t' P/ W# _
urea nitrogen, creatinine, and calcium all were
. s2 ]4 E; j, e8 Z' pwithin normal range for his age. The concentration
& ^ _$ K' H: P, m( ?! Yof serum 17-hydroxyprogesterone was 16 ng/dL4 e; i# O8 U9 K/ A; M% c
(normal, 3 to 90 ng/dL), androstenedione was 20: l! H* C5 {2 }' R
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( @- u' N$ F; q9 x, ]: |terone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 _! a8 T/ ~- e1 h! B2 qdesoxycorticosterone was 4.3 ng/dL (normal, 7 to. L; T" n1 F' e8 q
49ng/dL), 11-desoxycortisol (specific compound S)- ?' x; S }# o/ N+ {+ w/ e! ? L
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- ], |3 J u! ]
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total8 ~- n4 W- B' A& ?* m* j0 }# u8 s9 X r
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),. N6 D& \2 g6 p: {' n
and β-human chorionic gonadotropin was less than6 w# Z$ l" i: U" I7 j6 ?$ n8 k
5 mIU/mL (normal <5 mIU/mL). Serum follicular: }4 y$ v- t: v
stimulating hormone and leuteinizing hormone, i! z. ?* l, {
concentrations were less than 0.05 mIU/mL8 o; ?: D4 b) q* C' J5 f- r6 R
(prepubertal).
* T7 A9 Y; Q+ O: w% A% y+ VThe parents were notified about the laboratory
+ H2 a6 R$ x: r! B: [# k- ]results and were informed that all of the tests were
& D4 F0 H2 W' o; }: _! Tnormal except the testosterone level was high. The
0 X4 i4 n7 o$ e, Tfollow-up visit was arranged within a few weeks to
7 \( f* q" G* q* R1 Cobtain testicular and abdominal sonograms; how-$ Q' s- q0 v- B3 K! ~8 n
ever, the family did not return for 4 months.% N9 y; U4 C! |
Physical examination at this time revealed that the: I. l4 L; z$ |: B8 j
child had grown 2.5 cm in 4 months and had gained
- R: r; M/ g# q9 }3 G# a- s2 kg of weight. Physical examination remained
$ v% f: ^3 s: @5 c2 uunchanged. Surprisingly, the pubic hair almost com-8 V4 L' _, j. D, X- q: _0 n- y
pletely disappeared except for a few vellous hairs at! E% I. R P' D* ^
the base of the phallus. Testicular volume was still 2
6 o- {/ Y1 J) kmL, and the size of the penis remained unchanged.! k+ ^1 i+ ~( h) G: c. I2 ^
The mother also said that the boy was no longer hav-
8 U4 X' s7 i& Z5 a2 S" C( G0 ? C. Ting frequent erections.
$ l9 S% j) m! P7 E3 Q1 QBoth parents were again questioned about use of' Y! f' V* z5 ?. u! q
any ointment/creams that they may have applied to, L2 g9 o e% q# K" U6 u- L
the child’s skin. This time the father admitted the
9 a' Z& c: M7 Z* x h6 KTopical Testosterone Exposure / Bhowmick et al 541% g! t) r. _& O& I. x+ g2 U3 t* F- |
use of testosterone gel twice daily that he was apply-
+ P, e2 w$ a: ]6 m! hing over his own shoulders, chest, and back area for
& ]: g( Q5 K3 G9 t/ ta year. The father also revealed he was embarrassed
, d8 ~% a! d! C1 ^to disclose that he was using a testosterone gel pre-
, h) _2 M9 h, Z' t: mscribed by his family physician for decreased libido- s( v6 ]; f' X& b2 q. @5 U0 u
secondary to depression." q: s& I, G# d2 I: W' q$ ?
The child slept in the same bed with parents./ L J% d2 K0 t! W8 v
The father would hug the baby and hold him on his
9 l2 z; E4 y( n& ]* y& P( }' qchest for a considerable period of time, causing sig-
( t* F1 G& I z- \3 hnificant bare skin contact between baby and father.7 X) k% ?) c& i, S8 j6 A9 E$ Q
The father also admitted that after the phone call,
+ ^: a$ M/ O; E! [) _" m, Z, e Ywhen he learned the testosterone level in the baby
5 }) i& p. l/ J$ g5 ^1 Z" swas high, he then read the product information
& a& P W# b- E7 Tpacket and concluded that it was most likely the rea-
7 k- \$ U( a& ]. z8 V9 O; y$ Ason for the child’s virilization. At that time, they' A9 {! |7 O1 E% N1 C7 b- D
decided to put the baby in a separate bed, and the
# o. T; G I, b3 ~, i6 l: Q4 Efather was not hugging him with bare skin and had; E+ r7 ` F/ v# b
been using protective clothing. A repeat testosterone
8 Y( B/ s! ^6 Z6 J" p* ^test was ordered, but the family did not go to the& y& i! n* k0 C# N
laboratory to obtain the test." h) L2 I# Q" {2 S
Discussion @' ]* u& ^2 Z% j- U
Precocious puberty in boys is defined as secondary
- R1 [) i5 ~/ }9 w9 ~sexual development before 9 years of age.1,4
( p8 @2 _: Q* M# q# F: L) J( KPrecocious puberty is termed as central (true) when4 B. f- q' Y K: ]& y& a4 R7 ^) ]- i+ ~
it is caused by the premature activation of hypo-
: ?' C- W* s; z( ^$ c y3 n; ethalamic pituitary gonadal axis. CPP is more com-2 m, O& W, F% |/ X! q, z8 T' @
mon in girls than in boys.1,3 Most boys with CPP$ e/ A. Z" E) Q! h) K8 J
may have a central nervous system lesion that is) L( Q$ R' ]) p& j' g
responsible for the early activation of the hypothal-
. s* A( x: k. r; Hamic pituitary gonadal axis.1-3 Thus, greater empha-5 n# o& _3 t# F9 ^
sis has been given to neuroradiologic imaging in/ {6 q; d/ H3 v/ p- v) A w
boys with precocious puberty. In addition to viril-$ }& V9 _: E$ p0 }/ ^% l; t
ization, the clinical hallmark of CPP is the symmet-
! _" m2 m! Q6 W5 G- H, |rical testicular growth secondary to stimulation by
5 W* W, N6 d) x) S' N( B! N: Ngonadotropins.1,3, ?6 P# f+ h- _0 ^: k' W
Gonadotropin-independent peripheral preco-
9 p6 \% d5 R4 N8 h, I3 \: R; p6 Fcious puberty in boys also results from inappropriate
% ]4 r$ t# O0 p; handrogenic stimulation from either endogenous or0 W6 k7 N" I( t4 q# }
exogenous sources, nonpituitary gonadotropin stim-* G4 ^5 k; ?# @' ?
ulation, and rare activating mutations.3 Virilizing$ s* P: c5 s/ u+ P7 `* Q
congenital adrenal hyperplasia producing excessive" b2 s9 y6 s5 P) Q! |( t
adrenal androgens is a common cause of precocious
7 M9 I8 O9 z |6 w0 o5 p8 m5 @5 Wpuberty in boys.3,4; K$ ^5 x2 c( G
The most common form of congenital adrenal
" y/ D" r" w5 M" v, W2 Y& X8 Ehyperplasia is the 21-hydroxylase enzyme deficiency.
% x- @: p/ U# X& {: \The 11-β hydroxylase deficiency may also result in
+ O1 z# a! s S+ l8 Q Y) i% c2 R0 lexcessive adrenal androgen production, and rarely,! z4 v$ w( k. n7 `: E* r
an adrenal tumor may also cause adrenal androgen
1 |# z- M. R2 F- p. xexcess.1,3! l- P3 n% u; d+ ^4 m6 S6 R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! H5 v+ i ]: C; U V' x542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! y; v, l! f2 M) {) E! t5 z5 f& EA unique entity of male-limited gonadotropin-
X+ h/ o! ~( tindependent precocious puberty, which is also known8 o# F$ P2 b+ ?
as testotoxicosis, may cause precocious puberty at a
9 `6 p6 \& A# Vvery young age. The physical findings in these boys
) ? J/ y' o+ T( c; F& O0 ~with this disorder are full pubertal development,) ^1 l" T. ?1 ?
including bilateral testicular growth, similar to boys) F. O4 X" Y5 h% i( ?
with CPP. The gonadotropin levels in this disorder! u6 H* t# b# s0 w; z
are suppressed to prepubertal levels and do not show
- _6 I& |1 j0 @* m1 u1 ?7 \pubertal response of gonadotropin after gonadotropin- `: X! {! z( @2 ?4 X
releasing hormone stimulation. This is a sex-linked
' Y; r) X B! F9 i, h9 o5 R7 Cautosomal dominant disorder that affects only" C9 X3 K5 b' V- d- y$ ?
males; therefore, other male members of the family
2 k1 G, q4 S1 G, Amay have similar precocious puberty.39 T! U5 }- |0 u" j" l- J0 t! v
In our patient, physical examination was incon-7 d. w0 l v2 a2 c- S* Y8 D1 t3 y- {
sistent with true precocious puberty since his testi-' f' M5 ]+ U- J& d) u
cles were prepubertal in size. However, testotoxicosis
0 y6 {6 Q+ d/ u, P0 Swas in the differential diagnosis because his father
- _8 J% H. A; r+ p& e# ^* t( N0 }started puberty somewhat early, and occasionally,
: x; Q) s9 [$ j) [, g0 z; f7 e R6 {testicular enlargement is not that evident in the
, i6 r, x4 Z9 e8 R9 W4 L2 Rbeginning of this process.1 In the absence of a neg-# [3 C9 n! J |. K$ V% ]# g% R
ative initial history of androgen exposure, our
# H! d* M |6 m: rbiggest concern was virilizing adrenal hyperplasia,* k, Q4 e% h6 @/ {3 h
either 21-hydroxylase deficiency or 11-β hydroxylase
9 x ?5 z5 c. Y0 b" Fdeficiency. Those diagnoses were excluded by find-: ]. f: V4 i6 d5 l K( H7 y
ing the normal level of adrenal steroids.) D3 E7 _" Q+ c' l
The diagnosis of exogenous androgens was strongly
: r# B4 J; \# g# P* ysuspected in a follow-up visit after 4 months because
+ L: f) n$ I( lthe physical examination revealed the complete disap-
/ I( I- _1 @2 ]7 U! X' apearance of pubic hair, normal growth velocity, and: l; h5 [- L Y. q+ e( _
decreased erections. The father admitted using a testos-
( N1 E& Q7 A+ r2 T$ W4 Nterone gel, which he concealed at first visit. He was3 f! o) {' K0 z# M
using it rather frequently, twice a day. The Physicians’
& o z# R+ m3 ?8 R8 NDesk Reference, or package insert of this product, gel or) s Y# g, l/ N9 z \+ b, `
cream, cautions about dermal testosterone transfer to
9 I2 H. B$ V/ Uunprotected females through direct skin exposure.8 X" d) l0 g! p. T4 Y& l
Serum testosterone level was found to be 2 times the
3 q6 s6 C2 O7 ^6 ibaseline value in those females who were exposed to
7 E4 X0 P3 d- Q& peven 15 minutes of direct skin contact with their male' @% H* A" s: {+ k2 ~
partners.6 However, when a shirt covered the applica-
y/ p! I- ^7 L- Z; P) K& L* htion site, this testosterone transfer was prevented.
1 H; i7 a& ]$ [4 E! c5 M5 y4 mOur patient’s testosterone level was 60 ng/mL,) r- `. J+ H3 J# f
which was clearly high. Some studies suggest that
6 n4 U0 G H, B" m! u9 T; ndermal conversion of testosterone to dihydrotestos-
4 r3 G! t* q; fterone, which is a more potent metabolite, is more
* {/ k! f2 K. N2 q, Zactive in young children exposed to testosterone8 z6 Q+ s2 M9 q _* v
exogenously7; however, we did not measure a dihy-
4 d" H- b; S, l( Sdrotestosterone level in our patient. In addition to
8 W: t" m1 s: cvirilization, exposure to exogenous testosterone in
0 z) L6 o8 o bchildren results in an increase in growth velocity and+ c" d+ a. i, {: D: o# E3 G
advanced bone age, as seen in our patient.; x9 e3 q8 n- o- b
The long-term effect of androgen exposure during/ A9 a5 J( t$ t
early childhood on pubertal development and final* @+ @0 W8 D9 W3 y* J0 ~
adult height are not fully known and always remain. ?7 j! ~# M# ?3 X" D; P2 m
a concern. Children treated with short-term testos-
- U1 l l- j7 n% |terone injection or topical androgen may exhibit some0 B7 N# X* r2 \4 V" H8 a+ O# D/ O9 s
acceleration of the skeletal maturation; however, after
& l( h" P/ e3 B D- a6 }( [cessation of treatment, the rate of bone maturation7 J9 r0 ?) {. n$ W/ @# I
decelerates and gradually returns to normal.8,9
9 r. O; Q; O1 w4 Y" ~+ }7 PThere are conflicting reports and controversy
3 i# U h! B5 q$ b' F4 q! {over the effect of early androgen exposure on adult
; g# Z. L m- c, \$ q" J3 V9 ^penile length.10,11 Some reports suggest subnormal' {/ r! k& o j5 R9 M* t
adult penile length, apparently because of downreg-
2 j: X0 r% ]! `+ mulation of androgen receptor number.10,12 However,& e- b8 k* @0 o a# E& p% Y
Sutherland et al13 did not find a correlation between
6 j: ^; ]' S5 o4 w, q( R7 } N( dchildhood testosterone exposure and reduced adult
- q- A& l& ^4 [; e4 Cpenile length in clinical studies.
: `8 Q1 q4 A7 \: H9 j3 DNonetheless, we do not believe our patient is
' r" C& x# ]" Cgoing to experience any of the untoward effects from
( E& W4 @) N4 I& t4 ttestosterone exposure as mentioned earlier because5 r8 M) w1 t; x6 J. b, w9 s
the exposure was not for a prolonged period of time.7 W/ b, ]. g1 f9 x- r5 }7 z# r
Although the bone age was advanced at the time of
. V7 L" X" S A* xdiagnosis, the child had a normal growth velocity at+ D$ a7 [1 E/ Y7 A9 P- p; \6 T
the follow-up visit. It is hoped that his final adult8 ?4 D4 K2 B$ r3 ?7 Q
height will not be affected.5 E# n9 N! u- b) A+ g4 Z" L
Although rarely reported, the widespread avail-
- ~0 ^1 R& v( [9 ?- H& qability of androgen products in our society may
. H$ {, L, p: l: Z7 @indeed cause more virilization in male or female: D% ]2 a* x1 e
children than one would realize. Exposure to andro-
! h* W9 a$ ~+ F* S# ^1 k( bgen products must be considered and specific ques-$ ]6 b, Y7 x0 ~' U0 I7 n
tioning about the use of a testosterone product or, i' t- C( h9 j k' R) s2 ?* Y
gel should be asked of the family members during9 J5 x* o! ~% {/ i4 _$ F5 ]# O
the evaluation of any children who present with vir-
) r+ N% u; u5 x- c Gilization or peripheral precocious puberty. The diag-1 t5 |. x+ }- k9 }$ T/ x
nosis can be established by just a few tests and by
. r- c& ]8 k# N. C6 X; q* tappropriate history. The inability to obtain such a9 B4 B$ K" O4 ^' F
history, or failure to ask the specific questions, may. W6 J# s3 F; f6 r
result in extensive, unnecessary, and expensive( L8 d5 O8 P g$ E
investigation. The primary care physician should be
' w$ Y4 w' c; u. D! aaware of this fact, because most of these children
- r8 {4 F2 |& o( D( Cmay initially present in their practice. The Physicians’
+ D1 |* b6 t" \1 i5 V6 YDesk Reference and package insert should also put a! a6 O2 L% ]5 ]3 Q( ?/ U, m
warning about the virilizing effect on a male or
r/ ^5 U& x$ p1 b4 t0 c Wfemale child who might come in contact with some-
% }' `* g7 X- [' U: s( y {! gone using any of these products.2 H# `) R3 d9 v* X" w
References
- D3 m* E. i! ^+ i( s( a1. Styne DM. The testes: disorder of sexual differentiation. q' e( n$ V0 a3 t( N
and puberty in the male. In: Sperling MA, ed. Pediatric
8 e% e+ y0 m* T3 z' D1 `1 M0 ]Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 P9 q' Z; l g7 H: p& b2002: 565-628.- R. q7 ~- Q) v# O3 o1 e
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
3 V! W1 r0 U# ~! M- A7 Gpuberty in children with tumours of the suprasellar pineal |
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