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Sexual Precocity in a 16-Month-Old
: @- Y m7 O/ |% O/ cBoy Induced by Indirect Topical
4 X1 p; A* ]4 S/ |7 O- }Exposure to Testosterone
, ] c. b: [0 s( v4 RSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
) o( x$ _$ M/ c" Fand Kenneth R. Rettig, MD13 n4 N: \/ E5 k, R
Clinical Pediatrics, k2 o# [; I6 }
Volume 46 Number 6
, F7 G8 v" B& r, IJuly 2007 540-543
( `$ W/ ^) v- v4 R" K% o% h© 2007 Sage Publications
. F* ~+ v; h U6 ?' [10.1177/0009922806296651
$ v. r* s f9 m+ X+ I# Vhttp://clp.sagepub.com$ R$ O% B2 R" Y; V+ Z7 D
hosted at9 a7 g3 H# V7 |' o4 m; b
http://online.sagepub.com
% b! t" W$ E5 R+ Q+ X: R8 sPrecocious puberty in boys, central or peripheral,
+ T" e6 j8 z2 d/ J* X3 X$ Kis a significant concern for physicians. Central; A- p1 G1 \2 m* v. y* x
precocious puberty (CPP), which is mediated
Y( _8 o% H: ethrough the hypothalamic pituitary gonadal axis, has6 q; _" E* x5 k& x5 q6 F) f0 F
a higher incidence of organic central nervous system2 U: [/ G8 n2 R8 |8 n$ k
lesions in boys.1,2 Virilization in boys, as manifested
; A# f( h+ {5 j* C0 r3 Mby enlargement of the penis, development of pubic
6 t9 K# s8 k' i5 Q' ~; `+ P% Ihair, and facial acne without enlargement of testi-: l* ?: |& j( y! L
cles, suggests peripheral or pseudopuberty.1-3 We8 ~/ _& M& y `4 v6 }
report a 16-month-old boy who presented with the
0 _+ P" ^/ y5 Qenlargement of the phallus and pubic hair develop-( d$ c7 _: }3 k+ t
ment without testicular enlargement, which was due: k6 d9 g" G9 G: }, U [
to the unintentional exposure to androgen gel used by
5 _1 ]' z2 ~' }7 [+ u! m9 Lthe father. The family initially concealed this infor-8 f) t& L# m" H0 d1 [
mation, resulting in an extensive work-up for this$ G: d I3 q# `( `8 H9 n, ^
child. Given the widespread and easy availability of
4 u8 ?1 G- P. y ^2 J9 {testosterone gel and cream, we believe this is proba-4 }2 D+ p e* j9 `* {# }( r! {
bly more common than the rare case report in the6 t: o3 ]$ f6 r8 H) C/ u& }
literature.4
# I. g3 C/ Z, L! t( bPatient Report+ V! Z/ E1 ~# f9 w4 u
A 16-month-old white child was referred to the4 v6 O U9 P3 J( C4 O
endocrine clinic by his pediatrician with the concern
, g, {+ l2 q4 jof early sexual development. His mother noticed
" J( } X- n# u6 k7 c- M! E \light colored pubic hair development when he was
" Q0 x0 a$ h6 E9 WFrom the 1Division of Pediatric Endocrinology, 2University of. @6 o9 S) e" V) i3 W
South Alabama Medical Center, Mobile, Alabama.; x) V* N8 }: L, x
Address correspondence to: Samar K. Bhowmick, MD, FACE,1 w" }8 [* l. J! j1 j
Professor of Pediatrics, University of South Alabama, College of
" y4 b' h4 ^/ v2 a) o6 sMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 x+ \5 g4 {- `3 Y0 n1 \
e-mail: [email protected].
6 N& X- b8 l; H0 l' pabout 6 to 7 months old, which progressively became
1 l; G9 J6 I9 Xdarker. She was also concerned about the enlarge-2 \+ i* E; H, u* n+ W
ment of his penis and frequent erections. The child; e& M& m e' z2 U/ p. K+ v
was the product of a full-term normal delivery, with5 K3 m7 l0 {3 w
a birth weight of 7 lb 14 oz, and birth length of
4 `; C4 J3 g+ d2 q! J20 inches. He was breast-fed throughout the first year
# j. _5 G: d+ U6 H# ?of life and was still receiving breast milk along with
2 z% R" k2 T; D- P6 s6 L/ O0 [solid food. He had no hospitalizations or surgery,, `# n7 i* N8 Q, B' I4 i
and his psychosocial and psychomotor development; L& ^' L( A& V# G Q
was age appropriate.
x* P0 T. o/ X. f! k! ]The family history was remarkable for the father,
9 k l0 F" }, R/ _7 Vwho was diagnosed with hypothyroidism at age 16,
& s: M3 E, v, vwhich was treated with thyroxine. The father’s; G# {' {6 y) q' ?) {
height was 6 feet, and he went through a somewhat
' I; u) s( K# c2 ~ |4 searly puberty and had stopped growing by age 14.! V) d# Y# B# r D( c' S
The father denied taking any other medication. The$ x0 N' ?9 O% K+ ^: v1 N5 S
child’s mother was in good health. Her menarche. a. G" b5 Y$ m7 _/ a3 M8 L
was at 11 years of age, and her height was at 5 feet$ K- u* V. i$ Q. m# G! w
5 inches. There was no other family history of pre-9 k+ I2 A6 m& s! W
cocious sexual development in the first-degree rela-+ B! W: @: G( W, v& O5 A
tives. There were no siblings.
( R6 ?; {9 M9 T% @Physical Examination
i! s% V- r8 k1 A5 V- `7 TThe physical examination revealed a very active,. B) P0 ^. u& C2 \9 A1 ^, z; R
playful, and healthy boy. The vital signs documented$ G S; f6 I* D) d1 S, |
a blood pressure of 85/50 mm Hg, his length was( D+ S2 Z5 M8 j
90 cm (>97th percentile), and his weight was 14.4 kg
4 L$ @- v8 @5 N( T& E(also >97th percentile). The observed yearly growth' t5 s% r3 `+ c1 o3 R6 {; r5 b( ]
velocity was 30 cm (12 inches). The examination of
1 P' H8 z% W( O1 l' L8 wthe neck revealed no thyroid enlargement.' `7 F2 M& w) H2 n0 g" }% W0 P
The genitourinary examination was remarkable for
- X; w; n6 V6 l8 E/ senlargement of the penis, with a stretched length of% \6 ^ i: S0 E8 Z
8 cm and a width of 2 cm. The glans penis was very well
' @& s6 m. d. p" g8 Z ]- kdeveloped. The pubic hair was Tanner II, mostly around
. z6 |0 ] [0 A8 |1 C s540
) R! C& E. ? f' @3 j8 k. h& `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 ~" C$ r" q P$ E
the base of the phallus and was dark and curled. The" L5 g/ ]0 J. Q! t8 Q
testicular volume was prepubertal at 2 mL each.
: b, ?- H% z# ` y3 c3 pThe skin was moist and smooth and somewhat# w: s* W# y: K9 ^
oily. No axillary hair was noted. There were no
; ~8 i3 M0 p2 h; q9 A( K3 I, babnormal skin pigmentations or café-au-lait spots.2 j3 P# R. J" Q6 S
Neurologic evaluation showed deep tendon reflex 2+3 G$ y( t+ p3 D" u( \9 k
bilateral and symmetrical. There was no suggestion
: |, p5 [9 T3 P/ k3 {' Bof papilledema.% H( I" i3 A1 n4 t$ E) F
Laboratory Evaluation9 e, z0 Q- G# L
The bone age was consistent with 28 months by
* ~) `0 D5 R& @: q4 ~& ^- [+ ausing the standard of Greulich and Pyle at a chrono-$ k8 [0 v7 H* p1 m& E
logic age of 16 months (advanced).5 Chromosomal
) M7 V7 \- b$ |, J' x1 Y6 T! Fkaryotype was 46XY. The thyroid function test
- A/ J& T1 @& `5 mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-2 r6 W/ j& j' D, k; M; j
lating hormone level was 1.3 µIU/mL (both normal)., {/ o/ X+ d' a; R. U* g4 G
The concentrations of serum electrolytes, blood
5 Q+ s5 s" X) F* |urea nitrogen, creatinine, and calcium all were* G$ K1 I- `3 j& C" c, L$ U
within normal range for his age. The concentration
6 w4 ~! v/ O6 Q$ n1 Hof serum 17-hydroxyprogesterone was 16 ng/dL7 V0 ? x5 t6 Q9 ^/ {
(normal, 3 to 90 ng/dL), androstenedione was 20
) V- ^) D( z; q3 E8 ]ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' y5 H2 V' G) M3 i0 `+ G- fterone was 38 ng/dL (normal, 50 to 760 ng/dL),
& {# x2 Z- D( U( Rdesoxycorticosterone was 4.3 ng/dL (normal, 7 to1 V: J. w6 e/ B5 ~$ q& Z
49ng/dL), 11-desoxycortisol (specific compound S)
# m; D! ?7 T8 W" J* u- P$ Nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ |8 D* ]; B6 Z" J2 T/ X) Ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% c3 D* i9 o$ w4 f* Vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),) i2 x( V0 M8 D5 O/ U! X0 W- k
and β-human chorionic gonadotropin was less than
% f" q) B, T. I% F3 G8 \5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ V" d; T/ W3 U6 W; @( |. l5 ?( s! \stimulating hormone and leuteinizing hormone
! v1 u7 P- b1 F* }3 ?! uconcentrations were less than 0.05 mIU/mL
3 R4 {$ s0 j' C(prepubertal).
2 v6 Q" j6 {$ k6 r% \: b' K% y. SThe parents were notified about the laboratory8 D3 u- H8 y# K0 J2 D5 ^+ \
results and were informed that all of the tests were
1 M4 E! @( J( C& |. |( |* Pnormal except the testosterone level was high. The% l1 R! b+ l0 ~# J* b4 A1 G
follow-up visit was arranged within a few weeks to1 g! {) a% m Z9 Y; x0 A K
obtain testicular and abdominal sonograms; how-
/ w0 i+ Z( N! y% \0 h) z" Kever, the family did not return for 4 months., M0 R( f i; t
Physical examination at this time revealed that the, t2 _" i7 |7 G( Q
child had grown 2.5 cm in 4 months and had gained+ E5 s6 G8 w/ ^6 d. F. t6 a
2 kg of weight. Physical examination remained
) e( a- I% _# ~* _5 ]6 Punchanged. Surprisingly, the pubic hair almost com-
0 W' J1 O2 G* T2 d' kpletely disappeared except for a few vellous hairs at
+ a) h; K3 Q/ K1 Q9 V; W1 Wthe base of the phallus. Testicular volume was still 2
/ b5 h1 m) n' u' A8 ?mL, and the size of the penis remained unchanged.5 V7 ], C' `2 @5 [
The mother also said that the boy was no longer hav-
, u7 c0 I6 V/ c# Z2 T6 ring frequent erections.
, S1 W$ M" J% \: [' OBoth parents were again questioned about use of
6 a" h$ v/ A( f; g' [any ointment/creams that they may have applied to0 q' b) P& w6 Y% r( M# w
the child’s skin. This time the father admitted the$ f* b: K9 X' S
Topical Testosterone Exposure / Bhowmick et al 541; r4 B, a$ Z/ \7 J) J
use of testosterone gel twice daily that he was apply-
" O5 i r' x& e8 J. ling over his own shoulders, chest, and back area for
0 E1 B8 e, a7 s4 `a year. The father also revealed he was embarrassed% V6 x& K1 {% N
to disclose that he was using a testosterone gel pre-
$ u+ ] k- c" s6 |scribed by his family physician for decreased libido
, j$ A v: g/ ? a0 d4 k; ?secondary to depression.
9 ?$ y4 ?, g, L- j7 u, m! Q9 h& X, RThe child slept in the same bed with parents.
% Z* o) G% [5 _7 AThe father would hug the baby and hold him on his! z8 L1 l. s7 T# H1 j" u
chest for a considerable period of time, causing sig-
, o: {1 f0 @# N: c$ {nificant bare skin contact between baby and father.* v# E) @8 b% S% r9 P, ]* P' G
The father also admitted that after the phone call,: a0 S. N7 Q3 u& g- }) y: u0 d
when he learned the testosterone level in the baby
; F7 Q' f; [) M5 [, t* P6 k/ @was high, he then read the product information
6 Q% y1 R5 N; R+ q* v8 F" Ypacket and concluded that it was most likely the rea-
% Z+ F; F$ E, _son for the child’s virilization. At that time, they1 _- C; W; ^4 p0 A5 L+ V K$ k3 s
decided to put the baby in a separate bed, and the/ `* B& L! f p0 l) u
father was not hugging him with bare skin and had8 J/ t8 B m. I" O
been using protective clothing. A repeat testosterone
- q/ {: @7 F0 @7 ?. R& y; Y% Z# Dtest was ordered, but the family did not go to the3 H, C- |* W9 k
laboratory to obtain the test.( {* ?" F; R0 s8 Z1 i
Discussion% R: h& }. H' R7 B5 h& Z t
Precocious puberty in boys is defined as secondary4 s/ c! a Y5 O- u$ I
sexual development before 9 years of age.1,4, ?; u8 V. |5 J u- h& i
Precocious puberty is termed as central (true) when
. R2 S; f2 u! W. a" h3 eit is caused by the premature activation of hypo-) G4 q- P- h3 B+ i
thalamic pituitary gonadal axis. CPP is more com-
8 p! O4 C+ J( W' O( o6 bmon in girls than in boys.1,3 Most boys with CPP
+ Z2 B8 u6 o9 B! X7 ?% \0 _, Smay have a central nervous system lesion that is. z: w2 Z' L) ~. d- K: |
responsible for the early activation of the hypothal-
1 f& |2 [ J9 e8 L7 P: famic pituitary gonadal axis.1-3 Thus, greater empha-. ]* E0 u; P+ U, U5 t
sis has been given to neuroradiologic imaging in; }& l- p1 I3 [% ]* |8 Q) c1 m$ _( [
boys with precocious puberty. In addition to viril-
1 R: c4 A/ I/ y1 ?6 \, v# X) W5 D# Tization, the clinical hallmark of CPP is the symmet-. a7 A8 F- b! {, n0 R# |, x
rical testicular growth secondary to stimulation by# F& W0 b/ k2 Z* I
gonadotropins.1,3
/ y3 k/ ]9 _) P/ h, o4 _! tGonadotropin-independent peripheral preco-
! e9 _4 t, t% r- v- o& N3 @+ wcious puberty in boys also results from inappropriate
- S" i0 b% d1 [( B3 K% Aandrogenic stimulation from either endogenous or! Q# }) C/ Y \3 w' _# \( V
exogenous sources, nonpituitary gonadotropin stim-- [0 x3 H: P, I/ C4 K
ulation, and rare activating mutations.3 Virilizing& S) q1 k& h( W) E, t# F
congenital adrenal hyperplasia producing excessive
/ s2 A3 i8 p2 r; O( Vadrenal androgens is a common cause of precocious- A" G9 U1 H- \: Z5 f
puberty in boys.3,4. V; f m/ B1 G! o- ?' V- W g
The most common form of congenital adrenal
" M. m+ G! h' W& fhyperplasia is the 21-hydroxylase enzyme deficiency.
' x2 V1 g m6 x/ VThe 11-β hydroxylase deficiency may also result in
2 W/ A& N6 U. Jexcessive adrenal androgen production, and rarely,
7 B* n4 a) O9 N3 N2 m- Uan adrenal tumor may also cause adrenal androgen
$ k( W$ y$ G3 a9 H% x2 L; G# Cexcess.1,3' q [+ P( w7 w% @9 B1 U# `- E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, T5 d. Z a- |* t" q
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
( T" |) H7 j- e# a+ e2 D ]A unique entity of male-limited gonadotropin-
5 b7 h0 I5 d/ U1 hindependent precocious puberty, which is also known2 M3 m+ r! r) K. W1 h
as testotoxicosis, may cause precocious puberty at a
. \) H q6 W/ r6 U6 ?! P: Overy young age. The physical findings in these boys
' H- J& ]* U# D7 D1 J! h. b! Gwith this disorder are full pubertal development,
8 V f6 V. p& |+ t% M% Hincluding bilateral testicular growth, similar to boys
' g, v: P3 u& C3 U( d, ]* h! Ewith CPP. The gonadotropin levels in this disorder9 O8 ^: b, M6 ^4 ?/ Z
are suppressed to prepubertal levels and do not show
! y& {0 o- n- @. S9 hpubertal response of gonadotropin after gonadotropin-0 {( D1 T7 F: j: x F
releasing hormone stimulation. This is a sex-linked
6 B7 C( M: U( _" L+ x1 Vautosomal dominant disorder that affects only2 X* { C5 \6 X, y- n1 J
males; therefore, other male members of the family! `" _, K- t5 w- \9 A( v5 R9 J
may have similar precocious puberty.3
( ^8 T1 ]% w6 b5 L1 v6 Y1 gIn our patient, physical examination was incon-
( d/ T5 z0 y9 I7 Q& Fsistent with true precocious puberty since his testi-
# d# ^1 j# n+ r5 N8 P6 i) Scles were prepubertal in size. However, testotoxicosis" I# {+ P+ h/ J0 O: g- k# F5 B
was in the differential diagnosis because his father
8 I# s7 q; ^) { t" Wstarted puberty somewhat early, and occasionally,2 W# C8 D9 _1 V5 ]1 v [2 j
testicular enlargement is not that evident in the
( D" X! r2 `/ T9 `- B% Ebeginning of this process.1 In the absence of a neg-3 P( f$ ]9 k9 Q* _8 g/ h
ative initial history of androgen exposure, our" b2 N+ G3 W# }; i" R1 e' {
biggest concern was virilizing adrenal hyperplasia,+ J4 R( ?. c" N8 J) N l
either 21-hydroxylase deficiency or 11-β hydroxylase
D. f& J5 r- W2 Hdeficiency. Those diagnoses were excluded by find-0 A0 r% x" ?5 p6 P
ing the normal level of adrenal steroids.1 G! U3 _1 W4 _4 q6 @$ Y2 e
The diagnosis of exogenous androgens was strongly
4 M+ {% p2 }/ v; `suspected in a follow-up visit after 4 months because2 F. l4 r& q' l* l
the physical examination revealed the complete disap-
+ [2 x: V9 e# u6 t* ~4 spearance of pubic hair, normal growth velocity, and, r9 r# ]$ i' o: W8 ]6 \ |- e
decreased erections. The father admitted using a testos-9 `/ f9 D7 ]8 o+ E, U v5 ~/ T
terone gel, which he concealed at first visit. He was
. l% j6 ~5 i0 X2 q& {9 e* Cusing it rather frequently, twice a day. The Physicians’
1 e5 v) z ^ Y2 y2 z3 R% lDesk Reference, or package insert of this product, gel or2 \1 X/ U; B- \6 T" E1 L
cream, cautions about dermal testosterone transfer to! R) ?+ G5 |; H# v4 O$ ]1 b
unprotected females through direct skin exposure." o: L2 i4 P* D/ i _4 Y3 N
Serum testosterone level was found to be 2 times the
. z- l; n$ g- j) j% V* Ibaseline value in those females who were exposed to5 {) P3 ]0 d* J9 K
even 15 minutes of direct skin contact with their male
5 Y f7 {* _0 C" O' r: K- T5 p4 _* F' gpartners.6 However, when a shirt covered the applica-" f) v: f- [1 @
tion site, this testosterone transfer was prevented.
E" E% i% _& y0 s; }Our patient’s testosterone level was 60 ng/mL,8 @ v2 O+ v1 Y" n
which was clearly high. Some studies suggest that" W5 g' I4 D3 s* F }0 S
dermal conversion of testosterone to dihydrotestos-% P7 x9 B# R) e* K: P) [, }
terone, which is a more potent metabolite, is more* u6 |: h( r1 e9 [, y
active in young children exposed to testosterone, G- y- S5 a# E1 |
exogenously7; however, we did not measure a dihy-( K7 N, L' ?3 V! a4 K
drotestosterone level in our patient. In addition to
* }. b% Z8 u+ m( c& T% n+ }virilization, exposure to exogenous testosterone in) u Y- b% a X: C$ P. h* {
children results in an increase in growth velocity and
/ [4 K, r& S2 m6 N' s+ p# v; Iadvanced bone age, as seen in our patient.. \$ [9 Z' y+ l" Y7 [
The long-term effect of androgen exposure during$ Q# ?9 g" c" |8 u4 C! q' i) B
early childhood on pubertal development and final
0 A# C' J7 ?1 a) T: ]1 j; ]adult height are not fully known and always remain
; O( T+ l# y. B) z0 S0 Na concern. Children treated with short-term testos-, G9 v& b& M1 D3 q/ T/ f
terone injection or topical androgen may exhibit some
# T2 W4 F4 r. ~/ {; |, r- M" b9 s% ~acceleration of the skeletal maturation; however, after
7 u/ b. O3 _. ~+ ncessation of treatment, the rate of bone maturation" w0 @ q4 G+ p8 n# D
decelerates and gradually returns to normal.8,90 {- V: C. Y+ J2 n) n4 _
There are conflicting reports and controversy
" x1 h; A6 O" U! D& Q' Pover the effect of early androgen exposure on adult# Y; o7 ]" _: _; b }% Z/ H6 S
penile length.10,11 Some reports suggest subnormal
2 k; |4 @6 M' @adult penile length, apparently because of downreg-
$ V8 c1 [* @+ A$ R1 h% k8 e8 y2 }ulation of androgen receptor number.10,12 However,' g" C5 P" V5 s4 U
Sutherland et al13 did not find a correlation between3 S' z& Z7 g& \6 g. A
childhood testosterone exposure and reduced adult$ s, T* i& H! P% q
penile length in clinical studies.& S, ~$ e6 [, S# s- s$ U/ M
Nonetheless, we do not believe our patient is
: }$ K4 W1 v% Ygoing to experience any of the untoward effects from/ C }! b' X+ k
testosterone exposure as mentioned earlier because
7 {. _6 A* F9 B# X- h* p8 `, ~$ \the exposure was not for a prolonged period of time.
2 o0 ~3 S0 E( C6 t6 MAlthough the bone age was advanced at the time of
2 h. W" I1 z0 vdiagnosis, the child had a normal growth velocity at# D' |% A& n" O0 I9 @8 d8 }& W
the follow-up visit. It is hoped that his final adult. y5 p* J: A6 n4 e, u* b" Y
height will not be affected.
" I6 |5 K7 Z f4 IAlthough rarely reported, the widespread avail-
/ {/ x' P5 T% a) u* m) dability of androgen products in our society may# [& }! t# N% C9 U: f: K! q
indeed cause more virilization in male or female
/ P N! T$ K2 `$ d' R+ dchildren than one would realize. Exposure to andro-
' Y# w( ~& {+ W* bgen products must be considered and specific ques-
- i6 ^# ]6 V5 O! b: U5 Y0 e8 q6 P! vtioning about the use of a testosterone product or
% }# }& Z& c% s. a& H+ Jgel should be asked of the family members during3 ~; K, Y s K. s# Z5 C
the evaluation of any children who present with vir-
9 }0 k+ Z$ P6 X( }; V. @0 d% @' |ilization or peripheral precocious puberty. The diag-! \! H; F. V- t6 v& Z% O1 t
nosis can be established by just a few tests and by
9 i: e$ |; o2 ?& pappropriate history. The inability to obtain such a
6 _% u/ ~. `! Q+ L" Rhistory, or failure to ask the specific questions, may# Y) E. z8 I$ \+ F( l
result in extensive, unnecessary, and expensive" f6 n$ f- Z; V
investigation. The primary care physician should be; H; c! k, [! F' Y4 T, m# y
aware of this fact, because most of these children
& |; N0 M8 P! emay initially present in their practice. The Physicians’
3 i, m2 l4 ` R6 K! i/ sDesk Reference and package insert should also put a
# f8 J( R0 Z% c% R, Z: |1 ^warning about the virilizing effect on a male or
+ w; f, f& a9 w: l/ B$ c3 Wfemale child who might come in contact with some-3 P+ Z4 j7 r# Y: x L3 {( j
one using any of these products.
. x: V# q* w# Z5 X! AReferences
' ]* A1 h. D; I/ P1. Styne DM. The testes: disorder of sexual differentiation
4 |! s% m0 J# ^& H2 }% @and puberty in the male. In: Sperling MA, ed. Pediatric( M i1 _, L+ E- Q* `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: s9 D' \5 o$ s2002: 565-628.
1 A2 a4 X) l+ S" Y0 K0 F c8 P& c4 Q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 _8 a, G! Y5 l8 |5 L" u6 o
puberty in children with tumours of the suprasellar pineal |
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