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Sexual Precocity in a 16-Month-Old
! g- K# D8 t5 aBoy Induced by Indirect Topical( J. T( k( n' }, d6 o
Exposure to Testosterone7 G" q. O9 j; T9 Z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ H r9 O. m- I. eand Kenneth R. Rettig, MD1
$ G# a0 o4 Q8 T" V4 b9 @8 O8 MClinical Pediatrics! b0 d1 u: H" L4 ~! j3 a" w8 q
Volume 46 Number 6
1 J0 r! m" u4 J7 h5 BJuly 2007 540-5433 k' _- I0 k/ Z2 E) O# t7 S4 D
© 2007 Sage Publications$ ^9 I+ A% |: s* ~! y
10.1177/0009922806296651/ K; j q& a9 ^
http://clp.sagepub.com) H$ r+ @ F- E) Q
hosted at2 K1 U' u/ _- T2 a% ^) m' ~
http://online.sagepub.com/ F( d ~0 R- ?4 u$ l" K1 T
Precocious puberty in boys, central or peripheral,$ h, l& i B# A4 @& `4 {6 X4 G! F( f
is a significant concern for physicians. Central- K4 A1 w8 Q0 F
precocious puberty (CPP), which is mediated* h3 g8 {3 G0 j# I
through the hypothalamic pituitary gonadal axis, has
( [* a. o9 P6 ~% ya higher incidence of organic central nervous system0 L4 H6 E2 d7 F: f; w1 c
lesions in boys.1,2 Virilization in boys, as manifested% N' f3 @: f- l" _( D) s
by enlargement of the penis, development of pubic4 v( b# }* M0 J' k: _: R, b/ d
hair, and facial acne without enlargement of testi- }1 R+ X+ ~7 o$ x
cles, suggests peripheral or pseudopuberty.1-3 We* K1 u9 _/ @3 m! L3 h0 ?
report a 16-month-old boy who presented with the7 N3 J( H2 _! ] M
enlargement of the phallus and pubic hair develop-
2 Q& X8 \1 ?6 dment without testicular enlargement, which was due+ ` Q3 d+ l6 a# J
to the unintentional exposure to androgen gel used by- u2 }+ j* M# }2 ?6 ]5 {- i
the father. The family initially concealed this infor-% l, u& J6 {' A+ z+ R
mation, resulting in an extensive work-up for this
. b% Q: J7 P( ], m+ w" S* Schild. Given the widespread and easy availability of
9 P" u. m' r# q, n# V% q! vtestosterone gel and cream, we believe this is proba-
" H o7 Y* H ^: p( a" L# y6 zbly more common than the rare case report in the
: t9 m* V7 b* x+ \& X2 ^9 W+ zliterature.4
6 u0 Q+ G7 Z$ e; m+ cPatient Report
( Z. [' l4 N8 E; j' DA 16-month-old white child was referred to the
" K; ]5 @. O- b+ G7 ?* {) }endocrine clinic by his pediatrician with the concern8 j; S; n/ O% b& @/ G
of early sexual development. His mother noticed
6 F& }5 f" T) m( slight colored pubic hair development when he was
9 B$ s$ `6 o0 U- s! SFrom the 1Division of Pediatric Endocrinology, 2University of
; F1 f- o- i9 K/ pSouth Alabama Medical Center, Mobile, Alabama.
" T$ {4 M5 ]' r# Q8 P: ?( VAddress correspondence to: Samar K. Bhowmick, MD, FACE,' h& ?& ~0 ]; \4 @. u; V' L5 g: w* ~
Professor of Pediatrics, University of South Alabama, College of
# p6 i6 H: J" `Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
. z0 y4 q0 [4 _0 Z" ee-mail: [email protected]., f: m$ c9 Q: h% y
about 6 to 7 months old, which progressively became1 H2 K2 {6 b. U( c: ?6 P
darker. She was also concerned about the enlarge-% J9 b3 x% S: {6 s4 E
ment of his penis and frequent erections. The child
0 i4 a/ s. E! ]+ Dwas the product of a full-term normal delivery, with
9 `8 i/ `4 c( `+ T" B0 {a birth weight of 7 lb 14 oz, and birth length of
6 O- `9 |) P6 Z! o5 k20 inches. He was breast-fed throughout the first year
& D5 m V) E5 |0 j6 T- K; ^' {of life and was still receiving breast milk along with
6 Q& ^( W- ]5 k; \8 B4 N" gsolid food. He had no hospitalizations or surgery,
/ n) q& p& L6 q4 @1 o8 iand his psychosocial and psychomotor development
, o" o6 d5 T( c4 z0 }, P; Qwas age appropriate.7 _4 l$ A6 D* V& f2 s/ M3 u/ O
The family history was remarkable for the father,
% o0 @" o- Y5 m: c, N5 A; G- Y( Rwho was diagnosed with hypothyroidism at age 16,: |) _, z$ B1 q3 w& d, J
which was treated with thyroxine. The father’s
# d a5 I8 E8 Hheight was 6 feet, and he went through a somewhat
. a6 |/ T) ?7 v Jearly puberty and had stopped growing by age 14.( q) {) R- B/ f
The father denied taking any other medication. The
9 [! c& q! E: g2 Bchild’s mother was in good health. Her menarche
9 t/ j% M2 @% a1 c8 z4 }; d" pwas at 11 years of age, and her height was at 5 feet
$ E0 |# X; K# ^" ^3 m8 d5 inches. There was no other family history of pre-
. i7 u# {) C+ icocious sexual development in the first-degree rela-
0 \& u- O' F* `tives. There were no siblings.2 O* \9 L( R& ?- G
Physical Examination2 H `) w1 G( Y# U; \5 T+ N& k1 W
The physical examination revealed a very active,/ w1 ]9 O5 z: m
playful, and healthy boy. The vital signs documented
6 R3 p9 L6 E3 T x; }$ p$ a' Ka blood pressure of 85/50 mm Hg, his length was
" B+ F& W2 Z1 x6 ?' |9 D90 cm (>97th percentile), and his weight was 14.4 kg
+ N$ w7 y5 i( O, I0 k(also >97th percentile). The observed yearly growth
* Y& z7 t' |: e$ ?- Wvelocity was 30 cm (12 inches). The examination of
) ]( r$ {/ o B2 d# ythe neck revealed no thyroid enlargement.
* a3 D0 B5 M! J9 W7 Z' \! v3 sThe genitourinary examination was remarkable for6 R; n, s# x* U V2 y7 z* c; D
enlargement of the penis, with a stretched length of, Q, I7 q- n; ?7 B
8 cm and a width of 2 cm. The glans penis was very well0 ^9 ]% o8 L* Y
developed. The pubic hair was Tanner II, mostly around$ \3 b* f$ x# }
540# i. P; v2 S5 v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 l8 I! D+ m( N2 ?' A, U# M, `
the base of the phallus and was dark and curled. The2 R, m$ c2 a' R, b9 X
testicular volume was prepubertal at 2 mL each.3 N S* u! |. S3 \% W
The skin was moist and smooth and somewhat% X. x7 P1 B9 H! b. O& y
oily. No axillary hair was noted. There were no
. j. G4 S+ T* h4 {& D* C! uabnormal skin pigmentations or café-au-lait spots.
8 M5 l9 ^7 z7 ]# S: x( FNeurologic evaluation showed deep tendon reflex 2+
) i$ ^+ A4 v6 W% m6 h1 Bbilateral and symmetrical. There was no suggestion: t; |9 s% C7 P) d; ~
of papilledema.+ M: J; z; F% B- l+ I: c: q; z
Laboratory Evaluation8 i2 \2 D8 v) S" e5 l
The bone age was consistent with 28 months by
/ _6 H+ U3 `# @+ `: g) Xusing the standard of Greulich and Pyle at a chrono-
" S e; ^' Z7 o J' {; plogic age of 16 months (advanced).5 Chromosomal; n) J. F+ a( b% {2 k* ^! C/ P
karyotype was 46XY. The thyroid function test- A$ {* n' e8 \4 i# U
showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ U4 G3 i) Z7 ~+ y7 A
lating hormone level was 1.3 µIU/mL (both normal).3 `9 l; S. x( ]& |7 {- x* B
The concentrations of serum electrolytes, blood% F2 G% ~- H9 f, Z9 [
urea nitrogen, creatinine, and calcium all were
- ~6 U( K$ J! S$ K& V/ R6 gwithin normal range for his age. The concentration: A9 Q4 \; @6 T" f
of serum 17-hydroxyprogesterone was 16 ng/dL
! V5 g/ c6 o* M. }(normal, 3 to 90 ng/dL), androstenedione was 20' ?" }0 o+ i3 u9 x& Z/ e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
# M: x: I; @2 w# Eterone was 38 ng/dL (normal, 50 to 760 ng/dL),( u# E7 j% o; Z" X, p
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
. r2 u2 l* F$ X- d4 B- l8 k: E) [49ng/dL), 11-desoxycortisol (specific compound S)
4 E# G$ J9 n! h0 C3 ~8 Xwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% G& M8 U9 J+ _
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ C# j2 `1 I4 A/ q3 Utestosterone was 60 ng/dL (normal <3 to 10 ng/dL),, |. C9 H# ]% v4 ?
and β-human chorionic gonadotropin was less than
$ V/ S9 i/ d. X) n5 mIU/mL (normal <5 mIU/mL). Serum follicular1 k/ v% }( P1 w$ c7 [6 J" ?5 c
stimulating hormone and leuteinizing hormone
7 G- N& c! i, ~concentrations were less than 0.05 mIU/mL$ P/ s4 H6 D! ]4 V) K) c% q- _+ V) M
(prepubertal).
, {. O" M! _5 n8 f" hThe parents were notified about the laboratory
7 T: n; V! u! J7 N% gresults and were informed that all of the tests were0 U" D$ D3 u2 r, B6 s6 x" q& i
normal except the testosterone level was high. The
V) k+ w5 N: `+ P9 ?" n$ b8 }follow-up visit was arranged within a few weeks to1 `& }; l* X+ v
obtain testicular and abdominal sonograms; how-
9 L: c' c7 c" R$ J# Q' g" kever, the family did not return for 4 months.; q* y+ s. P; F% S
Physical examination at this time revealed that the) `# C% [: ?4 L+ x9 Z" ~
child had grown 2.5 cm in 4 months and had gained1 m5 e" k+ E, y
2 kg of weight. Physical examination remained3 e+ p6 y9 F3 i
unchanged. Surprisingly, the pubic hair almost com-
, [# [7 `; l/ K4 ^$ ~- d) B0 m, wpletely disappeared except for a few vellous hairs at
& k: _9 f9 J, `5 E; K8 Nthe base of the phallus. Testicular volume was still 2- e0 B, w! J ^; H: o
mL, and the size of the penis remained unchanged.
8 X* E0 A. V, j1 |- W$ J( ]The mother also said that the boy was no longer hav-" N2 k& m4 u3 ]- B- R
ing frequent erections.+ h* ~$ J4 p! Q4 `* w
Both parents were again questioned about use of
6 @) _& J2 P1 ~3 E! w) U& J( `any ointment/creams that they may have applied to
! k) Y x/ N2 K0 H; U) Q& v: q- Tthe child’s skin. This time the father admitted the1 ^9 n8 c. @3 \ [- Y% E( n R8 z
Topical Testosterone Exposure / Bhowmick et al 541" t9 p& l6 Q7 c4 m
use of testosterone gel twice daily that he was apply-6 P2 H5 E& }2 O% f, C
ing over his own shoulders, chest, and back area for
4 w* Y' J, b4 D* s- i8 ga year. The father also revealed he was embarrassed
$ n$ | _, D$ P. ?; u9 d& p- Z2 ^to disclose that he was using a testosterone gel pre-4 M1 \" W3 Y# ?. P0 i u
scribed by his family physician for decreased libido2 {1 W6 i3 P% u6 q$ X: {9 D
secondary to depression.
' e0 N4 |1 e& c/ B- AThe child slept in the same bed with parents.
8 E# A$ L5 e1 H* V1 d0 YThe father would hug the baby and hold him on his
/ e% H! C, t2 g7 {* W) Fchest for a considerable period of time, causing sig-
8 X* @: U+ J) ^+ M0 D0 znificant bare skin contact between baby and father.! [' A& I$ c/ v) i" T8 z
The father also admitted that after the phone call,
/ J9 w$ n- w" ^when he learned the testosterone level in the baby
# F j* o! [; n+ @3 v2 ~. G2 ^- R" nwas high, he then read the product information
" X, F& O% l, z# v; Q tpacket and concluded that it was most likely the rea-
: o! ^+ X& m% a, h7 ]3 Sson for the child’s virilization. At that time, they
4 x% J8 Q7 J7 T7 _+ P, [' f' B7 Rdecided to put the baby in a separate bed, and the; A% l% q: F' \3 m; h& g
father was not hugging him with bare skin and had6 y! B# n6 V4 H1 \1 @* z' o& n/ W
been using protective clothing. A repeat testosterone/ A( ^1 T) A2 ?
test was ordered, but the family did not go to the
# |3 x: P$ {6 elaboratory to obtain the test.
7 m/ }0 b7 x+ r% q3 kDiscussion
- O0 K t4 w8 B! MPrecocious puberty in boys is defined as secondary
) K& j9 @6 K+ @5 j" Bsexual development before 9 years of age.1,4
: B, [/ I% R' q v! c. }6 DPrecocious puberty is termed as central (true) when
& D& ^' y) ^( e6 t1 G. _it is caused by the premature activation of hypo-
3 N+ W: G5 {: G4 k' K' I1 tthalamic pituitary gonadal axis. CPP is more com-
! m3 j X6 ~; O# K# a3 t- smon in girls than in boys.1,3 Most boys with CPP
z0 [2 e9 m0 V" a' [- t1 ?may have a central nervous system lesion that is$ Q' A3 H: W3 x
responsible for the early activation of the hypothal-; f9 [+ e$ R h) q3 n- U
amic pituitary gonadal axis.1-3 Thus, greater empha-
7 ]) d/ }( g! L: A# fsis has been given to neuroradiologic imaging in
$ i# }- Q4 q/ i+ |0 K' I( Sboys with precocious puberty. In addition to viril-
2 Z( F" q" f* }5 Xization, the clinical hallmark of CPP is the symmet-
; n7 q) g" t6 h' [6 l4 _. Xrical testicular growth secondary to stimulation by
; j3 U4 F( i7 X/ M0 A- @gonadotropins.1,3; b: W; }' b3 o+ Q5 F, t% N% i
Gonadotropin-independent peripheral preco-/ Y; P1 O D$ H% A
cious puberty in boys also results from inappropriate
5 g# C2 H$ P6 B, d( Z) Qandrogenic stimulation from either endogenous or
* c. N9 i; ?$ E: `9 Qexogenous sources, nonpituitary gonadotropin stim-! Z5 b6 m7 E+ K
ulation, and rare activating mutations.3 Virilizing
5 D+ G, `: R- O$ h, @congenital adrenal hyperplasia producing excessive, ~$ t3 X# a6 G
adrenal androgens is a common cause of precocious
$ D. X' l4 Z: X5 H) apuberty in boys.3,4 Q: S! F8 f. U, j/ g6 w
The most common form of congenital adrenal( {' F- y* b: ^
hyperplasia is the 21-hydroxylase enzyme deficiency.: ]2 B- j* M5 @1 G& G. X
The 11-β hydroxylase deficiency may also result in4 x* Q1 n( h8 e) f4 C E
excessive adrenal androgen production, and rarely,+ a0 o- `- b4 [1 |& R
an adrenal tumor may also cause adrenal androgen
! o7 c; I4 ]% L" Y( N: c. y6 }excess.1,3 x, t7 k- v# |3 n& s- }5 ^' B' |
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
6 K d: F# l" c3 }5 n9 y" a( p542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
( u# o- b6 t" t' M$ i% SA unique entity of male-limited gonadotropin-
C, F' C3 z0 tindependent precocious puberty, which is also known( p1 z: J: L- N {+ O. m
as testotoxicosis, may cause precocious puberty at a
: w! l: H) O& i/ b, Dvery young age. The physical findings in these boys; _4 J" O, A/ V W t1 n, V
with this disorder are full pubertal development,
) } g6 y* X6 K. K) m5 [/ L2 @including bilateral testicular growth, similar to boys
) Y* m0 |* ~' V( bwith CPP. The gonadotropin levels in this disorder. C4 ~4 G7 C. \$ v% X4 T0 O
are suppressed to prepubertal levels and do not show s* Q# @- ^5 d0 b& B2 e
pubertal response of gonadotropin after gonadotropin-/ f7 o/ B8 m2 I: J1 @- x8 w/ u
releasing hormone stimulation. This is a sex-linked% Q( i+ [: {8 r% U# Z) h
autosomal dominant disorder that affects only9 }( L6 }6 Z- l8 B6 y
males; therefore, other male members of the family8 w& a/ P9 J, V& d2 m' ~1 _
may have similar precocious puberty.3* j, h' w3 F9 x; K" I# T8 R
In our patient, physical examination was incon-
8 U( ]3 b# u+ T7 s- W& Usistent with true precocious puberty since his testi-
5 Z* j+ y$ m' b- ?. \0 ~cles were prepubertal in size. However, testotoxicosis
# e# W5 h/ g; h( H: Kwas in the differential diagnosis because his father# b8 Y7 O! I+ a u; B( A: Y
started puberty somewhat early, and occasionally,. H# k: O t; m9 Z5 O7 W% Q
testicular enlargement is not that evident in the9 D0 G7 O! L+ s" B9 }
beginning of this process.1 In the absence of a neg-5 ] U) `4 v K: v. q( D5 L
ative initial history of androgen exposure, our$ H' ]# I. B( J2 w: @" Z
biggest concern was virilizing adrenal hyperplasia,
% E" k! k/ K+ X2 W& j2 qeither 21-hydroxylase deficiency or 11-β hydroxylase
4 a# h# s7 m3 o) V' [deficiency. Those diagnoses were excluded by find-
) o6 ~, }7 T+ Z/ P9 Jing the normal level of adrenal steroids.
, E) H4 b1 x3 v0 X* QThe diagnosis of exogenous androgens was strongly
, Z# N( d7 p9 |3 |/ m! g* Ususpected in a follow-up visit after 4 months because
% g! A1 G4 d2 V! f* y9 Z; I( Kthe physical examination revealed the complete disap-
8 x: E3 L3 | S, R3 @' \7 B# ]0 Vpearance of pubic hair, normal growth velocity, and
- C/ U) _# F: o! }7 ^decreased erections. The father admitted using a testos-
. H! H9 V, }7 A( _8 d) m/ @terone gel, which he concealed at first visit. He was5 G0 ]/ V- x+ F- m0 D( J# _
using it rather frequently, twice a day. The Physicians’' R1 W* a8 H8 x6 V. G0 E
Desk Reference, or package insert of this product, gel or
@7 E4 p0 a) I; Q4 ?cream, cautions about dermal testosterone transfer to {& d% e d! m3 u2 w: e% H6 \1 G
unprotected females through direct skin exposure.
+ r* S: M, F$ b& ~. _4 ^# s" KSerum testosterone level was found to be 2 times the
7 L3 U2 X/ c5 w5 | y$ \baseline value in those females who were exposed to
- a: U$ y% f: o) ` C+ r8 d, Leven 15 minutes of direct skin contact with their male
! _( U! w$ X6 B& F, m j* O+ i7 zpartners.6 However, when a shirt covered the applica-" r7 W' R. ]7 F3 Y/ v; }9 C
tion site, this testosterone transfer was prevented.
; { d/ y) A5 \2 e* \3 TOur patient’s testosterone level was 60 ng/mL,- h' f* J6 t Q) g* y
which was clearly high. Some studies suggest that
8 c* ^: f( c V$ }% C6 n7 L2 n* ]dermal conversion of testosterone to dihydrotestos-
7 T) j2 B) W7 S8 Y' ~, i1 o) tterone, which is a more potent metabolite, is more- u {, g& @8 V1 [: ~& `, G5 z- p
active in young children exposed to testosterone
/ ]9 c9 G. R5 W6 W' d# nexogenously7; however, we did not measure a dihy-7 c6 l& g S/ m7 K$ y
drotestosterone level in our patient. In addition to0 p) q0 c& e, k: Q
virilization, exposure to exogenous testosterone in
0 B ?" ]5 s8 b0 E% p5 nchildren results in an increase in growth velocity and" w- t# O+ j0 Z1 G. M
advanced bone age, as seen in our patient.
+ t; k! r: _+ S- [9 ]& `8 lThe long-term effect of androgen exposure during
( t/ t& Z9 x; w7 c1 F4 Wearly childhood on pubertal development and final. e* d: M! l% f- o
adult height are not fully known and always remain
% N' A; O# U6 o- Ya concern. Children treated with short-term testos-
8 r, A9 w( o; [( k' Qterone injection or topical androgen may exhibit some
# h5 v8 K8 Z% Q# R( a+ V& Wacceleration of the skeletal maturation; however, after- x; B- f# }; g- J, L
cessation of treatment, the rate of bone maturation# I+ j8 _9 {# v8 c) c
decelerates and gradually returns to normal.8,9. e% v7 T. |- y/ q3 Z4 Q* ~
There are conflicting reports and controversy
0 W3 v- V+ S+ |" V- qover the effect of early androgen exposure on adult" P8 A1 e" G, s" x( Q& p O( M
penile length.10,11 Some reports suggest subnormal; x$ q9 l3 T0 @) @9 B
adult penile length, apparently because of downreg-5 | K. N/ U: M* L$ V
ulation of androgen receptor number.10,12 However,
/ X6 c+ X. P1 }$ }# \Sutherland et al13 did not find a correlation between# A6 G! N, B# g+ N0 K, ~' J) I. {
childhood testosterone exposure and reduced adult
W. I* P" D9 ^+ k2 r) S; B2 npenile length in clinical studies.
# r/ {+ o% |' x* GNonetheless, we do not believe our patient is8 U1 |3 a) X! {% O2 k! f0 }& D9 Y
going to experience any of the untoward effects from; K, b, r0 Y2 i7 G' H- d5 E1 g& y
testosterone exposure as mentioned earlier because
7 L( c0 L# w1 ~% }$ Ethe exposure was not for a prolonged period of time.6 d! V3 S5 X" r/ t3 X
Although the bone age was advanced at the time of
2 e$ p$ _* a5 @- N2 g; l* Ldiagnosis, the child had a normal growth velocity at
9 i- d! D C4 zthe follow-up visit. It is hoped that his final adult
1 e) a H8 f2 dheight will not be affected.
. k0 G7 N0 ?9 I, n- R# w1 WAlthough rarely reported, the widespread avail-9 M- ~ ]& V* ^- E3 h+ S
ability of androgen products in our society may1 {! F3 \" t: E% F: ]1 x6 N* N
indeed cause more virilization in male or female' \( O: h, [# t5 C
children than one would realize. Exposure to andro-
! X9 _" @) Q' R- Ogen products must be considered and specific ques-
& y4 {1 n$ X$ N/ \1 q9 |* s* t! Itioning about the use of a testosterone product or
& Q" y" ]0 j0 l: M7 b6 fgel should be asked of the family members during
* R* D% ?. S# L- N7 z3 {9 Pthe evaluation of any children who present with vir-
! a9 x( E/ z) [1 y9 r* d* ^ilization or peripheral precocious puberty. The diag-+ o& x0 D5 W. b8 N. \. C' N
nosis can be established by just a few tests and by
' E( n; M, c: @6 e0 ?$ qappropriate history. The inability to obtain such a
* m6 ]& F; O5 s: _8 Nhistory, or failure to ask the specific questions, may; ]: h2 O- ^' b3 h
result in extensive, unnecessary, and expensive$ R0 e0 x- y) c! m) v& `# d* P5 }
investigation. The primary care physician should be
* t# b* Y& K4 L7 \, N1 h3 Aaware of this fact, because most of these children2 W1 ^- _9 g2 r, j! @7 `8 I& [
may initially present in their practice. The Physicians’
' K9 h3 L7 R' {; SDesk Reference and package insert should also put a6 Z8 I+ i3 E7 `, K, z' X
warning about the virilizing effect on a male or4 }2 W, G- O7 L' @
female child who might come in contact with some-. t# Z% k* h$ r
one using any of these products.
- W0 ~8 H9 b( i& {' m' o7 ]References J" g" j4 v/ c( r
1. Styne DM. The testes: disorder of sexual differentiation5 {! g0 F. ]6 O
and puberty in the male. In: Sperling MA, ed. Pediatric
) I! @5 \ I( n1 ~" A7 `3 L+ TEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 A6 E3 a$ Z3 i3 n
2002: 565-628.
" c) Y9 l) y5 S; a1 [9 J* f( {2 n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( X! m) P) @, f4 U
puberty in children with tumours of the suprasellar pineal |
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