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Sexual Precocity in a 16-Month-Old3 d4 N7 e4 T$ M
Boy Induced by Indirect Topical7 u( a i3 g9 U) L% O, B2 A8 d& s
Exposure to Testosterone
. i h7 e6 u r4 m6 ~Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! E* U* m9 X( ?. t" l0 Fand Kenneth R. Rettig, MD1
5 ]+ [$ E2 Z1 [ f3 n5 gClinical Pediatrics
2 j5 X# _0 O$ y- w# B) TVolume 46 Number 6
! l) C1 u" \% O; t" D9 MJuly 2007 540-5430 m0 Q; y) {/ {1 p8 T
© 2007 Sage Publications
! h+ {8 s Z; z( d9 I10.1177/0009922806296651
3 w- @ a8 g$ ghttp://clp.sagepub.com# s1 e; Y; k8 H2 L- t+ O1 J1 Y( X: P
hosted at* Q8 i9 C8 i2 h: b/ k
http://online.sagepub.com
+ {6 F/ }& c0 H6 U2 A% I) f) DPrecocious puberty in boys, central or peripheral,
4 V0 }' N3 n7 N$ f+ Dis a significant concern for physicians. Central
8 r, }2 H+ K# G' H$ tprecocious puberty (CPP), which is mediated
" o( h j" o' Q& Y3 xthrough the hypothalamic pituitary gonadal axis, has: w* L9 H6 c! w* x$ u
a higher incidence of organic central nervous system
/ f3 [; b) x& v9 u# ^- Alesions in boys.1,2 Virilization in boys, as manifested, C* D4 i4 U2 B0 s8 S
by enlargement of the penis, development of pubic
) p+ y! X6 m5 t6 O4 rhair, and facial acne without enlargement of testi-# r' q! k/ |: i% v
cles, suggests peripheral or pseudopuberty.1-3 We
% |5 @8 x; x$ q q. I( Ureport a 16-month-old boy who presented with the3 A) R$ I; n7 r& e# ~3 J
enlargement of the phallus and pubic hair develop-
+ j1 l2 T! X$ p( ^1 x2 g8 S8 ^ment without testicular enlargement, which was due3 n+ m; X) R4 s, x9 x% C
to the unintentional exposure to androgen gel used by) J" I; _/ ^2 W( O4 z: F( U9 x
the father. The family initially concealed this infor-; |/ H- {$ W# }
mation, resulting in an extensive work-up for this- \; A) z8 X3 \+ s- Y
child. Given the widespread and easy availability of
% C& h4 n. }. j2 S/ v- @# c1 itestosterone gel and cream, we believe this is proba-
, ~( n! G3 m# `& O6 V( z: zbly more common than the rare case report in the- v9 h. \ T7 m) j! k
literature.4: ?6 C6 K- v9 a9 G- q
Patient Report8 z* x; H; b3 h/ f2 G3 [
A 16-month-old white child was referred to the" G/ Y+ H% y% X; ^% x; Y
endocrine clinic by his pediatrician with the concern
4 J+ e8 {+ X! `of early sexual development. His mother noticed2 I y. u7 v: ^+ v) X( d% g
light colored pubic hair development when he was
4 O9 H+ }9 O3 l7 V( jFrom the 1Division of Pediatric Endocrinology, 2University of
; _- m6 y: ]4 Z7 bSouth Alabama Medical Center, Mobile, Alabama.
: `& l7 x, ~1 J* }" PAddress correspondence to: Samar K. Bhowmick, MD, FACE,
4 W, h3 }: m2 ~) u) H2 RProfessor of Pediatrics, University of South Alabama, College of" G" e/ c5 M. B9 r
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
$ X3 y5 `. @6 ]0 }3 g8 T9 se-mail: [email protected].) Q1 ^* X( y3 X3 c
about 6 to 7 months old, which progressively became
' b) [( A1 _) W' ydarker. She was also concerned about the enlarge-, ]6 t K+ [- V' E; P% i1 [
ment of his penis and frequent erections. The child) W; R; Y) d* a! |" U" A& ~, [
was the product of a full-term normal delivery, with* V) {& u$ Q4 L) N9 z% M
a birth weight of 7 lb 14 oz, and birth length of( C4 B1 H* I% ~, Y# @; U S
20 inches. He was breast-fed throughout the first year
4 w9 W/ M& `7 `8 N# Mof life and was still receiving breast milk along with4 j1 r$ \5 ?* l8 X5 M
solid food. He had no hospitalizations or surgery,
9 x& y" `% I' Z5 b ]( Y% a4 Mand his psychosocial and psychomotor development d7 |. M4 j- g) |
was age appropriate.
) w( J; p w8 E& tThe family history was remarkable for the father,+ v8 o/ S$ W) s
who was diagnosed with hypothyroidism at age 16,! R) s8 w) d% H* W
which was treated with thyroxine. The father’s6 Y, E A# P3 B
height was 6 feet, and he went through a somewhat
! y* Y/ c1 Z6 i1 ]+ p+ t }early puberty and had stopped growing by age 14.
( r: E8 U+ J) Q) K4 BThe father denied taking any other medication. The
9 c- J: n+ c* z" ?2 Wchild’s mother was in good health. Her menarche5 t8 \. w4 A5 O* `3 h; E) Q+ p8 {
was at 11 years of age, and her height was at 5 feet. w' h: N: K3 o$ K$ R$ S( o3 X7 I
5 inches. There was no other family history of pre-5 _/ x0 }$ L6 {1 A$ B( r6 u8 q
cocious sexual development in the first-degree rela-: J( H/ p. r, C. t" O9 \0 S+ I3 U ~
tives. There were no siblings.4 q& c- j! [: ^$ T
Physical Examination% ~8 Y, i/ P) ~9 m+ [7 ^% p
The physical examination revealed a very active,$ W) ^5 Q) M$ I! ?+ d3 J
playful, and healthy boy. The vital signs documented. o9 \. K+ ~/ t% u2 g" b, ~
a blood pressure of 85/50 mm Hg, his length was
& T# w1 q# \! c& c+ J9 l90 cm (>97th percentile), and his weight was 14.4 kg a. Q0 y! T1 h2 d M& i
(also >97th percentile). The observed yearly growth$ m `) q6 V, D4 S
velocity was 30 cm (12 inches). The examination of# d" Z' K6 z- N
the neck revealed no thyroid enlargement.
. G) A2 d7 {5 i6 f$ n4 y0 s2 UThe genitourinary examination was remarkable for
: M3 n9 w# Z- \/ O% ienlargement of the penis, with a stretched length of
6 W3 e# u5 e8 Z1 x8 cm and a width of 2 cm. The glans penis was very well
: L2 C! j+ F- k, z( Q( V7 s E# d Xdeveloped. The pubic hair was Tanner II, mostly around
" m# V W7 f4 n540- @+ K j/ X5 P; p$ f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% s7 t& y. s2 \ s6 @0 j, Kthe base of the phallus and was dark and curled. The
( \4 _' w8 i4 q6 Wtesticular volume was prepubertal at 2 mL each.- s7 ]( `$ @- v* m! P* C
The skin was moist and smooth and somewhat
6 Z8 T* x" w5 x C& Z* E. [6 [& xoily. No axillary hair was noted. There were no
1 q" T3 j5 z9 v6 y. ]% Gabnormal skin pigmentations or café-au-lait spots.- f s# Y% R+ C
Neurologic evaluation showed deep tendon reflex 2+
4 N6 H0 Y4 L% p* {bilateral and symmetrical. There was no suggestion
/ d8 l4 z# x8 V* v" D' Aof papilledema.
# B9 a0 A! m( y7 _( mLaboratory Evaluation
/ Q, U! K5 x; W) t! {( CThe bone age was consistent with 28 months by% N5 w- v4 b; P% p7 G( n
using the standard of Greulich and Pyle at a chrono-) B* `7 w( V9 b
logic age of 16 months (advanced).5 Chromosomal
8 m0 \9 H- \' c3 z( P Skaryotype was 46XY. The thyroid function test
" S+ o; d: M6 X& V5 @- `showed a free T4 of 1.69 ng/dL, and thyroid stimu-
: f0 o2 k/ F$ e; ]) H0 K* Y$ O* ylating hormone level was 1.3 µIU/mL (both normal).
! v; s( ^3 I3 K, e% V# YThe concentrations of serum electrolytes, blood# a8 l$ [! p- `& R
urea nitrogen, creatinine, and calcium all were) m2 h# c6 t/ T. \' ~4 G- J
within normal range for his age. The concentration
2 t) l( t" f. @/ yof serum 17-hydroxyprogesterone was 16 ng/dL
8 B+ Y. a, R f8 L$ H, W(normal, 3 to 90 ng/dL), androstenedione was 20$ y. T2 g+ e: F# ?3 ^5 R v
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; N9 q# A9 [6 I' s! ~" Cterone was 38 ng/dL (normal, 50 to 760 ng/dL),- B8 Z1 L. ?0 G7 z6 o
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
" T! r8 ~1 \& k- i" l. H- c0 f I49ng/dL), 11-desoxycortisol (specific compound S)
# ?# M2 J8 O- L5 p( g: h. C1 w- O' ~was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 t; n1 w7 h' V2 v& }* btisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total" D) o$ I* x ]
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ V4 _5 E, J8 f. `% d
and β-human chorionic gonadotropin was less than; Y5 q/ \5 K7 V) _- V2 T: a
5 mIU/mL (normal <5 mIU/mL). Serum follicular1 }, R5 A% F R1 H0 v5 J
stimulating hormone and leuteinizing hormone8 h3 l6 q! a5 v8 J
concentrations were less than 0.05 mIU/mL+ ?, e3 U) F% A, N
(prepubertal).# u# k0 q2 ~' W
The parents were notified about the laboratory! ?% p4 A9 A' v+ U/ \
results and were informed that all of the tests were
( u# c" e e# E/ D0 Y0 C/ ^) W: ~normal except the testosterone level was high. The
7 j2 R+ ]/ F, d) o: Gfollow-up visit was arranged within a few weeks to
- \- F3 g' {5 k; ]; U8 Xobtain testicular and abdominal sonograms; how-
. |$ u; w3 U$ U2 x( j& U2 Iever, the family did not return for 4 months.
5 `6 `7 G/ I9 \ D2 A2 @Physical examination at this time revealed that the
3 k3 A5 p; d$ a% Z5 e* ^+ P' J' tchild had grown 2.5 cm in 4 months and had gained: W) F$ s% r/ e; M' w: L, J
2 kg of weight. Physical examination remained
5 ]# D7 E8 ]( [2 v3 J* @; N4 A. aunchanged. Surprisingly, the pubic hair almost com-
- J, L8 I) o2 S# |pletely disappeared except for a few vellous hairs at& S+ P% E9 `; ^' J: L( X
the base of the phallus. Testicular volume was still 2
, R: @- ~! C. o X% W& i, QmL, and the size of the penis remained unchanged.- z" i( R" |/ {% N& _/ v
The mother also said that the boy was no longer hav-
4 P& x+ p, a9 Fing frequent erections.3 Q9 i8 C4 ^ G" h$ a
Both parents were again questioned about use of
" o3 P+ j( S+ a, w; P+ Z+ [any ointment/creams that they may have applied to8 A% @9 O! j. u. E* Z; q* J
the child’s skin. This time the father admitted the% q7 [3 u. W" {, t- L$ E
Topical Testosterone Exposure / Bhowmick et al 541
# k" S- W( {; V: E- ^) _5 Cuse of testosterone gel twice daily that he was apply-, m0 Z8 k) h. L; j v4 f: s" {' W
ing over his own shoulders, chest, and back area for( K1 @% o4 M' u+ M9 m. I
a year. The father also revealed he was embarrassed
7 c# L8 x# `& J3 A& N: {8 U: {to disclose that he was using a testosterone gel pre-+ A/ f/ I- N. [: {) b: R
scribed by his family physician for decreased libido
% r* s) J% i# d2 M& nsecondary to depression.
9 e: _. [: k9 U& OThe child slept in the same bed with parents.( H2 b$ t. s2 b
The father would hug the baby and hold him on his
7 I9 c6 W- Z7 E6 E1 @8 O& }# y$ q1 Cchest for a considerable period of time, causing sig-
: q1 `' G |+ g; ^, {nificant bare skin contact between baby and father.9 @; i& t3 Z* [- l+ q3 u* V' n
The father also admitted that after the phone call,
2 f6 `- h* o, J( D' h, g! Qwhen he learned the testosterone level in the baby
$ b2 v* K5 H, w1 M4 p- T3 {/ p( Twas high, he then read the product information% e% j4 W `4 U2 ^2 x; V, r, G
packet and concluded that it was most likely the rea-
0 l$ I8 c: Z' }1 T" v$ M6 D( Y! \son for the child’s virilization. At that time, they( `, ^4 P% x* t7 l
decided to put the baby in a separate bed, and the# }. f2 Q) m6 Q; [- t
father was not hugging him with bare skin and had
8 j( f3 r8 Q! X6 q7 E5 ]been using protective clothing. A repeat testosterone: S' e; D* s/ I9 d+ f6 {- G g- i! c
test was ordered, but the family did not go to the! Z3 `9 a- J# q, V. \! J6 C" g
laboratory to obtain the test.* I& R# Z4 |6 p
Discussion
8 S! `* W2 ?# O5 y- y- N6 jPrecocious puberty in boys is defined as secondary( u/ N$ z) q5 d; X1 \* ]
sexual development before 9 years of age.1,4
H( a, P' T, V. gPrecocious puberty is termed as central (true) when
: M* Q! y/ L( r5 p9 w7 Lit is caused by the premature activation of hypo-+ I ]" ]0 j0 D! `
thalamic pituitary gonadal axis. CPP is more com-" Q" Z: l+ D5 T$ s' ` f5 I) T9 t
mon in girls than in boys.1,3 Most boys with CPP# h. o- z# @( o' o+ F: o
may have a central nervous system lesion that is$ Z# c. o4 U, ]5 m9 d. Z
responsible for the early activation of the hypothal-
5 G7 o E) g/ U+ @amic pituitary gonadal axis.1-3 Thus, greater empha-! u+ f# q4 D$ g; |; t" R" F
sis has been given to neuroradiologic imaging in
8 k* K: o/ O# b% k0 }$ iboys with precocious puberty. In addition to viril-
9 E, \3 v8 B: i1 xization, the clinical hallmark of CPP is the symmet-" O p0 ]+ F D
rical testicular growth secondary to stimulation by0 G* t: h, P9 f, _
gonadotropins.1,3
6 m/ x0 ]0 m/ ^- C6 cGonadotropin-independent peripheral preco-3 W2 t7 R1 M+ S2 H, l
cious puberty in boys also results from inappropriate
0 C/ S. `/ e' f9 o! Y: I x0 Nandrogenic stimulation from either endogenous or
4 S5 d& v! r7 qexogenous sources, nonpituitary gonadotropin stim-
T* @: ]/ b& H) u1 E; Rulation, and rare activating mutations.3 Virilizing$ J7 s# P4 z- I) h- a" t. J, L8 ]
congenital adrenal hyperplasia producing excessive
4 P8 C4 U6 m* \7 h% Q7 L% ~adrenal androgens is a common cause of precocious0 h7 v& |8 |/ A' Y: G
puberty in boys.3,4 b7 S4 E! y+ q0 V1 ]
The most common form of congenital adrenal3 a- Q6 p1 s$ p" b4 q8 r e
hyperplasia is the 21-hydroxylase enzyme deficiency.
9 r/ u! I0 n+ q9 PThe 11-β hydroxylase deficiency may also result in, k+ E2 s9 q( `& _
excessive adrenal androgen production, and rarely,/ m* L4 h" _, C" y( l
an adrenal tumor may also cause adrenal androgen
6 e* B6 F3 f( t1 f: m/ Xexcess.1,3
$ W5 f6 ~& ]7 Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; r; Y! s& O- j
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 L! ?) ?$ u& f1 {A unique entity of male-limited gonadotropin-% E/ d Y* z5 |1 n6 ^% K v+ b
independent precocious puberty, which is also known0 D. C/ c* E* U5 M4 D
as testotoxicosis, may cause precocious puberty at a
% C( X' h: ~" M5 P7 b4 overy young age. The physical findings in these boys
- b; F9 `& q2 {" X7 Z; s) v& zwith this disorder are full pubertal development,3 x& N1 I3 m" m" v) q
including bilateral testicular growth, similar to boys& v( s+ ^% y& J$ Y) m6 a! {5 `
with CPP. The gonadotropin levels in this disorder
) Z1 [6 E! b: L+ A& i3 L6 ~are suppressed to prepubertal levels and do not show$ l! [2 `' x3 V( L- B. e
pubertal response of gonadotropin after gonadotropin-
& ^; h, L- z3 [" xreleasing hormone stimulation. This is a sex-linked+ I0 U% n: D3 ~
autosomal dominant disorder that affects only
) o0 ?% G" f4 j* H: b. a T+ hmales; therefore, other male members of the family
* R( r% X* ^& d; {1 }% ]7 imay have similar precocious puberty.3
# M: z$ I4 w9 v. A& L9 L6 C' T0 K8 KIn our patient, physical examination was incon-
& B% z$ M$ A5 M0 @" ~sistent with true precocious puberty since his testi-
# ?: [- O7 u; N8 p0 Gcles were prepubertal in size. However, testotoxicosis+ U( p8 x9 D: U; ~3 k
was in the differential diagnosis because his father" o# x( r* v1 P1 ]& r
started puberty somewhat early, and occasionally,. K/ ]1 B3 { c+ A& G& J4 C
testicular enlargement is not that evident in the
+ _0 P4 X4 q/ S0 G4 S. `/ [ x% u6 {beginning of this process.1 In the absence of a neg-
* w" c( g: M: W2 ?' ]2 jative initial history of androgen exposure, our
2 X" u. q; g+ c1 E2 I# ]biggest concern was virilizing adrenal hyperplasia,
* H, _6 o2 F8 o4 X, P7 W4 keither 21-hydroxylase deficiency or 11-β hydroxylase
! J' w, _/ d1 I# I- \! [deficiency. Those diagnoses were excluded by find-0 @1 V; [1 D& y9 C$ U
ing the normal level of adrenal steroids.
% ?0 B0 {# E2 gThe diagnosis of exogenous androgens was strongly( E e" V d K! t9 G# A, O
suspected in a follow-up visit after 4 months because
% O- q$ C) F. Q1 zthe physical examination revealed the complete disap-) t) P! j: b* |( B& e2 }
pearance of pubic hair, normal growth velocity, and- Z0 n; _% `) L4 u& B
decreased erections. The father admitted using a testos-$ R; l# Q Q8 u9 p$ W3 ~! ?) X
terone gel, which he concealed at first visit. He was
, B6 y. K2 }6 B7 d# q" G4 ^' u, dusing it rather frequently, twice a day. The Physicians’/ m$ u+ w% q: B- k
Desk Reference, or package insert of this product, gel or
Z5 D( u, L8 p5 n f; bcream, cautions about dermal testosterone transfer to
! t- N: E3 [% B4 ]: Aunprotected females through direct skin exposure.6 _$ q2 P) c1 q1 w, `
Serum testosterone level was found to be 2 times the" T& G3 y! u5 q. @ j- ~; [
baseline value in those females who were exposed to, _1 J/ |( V0 [( e" J
even 15 minutes of direct skin contact with their male
$ H3 }0 S8 {6 p: Q* U# Y5 qpartners.6 However, when a shirt covered the applica-4 W1 B/ k- n4 g
tion site, this testosterone transfer was prevented.
% g1 B2 A/ Y" I8 X3 bOur patient’s testosterone level was 60 ng/mL,
" K" C& k$ i# o0 M4 E P1 w& L: H1 @which was clearly high. Some studies suggest that
: h. t4 R4 j5 v* }! ~dermal conversion of testosterone to dihydrotestos-2 }8 r' p! l' \9 l& f4 L
terone, which is a more potent metabolite, is more- Q! K$ Z m1 b3 V$ l/ s& M1 K
active in young children exposed to testosterone
( t) {9 i" A/ Q j0 \exogenously7; however, we did not measure a dihy-2 M: A3 `% C2 m: R O1 N( X( t
drotestosterone level in our patient. In addition to3 d5 c- c* Q" A
virilization, exposure to exogenous testosterone in
: h- P/ f. x. S w2 X o( Ochildren results in an increase in growth velocity and
1 u; A( W. S8 {, kadvanced bone age, as seen in our patient.( i4 p" _ M+ m: _4 P* D6 X2 Z
The long-term effect of androgen exposure during9 f; ?" _. d2 [2 \7 o
early childhood on pubertal development and final! G6 j* W& o9 ?% O% W
adult height are not fully known and always remain
8 X* X, u% X2 N. w7 P# fa concern. Children treated with short-term testos-
0 ?3 i* v" e! sterone injection or topical androgen may exhibit some
& j; R* @- b, x/ U5 e$ Xacceleration of the skeletal maturation; however, after
2 e4 {5 V; r4 B* W! z0 R- Mcessation of treatment, the rate of bone maturation
/ J: o2 q% ?" S* T4 H% f* sdecelerates and gradually returns to normal.8,9 q' D7 L: e7 D4 `- z$ V3 ~
There are conflicting reports and controversy4 f5 r0 d R4 l) Q' Q) T9 F, b
over the effect of early androgen exposure on adult1 j8 n. ]: v& J! X
penile length.10,11 Some reports suggest subnormal8 ], W2 h: t) S
adult penile length, apparently because of downreg-, E5 i7 W7 x. h2 Q/ r, P
ulation of androgen receptor number.10,12 However,
3 K# w- m$ d9 e5 }: E. dSutherland et al13 did not find a correlation between8 n! d* }8 [; V
childhood testosterone exposure and reduced adult' C4 ^; x8 e1 a% R5 l
penile length in clinical studies.8 _5 z9 I: w% v, O$ v
Nonetheless, we do not believe our patient is
0 l4 b2 ^7 J: y" l& mgoing to experience any of the untoward effects from6 c& G( o# r8 O$ J. m
testosterone exposure as mentioned earlier because
+ R% H( h# M# Q& Y% jthe exposure was not for a prolonged period of time.
8 Q2 J/ N" ~+ {7 _Although the bone age was advanced at the time of2 l- w. `! Z0 f: R2 K6 m) p0 ?
diagnosis, the child had a normal growth velocity at5 }: p( F3 p" y \7 [
the follow-up visit. It is hoped that his final adult
" H$ G1 F$ r6 H) qheight will not be affected.1 ?1 B7 h- t3 D9 K0 F
Although rarely reported, the widespread avail-
A4 p5 U: n& R1 S( t& B* K3 Oability of androgen products in our society may
/ Y& R6 y4 `4 L. @indeed cause more virilization in male or female: j7 }& B. }( J$ g) @- [
children than one would realize. Exposure to andro-: w3 O6 U* {3 K9 b2 }
gen products must be considered and specific ques-" |, ?. I+ ] y( {' V: G
tioning about the use of a testosterone product or, U8 w7 n. \& h4 x+ T
gel should be asked of the family members during: [- ]- `: r: Q# J% w
the evaluation of any children who present with vir-8 F! [1 N: C3 C9 \2 G& c
ilization or peripheral precocious puberty. The diag-1 u; n. F6 s" D+ b: g6 k" [
nosis can be established by just a few tests and by
6 \1 R6 u, f+ D+ T2 ~appropriate history. The inability to obtain such a3 F" v' [' @5 T. g
history, or failure to ask the specific questions, may% m7 J0 I+ c8 T( a3 x) }4 w2 u
result in extensive, unnecessary, and expensive6 f& o9 y1 c8 s$ G9 c/ P
investigation. The primary care physician should be
! }6 q }; D- y! ^- t2 j( raware of this fact, because most of these children4 L' k6 v2 d0 h+ Y9 y' f& t
may initially present in their practice. The Physicians’
" x/ G& O7 P0 T* I, M; E' s& _9 _Desk Reference and package insert should also put a1 A5 R# N m K) \6 T2 c
warning about the virilizing effect on a male or
+ Z5 v2 h8 [- a- z5 |; O$ lfemale child who might come in contact with some-
$ s% j3 @3 Z7 ~, H: E6 R+ Fone using any of these products.
) K5 {+ N9 Z1 N* w/ Z, p/ uReferences l: o5 b5 @+ T. O( _
1. Styne DM. The testes: disorder of sexual differentiation% i4 d4 Z$ u4 H
and puberty in the male. In: Sperling MA, ed. Pediatric
$ B6 @( X: N: E' e+ W% P! REndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. [7 y$ m. \( \) t- Z
2002: 565-628.
6 @4 l. H+ \5 ?* u% x( Z2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( u' q' v8 ~! B5 W2 D5 y: w) R
puberty in children with tumours of the suprasellar pineal |
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