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Sexual Precocity in a 16-Month-Old
! D1 @1 w& a8 R" c; @Boy Induced by Indirect Topical
: x8 x6 M) l" B( _1 QExposure to Testosterone4 }" Z! M4 H2 }& G- Z! A& [7 M M
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 e+ C0 W* F* j0 X' C) band Kenneth R. Rettig, MD1* t; m; E0 b) E, |
Clinical Pediatrics
: C/ K( ]) _3 W9 VVolume 46 Number 6
" R; e1 I. u' Q1 WJuly 2007 540-543
# z' O/ v& D/ a9 ?+ R© 2007 Sage Publications
% s1 P, y9 a4 L5 x: w3 d2 |8 q+ E10.1177/0009922806296651% U% m8 N& h- `" u/ t
http://clp.sagepub.com- f' Q w) q% p. o o, x3 n0 {
hosted at
/ j0 x3 t5 E) r8 ^http://online.sagepub.com
) `: o& A0 b; ePrecocious puberty in boys, central or peripheral,
6 b1 a) b7 ^6 J: O7 Ois a significant concern for physicians. Central
' @5 m1 y7 @1 J: y _+ ~0 wprecocious puberty (CPP), which is mediated
7 [% b! |; A* y: n% K, ]through the hypothalamic pituitary gonadal axis, has
D9 z; Y& ?% m* e; Wa higher incidence of organic central nervous system
& e9 R' A( ?0 G* T5 slesions in boys.1,2 Virilization in boys, as manifested" U8 [8 N! E% t: J t$ g3 \
by enlargement of the penis, development of pubic
0 K) u# e6 D1 X5 ]; S( mhair, and facial acne without enlargement of testi-6 o5 C" `6 a4 x. N& n
cles, suggests peripheral or pseudopuberty.1-3 We: i% |, m" P& E1 r- K+ ]1 r: u
report a 16-month-old boy who presented with the
" v! K f8 }( ~; u- kenlargement of the phallus and pubic hair develop-" @8 g Q# X# a. G$ p: B
ment without testicular enlargement, which was due% T. x8 F1 y! R/ D: ~3 f
to the unintentional exposure to androgen gel used by# | k: Z: u, R1 A+ f! D
the father. The family initially concealed this infor-
! K9 S' f b: `) I6 z- M* `mation, resulting in an extensive work-up for this
/ s! b7 N' K6 d' z' e+ [child. Given the widespread and easy availability of! x" _# {2 X1 [7 z& w
testosterone gel and cream, we believe this is proba-: w, K5 q. ]: M3 z v i
bly more common than the rare case report in the0 m& k# H; F9 ^# A5 P
literature.4- P3 w7 o, g6 i: E/ h0 S/ f
Patient Report
6 |0 g1 N5 C6 o2 fA 16-month-old white child was referred to the3 f0 [% y2 d4 i5 Y0 i; [) V
endocrine clinic by his pediatrician with the concern
1 e! W9 o. m# u1 w, F0 R; lof early sexual development. His mother noticed
; V$ Z- I3 ]9 K! F# n4 u: |light colored pubic hair development when he was
- }, h5 N- m5 j6 @% LFrom the 1Division of Pediatric Endocrinology, 2University of* n* I) B7 v4 i- ?
South Alabama Medical Center, Mobile, Alabama.3 H% X* D! A! a
Address correspondence to: Samar K. Bhowmick, MD, FACE,& U; P3 L. l& N3 O! j( m9 o& D! z
Professor of Pediatrics, University of South Alabama, College of! X$ d% \, _, f1 P1 U
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ O; A1 N' }3 J* q% D0 y$ d
e-mail: [email protected].
4 p; ]8 [( Z7 |3 H0 Aabout 6 to 7 months old, which progressively became
3 q- v& R6 G% x$ ?5 p& Mdarker. She was also concerned about the enlarge-3 k. t; i n: z2 }1 v
ment of his penis and frequent erections. The child
; Y! f! U) G9 M- b8 Q2 R: ]( Wwas the product of a full-term normal delivery, with
# G8 J) Q5 \; b# o c! N: ca birth weight of 7 lb 14 oz, and birth length of. ^7 W" ], I9 m9 s: D
20 inches. He was breast-fed throughout the first year
+ r3 B6 h3 D6 m( Oof life and was still receiving breast milk along with
& r$ }4 V5 C$ ^' e# f5 }8 J! ssolid food. He had no hospitalizations or surgery,. O- @/ }4 d+ l$ Z
and his psychosocial and psychomotor development1 M3 R% a1 R+ w1 L: E
was age appropriate.# v8 T q- W3 d! |
The family history was remarkable for the father,
( c4 U" w/ k: }/ {2 i2 t2 Z& uwho was diagnosed with hypothyroidism at age 16,* D& j1 H1 d; ?
which was treated with thyroxine. The father’s
$ U( p; b+ V: J: theight was 6 feet, and he went through a somewhat3 L, n" w* Q" B; F C
early puberty and had stopped growing by age 14.
/ N0 G/ ^( x/ uThe father denied taking any other medication. The
2 q! b- }! X/ b1 ]. u2 ?1 y; cchild’s mother was in good health. Her menarche
2 B5 t; N2 s; f: s) zwas at 11 years of age, and her height was at 5 feet
2 ^ B5 ?/ ~5 i. b/ `. s& H0 X6 V: v7 K& n5 inches. There was no other family history of pre-5 A: P/ ?$ H+ K
cocious sexual development in the first-degree rela-
5 T, L' D, Y2 p5 H$ K: [tives. There were no siblings.: C+ {' h. c2 H5 |. V
Physical Examination% J2 [: M' z" F9 m' o% z( C1 D
The physical examination revealed a very active,; X' V3 o0 @) x" J' I# B& J
playful, and healthy boy. The vital signs documented
/ h9 f, L% M7 x2 k! e- c, ~a blood pressure of 85/50 mm Hg, his length was) J' h) }; Q1 c. T* P8 n7 ?" |
90 cm (>97th percentile), and his weight was 14.4 kg& |$ b: a1 R. s' @$ B. U& d, m: H5 V
(also >97th percentile). The observed yearly growth1 I7 \. R M& G* R
velocity was 30 cm (12 inches). The examination of/ f2 A; s3 V; `4 o8 D- o# Q- E! S
the neck revealed no thyroid enlargement.! b. s" e0 k+ ]8 ~3 \
The genitourinary examination was remarkable for
+ I: l4 ~: D* y R1 Cenlargement of the penis, with a stretched length of; {- B! z. F z- ~# A/ l T
8 cm and a width of 2 cm. The glans penis was very well4 {7 M$ V5 I5 }- n& |
developed. The pubic hair was Tanner II, mostly around
7 t- Q# }* X: ?$ ]7 @8 |3 u540
8 T: X( I/ d' l6 `; j. Q4 k; yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( j" k. ^5 ]3 J( A3 k
the base of the phallus and was dark and curled. The
, K" g8 i2 E& htesticular volume was prepubertal at 2 mL each.- K3 {9 b4 Y$ H! a
The skin was moist and smooth and somewhat
9 f6 i4 w: S0 I6 n. M- q2 g! y2 D2 uoily. No axillary hair was noted. There were no
! F3 q# d$ p4 @8 Y6 C; Xabnormal skin pigmentations or café-au-lait spots.
! G/ g7 x" }0 bNeurologic evaluation showed deep tendon reflex 2+9 D5 ^, w5 D, C- f, ?
bilateral and symmetrical. There was no suggestion* v& q& W0 W+ C8 M4 J& d
of papilledema.% _. o7 ^% c/ w W$ U5 w
Laboratory Evaluation
& z) _% Z. M& B6 q. VThe bone age was consistent with 28 months by
: u' Y. n, a. {9 I2 a$ ]/ \ [using the standard of Greulich and Pyle at a chrono-' c8 \/ [& }+ S- P+ H; S
logic age of 16 months (advanced).5 Chromosomal! W6 ?) K& n3 K3 B- O8 K
karyotype was 46XY. The thyroid function test
F; |/ t! F, P* B5 Eshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, H3 C( t& M+ l8 t
lating hormone level was 1.3 µIU/mL (both normal).2 A7 y6 _5 C, V/ `0 L" N
The concentrations of serum electrolytes, blood
$ C p6 Z5 W S+ k- b3 j7 [+ Qurea nitrogen, creatinine, and calcium all were" z( E$ G0 N, o9 x' ~0 p: n2 y
within normal range for his age. The concentration [+ O0 ]$ H5 m. f6 s& d q. J& W
of serum 17-hydroxyprogesterone was 16 ng/dL
, B7 H8 K9 [; ~(normal, 3 to 90 ng/dL), androstenedione was 20
5 G" k6 d0 N% X5 a# G, e+ Wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 X. z- z" j* X' u) lterone was 38 ng/dL (normal, 50 to 760 ng/dL),
3 X" \) R/ V7 h; X" i' tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 y1 p2 x& q0 a( B: V49ng/dL), 11-desoxycortisol (specific compound S)' m; l- ?. K) U
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! ^. E# _; N/ [1 z5 Y& L u
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: L2 ]) f, ^- u u% x
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),# G/ H0 W7 N9 Y; `
and β-human chorionic gonadotropin was less than
( [! z8 m8 [0 S5 I1 F2 e+ k5 mIU/mL (normal <5 mIU/mL). Serum follicular
; E8 p$ w" \) r% u$ qstimulating hormone and leuteinizing hormone% }9 W8 A$ u% d- q8 Z; C8 T: ~9 v% k
concentrations were less than 0.05 mIU/mL
% I% Y- l/ s) d- r! D& J(prepubertal).$ W, H' D: \0 G1 T% w0 _
The parents were notified about the laboratory
% G. z( T* V4 O0 g/ z& I8 _1 zresults and were informed that all of the tests were" T. H+ o3 S5 U
normal except the testosterone level was high. The. R+ R. d) W( p1 `: Z* i3 i, M
follow-up visit was arranged within a few weeks to7 u, B# H8 I% [1 V
obtain testicular and abdominal sonograms; how-2 z) F$ K. C M; I' L
ever, the family did not return for 4 months.6 n5 G! F9 r# I" x$ ?( ?
Physical examination at this time revealed that the
2 v& l9 l* J* h; X& t _# gchild had grown 2.5 cm in 4 months and had gained% X/ d5 W- c: p1 }* ~1 ^
2 kg of weight. Physical examination remained# c$ h- t, |( l/ B" I
unchanged. Surprisingly, the pubic hair almost com-
3 {+ A0 h; p, M6 Mpletely disappeared except for a few vellous hairs at
3 a# m) `6 G2 Z, T7 i! `/ L Vthe base of the phallus. Testicular volume was still 2/ o3 m$ d& G6 @
mL, and the size of the penis remained unchanged.
5 F- a( p# R8 Y( c, F, zThe mother also said that the boy was no longer hav-
6 V! N% h- G/ D& ]' Y P6 Qing frequent erections.# a4 l& q5 w! D1 B' W
Both parents were again questioned about use of
: i# x7 M; s# \any ointment/creams that they may have applied to
Y9 L& ~( J5 O6 b) Z8 t8 A# S1 M0 Cthe child’s skin. This time the father admitted the
' @) H8 G: C8 Y( h+ U5 T' n$ G* V: nTopical Testosterone Exposure / Bhowmick et al 541. z2 c4 g( g/ |7 h% h
use of testosterone gel twice daily that he was apply-
4 R7 s( z/ k' n) Hing over his own shoulders, chest, and back area for) g5 l) N/ ~- k+ M
a year. The father also revealed he was embarrassed
- z6 l$ e& q1 G2 uto disclose that he was using a testosterone gel pre-9 x* W5 F S+ U2 y9 X* j/ u( g
scribed by his family physician for decreased libido
$ G# D0 a6 H- R, t# z6 B( D2 v( \- psecondary to depression.
1 ]3 u, F3 y6 r1 U/ |6 n/ YThe child slept in the same bed with parents.
+ Q) E& \* N* \% a8 E5 G6 NThe father would hug the baby and hold him on his/ s3 g1 L* P' X7 n5 t) e4 p" K& z
chest for a considerable period of time, causing sig-
0 Z- ]7 H$ E( P7 Q. n O xnificant bare skin contact between baby and father.
; ~/ s/ n+ J8 aThe father also admitted that after the phone call,
; N! b1 M( _8 Ywhen he learned the testosterone level in the baby
0 |8 A- c: M8 p( x K0 H/ a7 O, dwas high, he then read the product information
% L$ _2 T. T0 g' m' Qpacket and concluded that it was most likely the rea-
0 z% K3 g( h6 n/ ?3 Hson for the child’s virilization. At that time, they
Y# g* V5 W+ w, rdecided to put the baby in a separate bed, and the
' H4 l/ y* \7 O' M( V. D$ Sfather was not hugging him with bare skin and had
( H' p/ V$ [$ Z/ G- F( v# e" fbeen using protective clothing. A repeat testosterone
: h1 u$ b$ }! t, }8 ?6 u% Utest was ordered, but the family did not go to the2 n3 a: V ^& x- O0 ^6 r5 e2 x4 S
laboratory to obtain the test.* F5 M6 V( P, q U
Discussion0 E5 Y; \" p. |, ~2 l0 v
Precocious puberty in boys is defined as secondary$ H7 n& o# L2 E) Z7 J0 {
sexual development before 9 years of age.1,4
1 j5 _. O: W. o. FPrecocious puberty is termed as central (true) when2 P( k$ Y7 M/ {0 k. v7 D
it is caused by the premature activation of hypo-% z2 A* {8 W, h9 H
thalamic pituitary gonadal axis. CPP is more com-6 q0 `/ W+ {/ U( ~, Z( Y
mon in girls than in boys.1,3 Most boys with CPP
3 K! _& J; b4 e. U" e/ amay have a central nervous system lesion that is
# Q e# _. z7 n9 Zresponsible for the early activation of the hypothal-
0 u4 G+ G+ c( {5 |& Damic pituitary gonadal axis.1-3 Thus, greater empha-
( i$ ^ b* ]; x+ H4 H" I6 isis has been given to neuroradiologic imaging in
2 e7 N3 _' _% t/ rboys with precocious puberty. In addition to viril-! L2 b3 m3 K& E: C
ization, the clinical hallmark of CPP is the symmet-
: |. }( i* |9 a0 {0 s# t |rical testicular growth secondary to stimulation by+ p- H: ?2 X, i, M
gonadotropins.1,3
) i9 I: p2 p3 I5 k6 m$ F' cGonadotropin-independent peripheral preco-
- m( e" a }" z" {cious puberty in boys also results from inappropriate& g4 I2 K; z- ]4 O# [$ V
androgenic stimulation from either endogenous or
7 s! p3 f2 M9 m# w; l* Z& Wexogenous sources, nonpituitary gonadotropin stim-5 T# X% ~& w. f* _; Y% b0 R0 R9 N! O
ulation, and rare activating mutations.3 Virilizing
& H! W; j) G! v$ k: ccongenital adrenal hyperplasia producing excessive
" k7 [1 o I7 G* W9 j* K5 fadrenal androgens is a common cause of precocious" Z6 n0 l# R! l' v, a
puberty in boys.3,46 A' V5 v3 Q% h2 |( a* }& r) Y0 L
The most common form of congenital adrenal
+ L4 b2 m+ ]3 ^5 l- shyperplasia is the 21-hydroxylase enzyme deficiency.4 f! d% Z! o5 e9 {$ |4 S; a- Y
The 11-β hydroxylase deficiency may also result in4 J9 }$ E- w+ r- t; G! P! C# j
excessive adrenal androgen production, and rarely,% d7 [! T" Q# V* Z( b' i8 a9 S( n
an adrenal tumor may also cause adrenal androgen0 g7 g! i2 j% J
excess.1,3
5 p, |: O' O2 Y- z9 dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 p: w# L, j# p0 M1 J
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 |" g4 |3 J- c% ?+ dA unique entity of male-limited gonadotropin-
: X3 | Q L, O6 a" B2 lindependent precocious puberty, which is also known
- l# |1 m, z6 O: l3 H+ E5 Has testotoxicosis, may cause precocious puberty at a
& S# P$ d6 W( D0 dvery young age. The physical findings in these boys
, p2 p+ }7 h, u8 s/ @with this disorder are full pubertal development,1 u1 |7 w4 `; \' T; h U& l( f
including bilateral testicular growth, similar to boys
1 X* g3 a! E3 x' ^2 w& @4 swith CPP. The gonadotropin levels in this disorder
. P& I5 q8 e$ I% h4 p' B/ c9 ]are suppressed to prepubertal levels and do not show
7 u3 ~+ V3 ^+ H# X; P/ |pubertal response of gonadotropin after gonadotropin-
- k2 ?1 i x6 x: O4 I& q! L) A$ Nreleasing hormone stimulation. This is a sex-linked
" u: `/ V1 u+ [+ Sautosomal dominant disorder that affects only; {3 T/ O( t- p# p+ m8 g" m
males; therefore, other male members of the family
9 ^3 ?, t8 ~4 q0 Qmay have similar precocious puberty.32 w0 r: D! b# ~* O& C' V% ^
In our patient, physical examination was incon-
# I4 o' M2 B3 k8 psistent with true precocious puberty since his testi-' V$ G. c; B. k; A
cles were prepubertal in size. However, testotoxicosis
" j4 U9 a9 |5 q5 {3 ~was in the differential diagnosis because his father
6 o* j- u. L Vstarted puberty somewhat early, and occasionally,1 W" x- f- `3 V/ _$ [9 r& L
testicular enlargement is not that evident in the3 f' E$ p) ? ?8 e. |
beginning of this process.1 In the absence of a neg-
5 {, v, @' W# ~! Eative initial history of androgen exposure, our
1 u4 _6 s0 k+ w! N2 `biggest concern was virilizing adrenal hyperplasia,
2 w& L. v8 _/ u' s3 t/ { t9 Reither 21-hydroxylase deficiency or 11-β hydroxylase
& @# N! {+ f m5 R4 fdeficiency. Those diagnoses were excluded by find-
6 i6 t m4 ` D4 x, w2 oing the normal level of adrenal steroids.
5 {/ v9 S' W# RThe diagnosis of exogenous androgens was strongly
5 @, E) T' F% Y' P* ?suspected in a follow-up visit after 4 months because4 e: w& q# g. ]4 j4 D
the physical examination revealed the complete disap-7 w- z7 h1 `2 w
pearance of pubic hair, normal growth velocity, and
- t2 d8 o6 L! idecreased erections. The father admitted using a testos-: b2 c! g8 c- G/ O7 _ L u1 @
terone gel, which he concealed at first visit. He was
* F6 ]1 B# q# _0 Iusing it rather frequently, twice a day. The Physicians’
$ W7 a0 E- D: \) L1 pDesk Reference, or package insert of this product, gel or8 n& g; j0 `+ i( I. G/ \5 Y! E
cream, cautions about dermal testosterone transfer to
8 L0 v( p; D+ N! m0 q5 k7 I- Ounprotected females through direct skin exposure.
0 ]+ ~: h2 L: E# q* VSerum testosterone level was found to be 2 times the
/ Z" T2 X4 @# T4 ?1 Sbaseline value in those females who were exposed to3 h( x0 X# ~6 d9 b
even 15 minutes of direct skin contact with their male
$ m' a) X% H! @! c1 C9 Jpartners.6 However, when a shirt covered the applica-
% i2 ]5 @: H1 C; Q% u0 t/ ]tion site, this testosterone transfer was prevented.4 F# }) ]& a' ]. q& m
Our patient’s testosterone level was 60 ng/mL,
q: Z3 }1 e, pwhich was clearly high. Some studies suggest that
* w/ q- U' K: gdermal conversion of testosterone to dihydrotestos-
9 J4 C3 l# G+ N0 Qterone, which is a more potent metabolite, is more
' z' g( {: L- u/ ~+ cactive in young children exposed to testosterone$ z, S8 {2 A, ~- o5 u- H* v
exogenously7; however, we did not measure a dihy-
4 u) ?) |4 H5 d, J/ Gdrotestosterone level in our patient. In addition to
1 L! V' W; v5 j Ovirilization, exposure to exogenous testosterone in5 z0 ?1 B- F5 h; ?
children results in an increase in growth velocity and
( A, D, @; T9 r' V7 }0 m8 J; Nadvanced bone age, as seen in our patient.
2 m% y# \* b/ XThe long-term effect of androgen exposure during
5 ~ |' J) ~$ j8 y( F+ Z0 R, S1 d. y: iearly childhood on pubertal development and final0 Y7 \8 `% ?) Z4 u" L
adult height are not fully known and always remain
2 H3 w3 I! \ T8 d) c/ Ea concern. Children treated with short-term testos-
! X4 F* U- F4 u r. C5 S& f& v' Kterone injection or topical androgen may exhibit some- |8 d) U+ ]( o/ g
acceleration of the skeletal maturation; however, after6 _5 h2 P4 i4 V8 ^& B: b) x
cessation of treatment, the rate of bone maturation
/ N4 _7 l3 g9 q* X7 q1 _decelerates and gradually returns to normal.8,9
- i! h; J$ ~9 y% W# `' t4 IThere are conflicting reports and controversy
7 ]) u/ \* l* ]# X! s( O. v1 H+ gover the effect of early androgen exposure on adult# f4 N9 n! B0 i7 O& ]
penile length.10,11 Some reports suggest subnormal! p! l% Q+ W* j; S! z5 D
adult penile length, apparently because of downreg-
5 i* M$ C! G( N4 vulation of androgen receptor number.10,12 However,/ f# Z; |, [5 b7 \9 B; @
Sutherland et al13 did not find a correlation between
) Q/ p. F2 j( h) }- Zchildhood testosterone exposure and reduced adult
. ~' ] X/ K" A/ X' Q6 @! mpenile length in clinical studies.7 ]$ B, R K( y
Nonetheless, we do not believe our patient is6 ^& h' E; Y8 ~" m% z% S
going to experience any of the untoward effects from! o" D) \' E% d9 R3 Q8 G
testosterone exposure as mentioned earlier because! w2 M+ r3 y+ e9 K- `6 o3 g% |
the exposure was not for a prolonged period of time.
4 {4 k8 p& V0 QAlthough the bone age was advanced at the time of8 E: ?# B) T7 P; {1 X
diagnosis, the child had a normal growth velocity at7 C! p+ A0 Z. b- \7 R, [
the follow-up visit. It is hoped that his final adult
/ U* {" r2 }! U, mheight will not be affected.
( m3 t$ m. s) IAlthough rarely reported, the widespread avail-
- o: w0 C* S7 a- N. n2 dability of androgen products in our society may
3 P& F: T( E3 d% Cindeed cause more virilization in male or female3 V, v3 |% E) T; a
children than one would realize. Exposure to andro-$ H5 q- d; v1 p! h7 f/ q& A
gen products must be considered and specific ques-
! g0 T- P- X3 {8 gtioning about the use of a testosterone product or
. d7 U, L7 W, a/ s* ygel should be asked of the family members during/ Z/ \2 H) v0 t0 K5 ?! y( C+ W
the evaluation of any children who present with vir-, I. `+ |+ j( x4 M) @; i
ilization or peripheral precocious puberty. The diag-
& e s& y6 N. u2 c2 z! j- c: V; A6 Onosis can be established by just a few tests and by
1 ]% O; N- K, S1 {: A9 cappropriate history. The inability to obtain such a5 ~2 g8 X0 ~' C3 J* z6 d- R1 s1 F1 a z
history, or failure to ask the specific questions, may
# t# S# N$ I, y! X2 fresult in extensive, unnecessary, and expensive
/ i$ Q) F1 }' A0 \/ iinvestigation. The primary care physician should be9 X6 S) m3 e0 v" H% j$ m
aware of this fact, because most of these children$ [+ K( f2 \5 S5 c
may initially present in their practice. The Physicians’
5 I, I2 u1 X$ gDesk Reference and package insert should also put a
6 {+ j# H: n5 ?& nwarning about the virilizing effect on a male or
) G: M+ J- Y: ^' C4 H/ @; Ffemale child who might come in contact with some-$ P: Z: |2 i2 w/ `
one using any of these products.7 }7 J! B: y0 \- n4 k7 c
References* [. R- V3 l1 ]9 b5 ]
1. Styne DM. The testes: disorder of sexual differentiation- |1 o+ ], N1 K* z) G( {
and puberty in the male. In: Sperling MA, ed. Pediatric5 n t) M3 B: W) k7 I7 [
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) _- N8 j6 h* B# F" M
2002: 565-628.
$ J! W! u& A0 y6 D, x3 \/ c2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 P- ]. N$ x2 V, b+ a4 Bpuberty in children with tumours of the suprasellar pineal |
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