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Sexual Precocity in a 16-Month-Old
: _! @% h! G4 t5 {9 eBoy Induced by Indirect Topical6 P3 q$ J, c3 i5 U& S+ K" B
Exposure to Testosterone
) [: c# k9 r! Z7 y5 S9 H& Q+ ~7 PSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 \ s1 o5 L& i0 y
and Kenneth R. Rettig, MD10 }- R- D! I9 E9 M, c8 T- ~( N
Clinical Pediatrics2 Y" g7 P; _. N( E: c$ ]' U
Volume 46 Number 6/ v. u5 r5 g/ \* A* w- H
July 2007 540-543
% Q* P5 @3 {* U2 E; K- N© 2007 Sage Publications( B; h# Z3 d2 [9 D3 ^
10.1177/0009922806296651& |# @. t% o$ [) I3 }$ t
http://clp.sagepub.com0 m/ j& Q8 J. F! u/ @& k: k5 F
hosted at" B4 E8 F! }. O# S7 F* q
http://online.sagepub.com# |. d3 l' M4 R% M
Precocious puberty in boys, central or peripheral,
2 }1 F* L/ f* r' a' w5 }) R' Iis a significant concern for physicians. Central3 D% j- L0 O+ ~9 R9 F
precocious puberty (CPP), which is mediated5 ~& d, K3 d: K3 r, `) V7 J* I
through the hypothalamic pituitary gonadal axis, has9 L) w. p4 d- }0 S$ f6 h% l
a higher incidence of organic central nervous system
/ U5 x+ G& n/ Q4 U: X! Plesions in boys.1,2 Virilization in boys, as manifested
" R8 u+ z) X( }1 u9 R" Pby enlargement of the penis, development of pubic# ]' s& y- S" t! P, Q. M/ \: h8 C9 Q% V
hair, and facial acne without enlargement of testi-
) ~1 c7 m( Z' n2 G+ k' M! v$ s ncles, suggests peripheral or pseudopuberty.1-3 We
( ] f. x. S8 c7 z* E9 w! X7 ireport a 16-month-old boy who presented with the3 J9 m) z' F ~5 W: M
enlargement of the phallus and pubic hair develop-
0 m* q( s5 K/ Sment without testicular enlargement, which was due' o& ^1 d% w( s* \. K. |! H" b
to the unintentional exposure to androgen gel used by( a' L% l5 }. X0 }$ U5 `! ]: b, @+ {
the father. The family initially concealed this infor-
" S( C# P- I$ N2 Y+ E0 M0 I$ @mation, resulting in an extensive work-up for this
" L/ o: b, r1 X& x6 x5 t+ cchild. Given the widespread and easy availability of
5 ^4 c- ~, `2 B" I. A \0 Ktestosterone gel and cream, we believe this is proba-4 c2 c/ b/ G+ B) ^* f- Y, C
bly more common than the rare case report in the
# [+ W) J* x: L% D# m& I8 mliterature.45 x, H p2 x4 t2 _5 O5 J
Patient Report& `' J1 j+ ]4 _3 V ~# J
A 16-month-old white child was referred to the K$ J6 b$ o% E
endocrine clinic by his pediatrician with the concern
0 U/ y4 @+ b1 Lof early sexual development. His mother noticed
0 L9 F, w+ n. t: q8 K0 D3 ~light colored pubic hair development when he was
9 c6 k9 V/ P o8 Z4 w* xFrom the 1Division of Pediatric Endocrinology, 2University of
: s) K0 g. \# N6 BSouth Alabama Medical Center, Mobile, Alabama.
( t7 e1 T2 X. H$ Q- |Address correspondence to: Samar K. Bhowmick, MD, FACE,
( i- J8 b3 v+ e' `) a/ O9 U6 iProfessor of Pediatrics, University of South Alabama, College of) B, x$ R5 B' [5 R
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- U& W" G& q1 D8 j1 W7 \e-mail: [email protected].
4 V/ S4 F* m& R/ cabout 6 to 7 months old, which progressively became
8 [. D% r% I- {/ @& u" e0 ]" cdarker. She was also concerned about the enlarge-+ e, x. r8 F9 s) }1 T0 Y1 m
ment of his penis and frequent erections. The child6 s. R& _- \: @. w9 A+ m
was the product of a full-term normal delivery, with
]) ?$ Y: e+ Wa birth weight of 7 lb 14 oz, and birth length of
6 ~! }/ U6 y; A) T# M/ a; g q20 inches. He was breast-fed throughout the first year: Y6 U# D, u+ M3 ]& ^' K
of life and was still receiving breast milk along with
0 M3 V: w1 D9 d! gsolid food. He had no hospitalizations or surgery,6 @# Y1 d9 y9 ~& `7 Q
and his psychosocial and psychomotor development
, v& i; e+ M8 E+ N% Jwas age appropriate.( O3 Y# z: {/ p! t! ~8 Q
The family history was remarkable for the father,
) i0 \2 q5 l; ~who was diagnosed with hypothyroidism at age 16,
# n ~9 y8 {* g4 cwhich was treated with thyroxine. The father’s( Q( v) j& ~, ?: m# i$ [5 Y1 w
height was 6 feet, and he went through a somewhat
3 g5 O$ }" N- \0 K* Y. v) K$ tearly puberty and had stopped growing by age 14.' p- s5 ~4 [/ ^* X0 R4 }; B* E3 I0 n7 q
The father denied taking any other medication. The
: L9 w& a) q: k' w1 r0 A" gchild’s mother was in good health. Her menarche
2 _ [& P$ {1 R3 bwas at 11 years of age, and her height was at 5 feet; y6 L$ N6 x" |% t) w
5 inches. There was no other family history of pre-8 n9 V7 ^" _4 w# e: R
cocious sexual development in the first-degree rela-! r' m" {: j) ?, _- u: ^9 X1 l/ }
tives. There were no siblings.
* m; p8 u" s- L1 J8 c+ `2 ~$ j* FPhysical Examination0 z9 S5 |1 u: O' t
The physical examination revealed a very active,
1 d7 ` a' z6 M$ j0 x4 Oplayful, and healthy boy. The vital signs documented
+ K+ H5 G L0 w. K+ Na blood pressure of 85/50 mm Hg, his length was2 ~3 i& D5 {- T. l
90 cm (>97th percentile), and his weight was 14.4 kg3 t8 G# l4 b7 X) |8 I+ |5 k/ ]
(also >97th percentile). The observed yearly growth/ b! m7 c0 n$ i2 v+ p
velocity was 30 cm (12 inches). The examination of
, ^/ O& G2 E6 w& k6 x; L! Sthe neck revealed no thyroid enlargement.7 H4 ^5 V+ l) O" S, a$ u
The genitourinary examination was remarkable for
; e+ s: Q$ Y. @5 N7 ]enlargement of the penis, with a stretched length of
: ^; P2 {- R# \/ f8 cm and a width of 2 cm. The glans penis was very well4 N1 [7 X2 p( W' h
developed. The pubic hair was Tanner II, mostly around% f& t8 U" d, S6 A& N" B
540
7 `% L4 C# e0 w, J4 w zat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 O& k' j' Y$ q
the base of the phallus and was dark and curled. The
/ a3 ~$ r/ T% L( K7 xtesticular volume was prepubertal at 2 mL each.- y) {1 R, Y3 A4 G2 \6 K4 M3 |9 {% ]
The skin was moist and smooth and somewhat8 g: T" p9 j2 v
oily. No axillary hair was noted. There were no
" C( w& N4 t8 ]6 uabnormal skin pigmentations or café-au-lait spots.$ a2 }! y/ f* H+ w& q
Neurologic evaluation showed deep tendon reflex 2+/ L1 S* x1 |% L' a- _9 I' R* P5 l: v
bilateral and symmetrical. There was no suggestion8 L5 g& V" r, d, B
of papilledema./ E( ]" c$ A8 c, `; l2 |
Laboratory Evaluation
: R; g. n+ Y) P( C" w* s, i, BThe bone age was consistent with 28 months by- ?" I; X1 A& R- `* c# D
using the standard of Greulich and Pyle at a chrono-3 w% M# R; s4 Z! z- F6 ^' c% p
logic age of 16 months (advanced).5 Chromosomal
" V9 W+ ~: }9 q9 J, |0 }karyotype was 46XY. The thyroid function test( s$ z0 W$ u3 r! A
showed a free T4 of 1.69 ng/dL, and thyroid stimu-, m" ?7 l$ c, K0 }1 ?) @
lating hormone level was 1.3 µIU/mL (both normal).; s2 W' n- h/ E( D" ^) r
The concentrations of serum electrolytes, blood
; h p( G; S3 Y. o6 J( Rurea nitrogen, creatinine, and calcium all were
8 f( T" m" V" Iwithin normal range for his age. The concentration$ T1 ]/ ]0 q0 J# F5 E5 X* [
of serum 17-hydroxyprogesterone was 16 ng/dL$ v% N/ s1 O4 k
(normal, 3 to 90 ng/dL), androstenedione was 20! P' p6 A" g2 b2 g
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 ?. z* [1 W+ J' v
terone was 38 ng/dL (normal, 50 to 760 ng/dL),4 h. m6 U: W* E, h2 r
desoxycorticosterone was 4.3 ng/dL (normal, 7 to- ]8 D w4 D2 q& [* w; }
49ng/dL), 11-desoxycortisol (specific compound S)4 }" T; X, W6 Q4 d5 [/ E9 v+ p' X' L
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-0 [% e) n' v' W# g1 ]: l
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 o! R/ Z5 H3 R# n. j& q6 i$ _- S" W
testosterone was 60 ng/dL (normal <3 to 10 ng/dL), S% \( U4 _6 W% p8 h o
and β-human chorionic gonadotropin was less than
^8 p# k( v$ s% K5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ t8 ~) a/ J- istimulating hormone and leuteinizing hormone
6 K2 W5 n$ g& tconcentrations were less than 0.05 mIU/mL+ e6 v$ a* X1 P2 w4 I
(prepubertal).
0 u- S# I8 p- S* K- j7 G P% SThe parents were notified about the laboratory" G6 ]' _3 q2 ] [2 I5 ~. D
results and were informed that all of the tests were
9 N- q# W; R: l2 T" A. anormal except the testosterone level was high. The
2 X' |9 S/ @9 G2 r( T8 j3 y$ {5 \follow-up visit was arranged within a few weeks to8 s3 i; [! a) @$ e& T
obtain testicular and abdominal sonograms; how-3 E! h, R0 D. s+ J4 q
ever, the family did not return for 4 months.
/ [* k0 C6 {8 T/ J3 q! vPhysical examination at this time revealed that the
$ _3 V' n/ v! G+ w' _' @# Lchild had grown 2.5 cm in 4 months and had gained
( @0 @: H" j( ]# u2 kg of weight. Physical examination remained
4 z$ g C: c3 g8 n# b; Lunchanged. Surprisingly, the pubic hair almost com-
8 i- |) z8 @0 j( B: ipletely disappeared except for a few vellous hairs at
6 ?) T- n+ L* B9 F( u0 ithe base of the phallus. Testicular volume was still 2
9 Q8 x5 v& t& u& v: @, G emL, and the size of the penis remained unchanged.) t, w b. h8 Z) l
The mother also said that the boy was no longer hav-
& ]: W8 O1 G3 O( K$ ^8 X& i: Ring frequent erections.( x8 n: U6 v/ C5 Y- U' l/ i
Both parents were again questioned about use of
* v) C; {4 W( q; }9 N5 Uany ointment/creams that they may have applied to7 u0 m T- s0 p( b4 Q( k
the child’s skin. This time the father admitted the1 u. n8 h2 A5 U) r) z. E: B
Topical Testosterone Exposure / Bhowmick et al 5411 }+ E) ?( F* F# S' o
use of testosterone gel twice daily that he was apply-
9 L0 Y6 b P6 {6 P7 g" c# \7 King over his own shoulders, chest, and back area for
: g( ]4 D. r2 @& `* J& V- t( ]% a/ ra year. The father also revealed he was embarrassed
0 `' c# b- C: r0 x1 A* mto disclose that he was using a testosterone gel pre- B5 R, d! U2 ~! d0 E' C
scribed by his family physician for decreased libido' [& @4 |, a9 a0 d
secondary to depression.4 V! e" a7 ?8 w* q
The child slept in the same bed with parents.. b8 K6 T }' v# E8 b s& c
The father would hug the baby and hold him on his
6 e# r' w! c5 ?; X1 D3 e3 T/ Cchest for a considerable period of time, causing sig-- `7 r7 Y# e/ ^4 Z. r4 L- S0 P
nificant bare skin contact between baby and father.
# [" T- o" e n) W" wThe father also admitted that after the phone call,- l% e" h" _" {5 Y2 q& U1 I
when he learned the testosterone level in the baby% H) Q5 S1 z- \( D
was high, he then read the product information/ ~' F& }8 l$ J" M/ O
packet and concluded that it was most likely the rea-
- ^9 r7 n; n* D# _4 m7 n! S; M8 Json for the child’s virilization. At that time, they8 q" B$ L2 {9 V( z3 Y5 Y
decided to put the baby in a separate bed, and the
) m0 s; c6 U% s0 ^5 m5 z! O8 ~father was not hugging him with bare skin and had
5 Q |8 O' y. A' |4 Pbeen using protective clothing. A repeat testosterone
8 y1 h7 o# @$ { }/ ^8 ^9 Vtest was ordered, but the family did not go to the" g5 z9 O' w/ \
laboratory to obtain the test.% I( g; Q* w& Z/ V% O
Discussion
, m1 e6 b1 s8 [4 oPrecocious puberty in boys is defined as secondary* o2 j( G' \, p" t8 R( I: m- E
sexual development before 9 years of age.1,4" o. ?# }& [5 `8 u5 w+ }
Precocious puberty is termed as central (true) when5 v# Y# V, \8 a' V# @7 Y3 I: a
it is caused by the premature activation of hypo-
* J! _ i+ P5 m% v& A/ m! f& sthalamic pituitary gonadal axis. CPP is more com-- C! ?' R! g% o- j; B' N
mon in girls than in boys.1,3 Most boys with CPP
! a2 J5 G* C! s( o. i% Q& Amay have a central nervous system lesion that is4 v x: }+ v5 Y( P9 o) P
responsible for the early activation of the hypothal-& r1 ]2 t5 T7 g
amic pituitary gonadal axis.1-3 Thus, greater empha-% n) M0 v8 m5 ?( N
sis has been given to neuroradiologic imaging in
' I! h' O0 `) {boys with precocious puberty. In addition to viril-
7 ~- \( u& Z- g, P' Gization, the clinical hallmark of CPP is the symmet-( G9 [6 V6 \+ u ?& c5 \
rical testicular growth secondary to stimulation by. \3 \# g3 n- V6 N2 e7 |7 Q* w
gonadotropins.1,35 d5 L \( D6 U% c i$ r8 H/ u3 I/ F: R
Gonadotropin-independent peripheral preco-" K5 N b2 b' b8 T
cious puberty in boys also results from inappropriate
- R# j4 |+ p8 O% V% xandrogenic stimulation from either endogenous or
6 H: w9 m2 c0 mexogenous sources, nonpituitary gonadotropin stim-
; Y- ~" Z) X3 p7 ]8 m$ gulation, and rare activating mutations.3 Virilizing- ~& U6 _5 Q$ x6 n0 p! l
congenital adrenal hyperplasia producing excessive
4 ^) y- Z7 R Q1 t+ U- Badrenal androgens is a common cause of precocious8 `) S7 s( R; y7 e! x4 [
puberty in boys.3,4; \) s* D# z# [
The most common form of congenital adrenal- m8 B4 L' F* m: R( h- _2 o
hyperplasia is the 21-hydroxylase enzyme deficiency.
. \) o) M' ]! YThe 11-β hydroxylase deficiency may also result in& ?* v6 t8 ]1 F, {, n: M+ ]( C& C7 l
excessive adrenal androgen production, and rarely,! i) Q* t+ c9 j& Q8 g1 Z
an adrenal tumor may also cause adrenal androgen
7 A) {, H* s4 \. U7 t8 n# Bexcess.1,3; ^6 ~( i( r0 Z7 P U& @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- h% Z3 P5 W7 X3 B* X# H2 B542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 }+ K5 f( a; P( w' [. lA unique entity of male-limited gonadotropin- F/ X' H$ k$ }" V( B
independent precocious puberty, which is also known6 b6 \1 G/ e: j* w
as testotoxicosis, may cause precocious puberty at a- ]; j) G; ]& s
very young age. The physical findings in these boys9 y0 i* l: ^. e, T: r4 E
with this disorder are full pubertal development,
v: ?3 P0 [7 c0 Vincluding bilateral testicular growth, similar to boys
: A* g7 f6 V. b# Lwith CPP. The gonadotropin levels in this disorder" m" _0 z6 H7 F$ ^
are suppressed to prepubertal levels and do not show
0 C' {/ l; c' Q/ W" y2 g0 r3 S R; a3 bpubertal response of gonadotropin after gonadotropin-
2 a+ I7 w O! vreleasing hormone stimulation. This is a sex-linked
1 V- Z4 {0 }) @# S, ?$ Z9 Sautosomal dominant disorder that affects only# n# ~' x# }( d- c2 t0 U: M. S4 ]
males; therefore, other male members of the family
0 q1 \9 b% w! emay have similar precocious puberty.3) x. B. v; K0 E
In our patient, physical examination was incon-
" ^6 o5 x4 F- }# S% M+ h) ]sistent with true precocious puberty since his testi-
5 W1 P1 C2 m' h$ z; r4 b E$ G Zcles were prepubertal in size. However, testotoxicosis ` f3 M* P8 h4 ^% z" n+ p, g
was in the differential diagnosis because his father( _4 W6 C" V% `
started puberty somewhat early, and occasionally,
) ~% P4 ^. I: {# J. a: z5 V# Xtesticular enlargement is not that evident in the" d# y3 `0 d. \5 c* R" \
beginning of this process.1 In the absence of a neg-
# D) R+ ?, _' U5 u9 C- A- Tative initial history of androgen exposure, our9 X% t7 c5 P. g n# T
biggest concern was virilizing adrenal hyperplasia,
- f6 U9 J4 N0 f- ^2 |+ m: q+ Oeither 21-hydroxylase deficiency or 11-β hydroxylase
0 |; _9 E) J( U" |deficiency. Those diagnoses were excluded by find-
r7 d% M( x" B: Z) Wing the normal level of adrenal steroids.
. S# q( S! j% mThe diagnosis of exogenous androgens was strongly
0 q& t2 F/ ?5 J/ r& s4 T Dsuspected in a follow-up visit after 4 months because
9 n5 ^; \: y( O d* K0 Hthe physical examination revealed the complete disap-
1 H/ z5 Y4 O/ N0 S, V3 s0 }5 epearance of pubic hair, normal growth velocity, and
2 j5 t8 Y" ?& f# @3 p+ Z/ ddecreased erections. The father admitted using a testos-, B }- I( f4 _) j; C
terone gel, which he concealed at first visit. He was5 P3 d5 _( R. k7 q# f% M6 P9 T
using it rather frequently, twice a day. The Physicians’
l2 G2 h+ i, qDesk Reference, or package insert of this product, gel or# ]5 x% e# H5 r# W0 _) y
cream, cautions about dermal testosterone transfer to8 h8 t! c& {4 R9 c9 X3 D3 A4 Y
unprotected females through direct skin exposure.
; @. W; J3 Z* @* f w& \Serum testosterone level was found to be 2 times the
7 O7 Z. l) v0 }2 v$ T7 D4 i/ |4 G t. ?baseline value in those females who were exposed to; T7 M- Q7 W7 w
even 15 minutes of direct skin contact with their male6 C- w2 z. B$ b& f
partners.6 However, when a shirt covered the applica-( W) ^& g+ u& g+ a
tion site, this testosterone transfer was prevented.% S# o5 C% q( `
Our patient’s testosterone level was 60 ng/mL,
* r7 o+ P4 k2 a* [3 w- L- Qwhich was clearly high. Some studies suggest that
- A7 L, U& A3 E: D8 x7 d! mdermal conversion of testosterone to dihydrotestos-: P6 u8 Z' g2 r: u9 W0 O) w3 A
terone, which is a more potent metabolite, is more" M) M/ u9 M2 X# F; h
active in young children exposed to testosterone
8 s8 Z: ~, Q c# c! O5 j. dexogenously7; however, we did not measure a dihy-- k+ z) a, M" n
drotestosterone level in our patient. In addition to! v$ e6 ~( U, A# Q- F9 Y8 C
virilization, exposure to exogenous testosterone in! A5 h- c. z# u& M4 j
children results in an increase in growth velocity and R1 R1 W! Y" E n& s7 l: L/ m
advanced bone age, as seen in our patient.
5 T! H7 G4 X3 `: Y$ tThe long-term effect of androgen exposure during
1 a1 l" }& e' P+ }8 z, `8 A7 x7 t& n gearly childhood on pubertal development and final
; j3 H! ~3 r3 V8 ]adult height are not fully known and always remain; t9 a& c& }4 m1 f% Z
a concern. Children treated with short-term testos-* W: ]3 n/ l1 m7 {. R. J
terone injection or topical androgen may exhibit some) E- m% X: y0 u
acceleration of the skeletal maturation; however, after5 ]; u1 d+ f, N3 l, S- g
cessation of treatment, the rate of bone maturation
) _- s/ f# p- T8 O, r+ {decelerates and gradually returns to normal.8,9
6 V4 U. ?6 i2 t% h, i, w! GThere are conflicting reports and controversy
& F, k0 o3 k% X: Y, o$ oover the effect of early androgen exposure on adult
& k% J4 t* d7 y$ R0 Mpenile length.10,11 Some reports suggest subnormal
8 }, ]7 f# ^6 G7 Yadult penile length, apparently because of downreg-
$ c# A- J) X% R! b' @ulation of androgen receptor number.10,12 However,
' O( q6 {* o; M. CSutherland et al13 did not find a correlation between. K( d' A3 n% R- G3 k3 U3 L
childhood testosterone exposure and reduced adult; Q, Q# Y4 ?# d: z% [, [7 a
penile length in clinical studies.
6 S: i; m' y6 v$ `' DNonetheless, we do not believe our patient is
6 K2 Y' D. Q) kgoing to experience any of the untoward effects from, Y" @, Z- L& W$ b
testosterone exposure as mentioned earlier because
/ v, x l1 T4 t% kthe exposure was not for a prolonged period of time.6 Z7 M2 }7 Z+ H t8 U3 J ]# _
Although the bone age was advanced at the time of% g1 V& h6 T- Z5 o8 c
diagnosis, the child had a normal growth velocity at. G& R: m7 H- K0 d+ x, s: x
the follow-up visit. It is hoped that his final adult
( Y" w* g% P4 ?7 i+ D+ Pheight will not be affected.' p1 Z, X5 [( ?* [ @. _
Although rarely reported, the widespread avail-
) m4 Z( V& L/ ]. S; o" D! \$ sability of androgen products in our society may
9 Z2 n2 [5 k# C5 a) g# V/ W2 Oindeed cause more virilization in male or female/ Z+ N B4 m9 s! }+ k) s
children than one would realize. Exposure to andro-
, P; d! ^- v h, o. W; g9 p! n% Jgen products must be considered and specific ques-
' O% \. o6 ?# u5 a3 r9 Utioning about the use of a testosterone product or2 z, ]6 }1 D9 P# v9 q4 T
gel should be asked of the family members during
4 |6 Z+ w i0 w5 V1 [) mthe evaluation of any children who present with vir-, M0 G0 w9 ^' K' V, r
ilization or peripheral precocious puberty. The diag-
4 {! F/ R9 w, A% s4 A$ `0 ?& ?5 Fnosis can be established by just a few tests and by
, k9 L, I+ X2 h" M: x9 G( dappropriate history. The inability to obtain such a
# }5 P& q) O4 [history, or failure to ask the specific questions, may2 E( O+ _( ], W0 g6 y$ A6 k; a
result in extensive, unnecessary, and expensive
6 Z8 a8 \% R; ]7 @* o( }% Tinvestigation. The primary care physician should be p# Q' c U2 v4 X! h
aware of this fact, because most of these children9 v: @: P' E/ T$ X$ S" M) f K
may initially present in their practice. The Physicians’
/ W, `+ r/ O$ r5 }( M5 e( RDesk Reference and package insert should also put a
# F: U$ z& A7 G5 \' T6 R/ U4 rwarning about the virilizing effect on a male or
0 g: B1 b: I: _5 r' T; ~! ^: afemale child who might come in contact with some-' A2 t: f" N$ i5 @5 {2 l+ F3 v
one using any of these products.
! U; v# m+ h( m( |; [References
. m, f3 d6 I9 ]( E% C" h& ]( y1. Styne DM. The testes: disorder of sexual differentiation
$ [6 v: P: ]8 h- ]and puberty in the male. In: Sperling MA, ed. Pediatric
9 M7 p9 B9 Q; LEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# X! Q& T ]3 A; M5 z& ]) A1 B6 W% F2002: 565-628.
& `, @2 _8 T, g. U2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 K" v# _. G2 }6 L6 q" Q0 y. apuberty in children with tumours of the suprasellar pineal |
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