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Sexual Precocity in a 16-Month-Old' E- i4 G- ^" G9 Y2 ]
Boy Induced by Indirect Topical
3 C3 f3 \2 i V; IExposure to Testosterone0 X' c, D/ {! ~5 `
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 T% ~3 }% _7 Y: y0 B2 V
and Kenneth R. Rettig, MD1
' z X! ^% B. L6 ?8 \2 _' F( cClinical Pediatrics
! U5 L* P# G5 r1 q6 v3 kVolume 46 Number 6
6 }5 ]- X7 W0 w. {) t1 l% C1 Y% u8 BJuly 2007 540-543
0 H9 }# D& C" H© 2007 Sage Publications' _; k( n8 O/ I8 a) I$ Y
10.1177/00099228062966510 I0 O' @6 l9 o b, Z0 w `
http://clp.sagepub.com" T3 Z; z5 v% f# W8 j, |
hosted at
1 y$ @; g- P0 t9 H& Q. k( V7 Dhttp://online.sagepub.com
3 l5 V' h; ~6 X, S e: NPrecocious puberty in boys, central or peripheral,
1 X/ a ^2 b5 e9 r1 gis a significant concern for physicians. Central
: {1 V- p8 G$ u1 R ]0 e( m# ?2 ?4 aprecocious puberty (CPP), which is mediated6 m4 t/ Z' r9 P% s1 J
through the hypothalamic pituitary gonadal axis, has
! }, J' m4 a& ~$ W6 U9 q9 la higher incidence of organic central nervous system; F8 K, E+ l. g+ V) T# _
lesions in boys.1,2 Virilization in boys, as manifested' d+ M9 r: T7 Y
by enlargement of the penis, development of pubic2 K! r- t* P* q* l* n: W. L
hair, and facial acne without enlargement of testi-
, A" W* t6 b0 U, ycles, suggests peripheral or pseudopuberty.1-3 We% l; i& l( F9 o' K
report a 16-month-old boy who presented with the
# @, p4 Y. z. H+ ]enlargement of the phallus and pubic hair develop-
B3 ?; Z- ?! fment without testicular enlargement, which was due
b" l4 ]& o+ K% Q4 g( U' Ito the unintentional exposure to androgen gel used by! j: L8 y* S! v' b4 i
the father. The family initially concealed this infor-
. ^/ F) X: u1 \mation, resulting in an extensive work-up for this
% {+ v# C' A6 A2 ?3 }1 _& Q. Echild. Given the widespread and easy availability of
% |& J1 C( H( C6 Atestosterone gel and cream, we believe this is proba-
- z8 ]: H+ S! V8 obly more common than the rare case report in the! l) @$ f. z, U/ w( }2 L
literature.41 B" l# z+ d1 d3 L3 Y) D& K
Patient Report4 Z9 H7 c2 ~6 F$ c, V
A 16-month-old white child was referred to the4 n' y, M: D" N* Y0 @% j
endocrine clinic by his pediatrician with the concern
/ _/ U8 r$ G+ u/ y% _ ^1 v3 ^of early sexual development. His mother noticed
; g* f5 w, p0 b( @light colored pubic hair development when he was% Y: L9 u; V+ G, B8 ?3 ?
From the 1Division of Pediatric Endocrinology, 2University of
3 O% G5 |% X: _South Alabama Medical Center, Mobile, Alabama.5 B1 Y+ e. i7 _. _# q7 [. L$ |$ v
Address correspondence to: Samar K. Bhowmick, MD, FACE,. N( E' Q0 Z# J/ @: [$ b# ?
Professor of Pediatrics, University of South Alabama, College of
( R" D3 W6 ]/ c% n5 ]Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
! f9 D/ g# ~3 h9 D: P0 Y4 @- f, U& re-mail: [email protected].# Q& e! F4 e5 G" o; g c
about 6 to 7 months old, which progressively became) }- n3 n1 B3 \' a0 o& f& h
darker. She was also concerned about the enlarge-
* A- N- b5 _0 X. v, `4 Hment of his penis and frequent erections. The child; E3 O: O7 d O' L: m3 M
was the product of a full-term normal delivery, with
* ]3 K, `- \: D6 Z- J/ s- ^, Za birth weight of 7 lb 14 oz, and birth length of
$ q" R) }. {. _. w20 inches. He was breast-fed throughout the first year
: J- L4 U3 S; X. ~of life and was still receiving breast milk along with% n/ C8 S& L$ @6 O5 @0 Y6 @5 {
solid food. He had no hospitalizations or surgery,
0 W5 |0 K' ]* E6 x: O0 @3 Jand his psychosocial and psychomotor development) `" t& b$ n9 }1 m" H1 P, P
was age appropriate., |$ w* f, }* ]) B
The family history was remarkable for the father," C# Y O; x: x4 s% R( Q7 J' W
who was diagnosed with hypothyroidism at age 16,
+ H6 d, J' ]. l, O2 twhich was treated with thyroxine. The father’s
2 u, S/ \" b0 x# F" o% wheight was 6 feet, and he went through a somewhat
% j( y: z8 V' i# {2 b% ?early puberty and had stopped growing by age 14.
# G. ]1 \& B# h; vThe father denied taking any other medication. The
' Q, ]$ J3 |6 v, K* Lchild’s mother was in good health. Her menarche+ u y: @$ M3 w$ ^ Q/ j. p
was at 11 years of age, and her height was at 5 feet
- l- \- i$ `# H* Y; v$ X F8 w5 inches. There was no other family history of pre-0 i( `3 v- |/ l) C% u. H
cocious sexual development in the first-degree rela-
' i( d$ G- B. X7 L# L# O% X9 n$ Ltives. There were no siblings.2 s! @% Y8 [- a# D# ^9 p% ?" ?9 d/ b
Physical Examination: l# W/ t9 u/ }3 y
The physical examination revealed a very active,
' R& @* e+ B: Z+ C' {2 X. F/ Oplayful, and healthy boy. The vital signs documented
{6 m. P7 |8 g5 Q! Z) ha blood pressure of 85/50 mm Hg, his length was: s; q- P% A# o, Q
90 cm (>97th percentile), and his weight was 14.4 kg
* i* ^9 x# X, r) ~8 G& a5 S(also >97th percentile). The observed yearly growth1 c5 f, f. ^$ E5 b9 g; b( x/ y6 G
velocity was 30 cm (12 inches). The examination of8 _7 Y0 x% ]5 j0 _' k
the neck revealed no thyroid enlargement.
% ?) S7 e8 {$ X5 HThe genitourinary examination was remarkable for
% t3 M3 U; j$ R* |% O& renlargement of the penis, with a stretched length of
4 k( A0 r3 Y8 U. R# {& V* P8 cm and a width of 2 cm. The glans penis was very well: \& p! w1 n- J1 t, L1 n
developed. The pubic hair was Tanner II, mostly around" s z/ \) y# C9 q: K* C8 o
540
. g; T' |' K$ N9 h' u' `1 \1 Cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 |: O* |5 Z" E3 m7 P" x
the base of the phallus and was dark and curled. The5 x9 U8 N6 T( e+ h5 |+ X
testicular volume was prepubertal at 2 mL each.- I1 t9 m& V, ]( }, y" [
The skin was moist and smooth and somewhat+ r& b7 v0 f/ @4 g
oily. No axillary hair was noted. There were no7 D& r- m( m1 y+ z+ z# q
abnormal skin pigmentations or café-au-lait spots.. m/ i" e7 Z" h4 L/ R% ^
Neurologic evaluation showed deep tendon reflex 2+; N. R- e3 B& I8 k) n9 V
bilateral and symmetrical. There was no suggestion2 A7 L7 R B- G* `
of papilledema.2 |. H( H, R* s! D' a2 P
Laboratory Evaluation
9 C. _# r" t# a# v+ ZThe bone age was consistent with 28 months by; X4 J% ^6 g: U
using the standard of Greulich and Pyle at a chrono-
4 d2 z- D7 |+ A; z6 ~3 H% Y1 C/ Llogic age of 16 months (advanced).5 Chromosomal7 O! B7 S, ?, }4 @! P
karyotype was 46XY. The thyroid function test; f; U( q" s! X3 N, i- d
showed a free T4 of 1.69 ng/dL, and thyroid stimu-# P6 p8 U0 l0 c) Z i
lating hormone level was 1.3 µIU/mL (both normal)." h$ _/ g, X; N3 J( V; e
The concentrations of serum electrolytes, blood
2 x+ l- b$ F$ Z; c$ jurea nitrogen, creatinine, and calcium all were
+ c9 b1 n: [+ Wwithin normal range for his age. The concentration
" X3 i& X5 \# b' sof serum 17-hydroxyprogesterone was 16 ng/dL
( a7 v( j1 X5 J# H/ m(normal, 3 to 90 ng/dL), androstenedione was 206 r+ ^( g" z' `9 E
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& j" G, n- K$ U" p! Q+ S6 kterone was 38 ng/dL (normal, 50 to 760 ng/dL),& ]0 ?! e: C! H8 W& o
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 ^6 e2 `* C3 i$ n: |49ng/dL), 11-desoxycortisol (specific compound S)
4 [0 s4 n) G2 k6 q. v- Ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) m( _3 A4 d& A+ p6 z9 o2 X* h
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- ]- r$ i* A% @* wtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
3 e0 d! |1 C" D: ^and β-human chorionic gonadotropin was less than
$ ? a F* W& ?5 mIU/mL (normal <5 mIU/mL). Serum follicular, Q# i, A' b$ `+ u) _0 [+ n' ^
stimulating hormone and leuteinizing hormone! }. J0 i% c! d% c
concentrations were less than 0.05 mIU/mL% j2 q# b. e4 f1 U
(prepubertal).
0 n& s" X: A9 ~1 @8 QThe parents were notified about the laboratory5 |- E- q _ D9 o& |5 o- c8 j
results and were informed that all of the tests were
8 K. F; }/ f3 i2 gnormal except the testosterone level was high. The: p* ?; ~9 c" |* c/ v7 k( v
follow-up visit was arranged within a few weeks to$ x" z2 C5 ~/ v( s+ e5 X
obtain testicular and abdominal sonograms; how-
X7 J' N1 A+ \: P4 }8 o; o; _. l. V% Rever, the family did not return for 4 months.
& G9 _4 W1 ^/ z$ `- o( U: aPhysical examination at this time revealed that the
; V' H# E1 q# o0 s) L. _% D- s7 |child had grown 2.5 cm in 4 months and had gained3 \, W. ]8 X0 ~
2 kg of weight. Physical examination remained H9 ^. V' I" b- N; C' `7 C
unchanged. Surprisingly, the pubic hair almost com-" n" k2 K1 l0 i0 r2 v
pletely disappeared except for a few vellous hairs at% m% h8 S6 P: ^4 T* R9 v9 n8 D8 G6 J
the base of the phallus. Testicular volume was still 2, X' n, l R- H, I7 _: |
mL, and the size of the penis remained unchanged.' j) I. l! O4 O5 [
The mother also said that the boy was no longer hav-
! \4 } v) M& L- j! oing frequent erections.
/ j+ W/ i* m# s9 r6 X5 r* yBoth parents were again questioned about use of
1 D( Z9 H8 [: m2 i) ^any ointment/creams that they may have applied to
4 d( j0 S' w/ v2 ~- ?4 }( Rthe child’s skin. This time the father admitted the; E- o$ ^) ^6 j4 u0 L% X
Topical Testosterone Exposure / Bhowmick et al 541
5 m6 W9 J7 Y4 o Y% q/ |) quse of testosterone gel twice daily that he was apply-
% F( _% h' p8 p# h7 l5 c; sing over his own shoulders, chest, and back area for7 W; u6 ]3 _) U; D0 S6 D
a year. The father also revealed he was embarrassed
8 _/ k) f/ Y4 F" Gto disclose that he was using a testosterone gel pre-/ Z! v. i/ g) ]5 g$ s
scribed by his family physician for decreased libido0 q+ w+ y/ b/ ?; |6 l7 f
secondary to depression.
- }: [' s4 y' D" RThe child slept in the same bed with parents. z/ Q; s( t, E. `
The father would hug the baby and hold him on his) v, _9 d/ `6 d {5 p
chest for a considerable period of time, causing sig-- T. M4 v* w' S. c: c/ j
nificant bare skin contact between baby and father.
! K x: L5 T, C3 {" ~4 q8 A* YThe father also admitted that after the phone call,4 A4 @" {/ r& X. y3 X9 u
when he learned the testosterone level in the baby& G; a+ E# A1 q4 J0 f9 u+ e. H" d
was high, he then read the product information
b, }: m x4 A, C Vpacket and concluded that it was most likely the rea-8 z* M$ P* G3 U& d! v* l9 v
son for the child’s virilization. At that time, they- ]& p# e% c, v& d, e* A
decided to put the baby in a separate bed, and the
2 W1 B+ t3 A, ?" C9 ~: k5 ~father was not hugging him with bare skin and had: I1 r5 s/ i s5 o# r: m$ z$ M4 n
been using protective clothing. A repeat testosterone' Y X# w5 S0 [& i
test was ordered, but the family did not go to the
: n6 P; g6 U$ A! Rlaboratory to obtain the test.
9 K: ^7 P5 i& }4 m; GDiscussion
4 U- I/ t) l* `" [. t! Z* F2 z/ e8 W2 fPrecocious puberty in boys is defined as secondary
6 R0 X- L+ h7 h' _: X3 o) e+ tsexual development before 9 years of age.1,4# |* B0 D! \9 O+ a3 C1 u
Precocious puberty is termed as central (true) when
7 F* b% @4 T1 ]( uit is caused by the premature activation of hypo-
6 h B. {% g3 C P5 E5 S5 v% qthalamic pituitary gonadal axis. CPP is more com-" X& U, s) |% B
mon in girls than in boys.1,3 Most boys with CPP
+ |) n* w; v2 L' y4 J; @may have a central nervous system lesion that is' p) F* I/ n: a9 M' x9 ]1 t+ k V
responsible for the early activation of the hypothal-: o) [" P; c# U4 {. _1 y
amic pituitary gonadal axis.1-3 Thus, greater empha-
3 ]5 q/ q6 s, j$ f2 ]( w# Rsis has been given to neuroradiologic imaging in0 {/ p" m; U! {) @
boys with precocious puberty. In addition to viril-5 R' h% X6 d, h
ization, the clinical hallmark of CPP is the symmet-/ o7 m, h$ L+ i; g- z
rical testicular growth secondary to stimulation by" q1 X6 y$ W" L+ G- H6 J* U
gonadotropins.1,3; d3 r2 R9 t/ r3 x
Gonadotropin-independent peripheral preco-
# Y2 F' V2 }1 R5 @) b, }+ kcious puberty in boys also results from inappropriate5 @5 {) s" T8 ~
androgenic stimulation from either endogenous or" t Z, y3 j% c9 Y( @' z) l1 b
exogenous sources, nonpituitary gonadotropin stim-1 ?- ?5 S6 P, T
ulation, and rare activating mutations.3 Virilizing) Q$ a8 P4 ?7 |+ I/ q* X8 J8 X
congenital adrenal hyperplasia producing excessive
( }8 o! i7 \4 j+ a6 k- dadrenal androgens is a common cause of precocious+ _7 z8 v! |$ e; m0 l( I$ x3 D
puberty in boys.3,45 H; \9 Y- ?. f9 y+ M: ]3 j
The most common form of congenital adrenal
0 z8 k9 C9 S6 l! ?, h$ Fhyperplasia is the 21-hydroxylase enzyme deficiency.' ^2 [! w( m' _, Y) A6 F
The 11-β hydroxylase deficiency may also result in
5 q" r- d; s- L, R3 u: B) Q+ k/ ~+ rexcessive adrenal androgen production, and rarely,
) }5 A) C. l) a4 V9 K, Xan adrenal tumor may also cause adrenal androgen9 M% p! v! i1 R E5 P* e& x
excess.1,3
- Q% M5 T) |- s- p; xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 i1 k) j. B2 [( ?% V- g
542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 E9 e0 o# _0 l- h
A unique entity of male-limited gonadotropin-
. }0 \' |0 u/ a$ `. B2 Xindependent precocious puberty, which is also known
7 Q" y1 p& [5 Oas testotoxicosis, may cause precocious puberty at a; Q$ U) f7 d; }: U% g
very young age. The physical findings in these boys! S( ^7 y B5 _$ ], y
with this disorder are full pubertal development,
" m- O) N7 D8 `6 t, f$ Bincluding bilateral testicular growth, similar to boys
$ o1 S; i) P' f/ i* Owith CPP. The gonadotropin levels in this disorder0 A$ t1 i( ?/ l& p
are suppressed to prepubertal levels and do not show8 i6 y0 L( d7 P: E
pubertal response of gonadotropin after gonadotropin-* \8 E" k4 Y3 P; A7 a
releasing hormone stimulation. This is a sex-linked# w1 B+ X/ \8 `& |
autosomal dominant disorder that affects only
4 \* C9 m D* [' q# Gmales; therefore, other male members of the family
9 j: e9 _" y2 `* \: L. Fmay have similar precocious puberty.3; v& e$ }! c9 a6 ?/ }
In our patient, physical examination was incon-* Q4 w- v3 z, j
sistent with true precocious puberty since his testi-
# _, d6 V7 g: X. K2 e8 xcles were prepubertal in size. However, testotoxicosis4 q& K7 m7 C' E+ |
was in the differential diagnosis because his father
/ [- Z% b9 `6 S* h( p, L7 Qstarted puberty somewhat early, and occasionally,0 ]+ |) d% K# H) V' i# x f% {& p1 Z5 D
testicular enlargement is not that evident in the
0 u4 w! u% M0 r2 P' l/ lbeginning of this process.1 In the absence of a neg- T* _# Y7 C8 O% D
ative initial history of androgen exposure, our
; h) u& c, v9 v5 i2 ebiggest concern was virilizing adrenal hyperplasia,' j& S* q. b; ^$ _) J5 N e% _, k7 q
either 21-hydroxylase deficiency or 11-β hydroxylase# v& \; v! }" z1 [) `; \
deficiency. Those diagnoses were excluded by find-
5 } W: Q- l( m6 A; Eing the normal level of adrenal steroids.
- S2 a$ J: b3 D/ i/ U: nThe diagnosis of exogenous androgens was strongly2 U: g- ~2 L2 ^1 t) W
suspected in a follow-up visit after 4 months because
( S4 q/ |9 T# k+ J: T3 ]the physical examination revealed the complete disap-
1 T$ \" D) Z9 \pearance of pubic hair, normal growth velocity, and
/ T6 l* a+ H% y0 u: z9 s. wdecreased erections. The father admitted using a testos-
0 _/ X- X( {/ U: c& ^' pterone gel, which he concealed at first visit. He was) y9 v" K# t& R( @3 P6 r7 C
using it rather frequently, twice a day. The Physicians’
2 W+ _* C1 F/ b( U& S5 F; g- Q5 z4 }Desk Reference, or package insert of this product, gel or
5 j* I; d2 [, o% j7 w5 dcream, cautions about dermal testosterone transfer to
- u8 o) Q u% a* m% Punprotected females through direct skin exposure.
5 s9 C# f7 M+ Y8 |Serum testosterone level was found to be 2 times the
* ^& O, @8 s5 s! p+ W: j3 G, jbaseline value in those females who were exposed to
2 R0 ^) D2 _( H- g7 `even 15 minutes of direct skin contact with their male! X0 O t8 `6 }3 n4 n; i
partners.6 However, when a shirt covered the applica-
. F E/ i5 W4 J4 \tion site, this testosterone transfer was prevented.
0 L9 ?3 f2 n, u Z8 |( J; K6 j- SOur patient’s testosterone level was 60 ng/mL,6 I- ?) t, n- y; f
which was clearly high. Some studies suggest that
& Q+ T' \- O8 Z0 H$ ydermal conversion of testosterone to dihydrotestos-
% i* m, _7 a6 f" q xterone, which is a more potent metabolite, is more& u2 B" s, B: h ?) }2 J% T4 T6 v8 N
active in young children exposed to testosterone
, O6 `: A! E- i; Nexogenously7; however, we did not measure a dihy-8 y t1 X6 v9 G$ s: A+ z0 k
drotestosterone level in our patient. In addition to
, N7 n8 J) I! V8 I5 p* _# qvirilization, exposure to exogenous testosterone in8 `$ P0 i" B9 P/ d% f% ^# }+ g
children results in an increase in growth velocity and( M; {, J9 A7 K3 ]0 s. u( y" a
advanced bone age, as seen in our patient.) v" h7 A) ]4 Q9 j
The long-term effect of androgen exposure during
4 d& ~1 }5 o: j' Cearly childhood on pubertal development and final
6 X5 M& z: s8 U9 |adult height are not fully known and always remain
: C' Z. T8 C. P1 O: ~( `4 Za concern. Children treated with short-term testos-
) z, T* Z( J+ I/ N( z+ i, \terone injection or topical androgen may exhibit some6 O1 R! l M# o
acceleration of the skeletal maturation; however, after
) A3 z, x" O# k6 L! ]% l) k H- Hcessation of treatment, the rate of bone maturation4 ^; x" O, E" |( z! C9 B
decelerates and gradually returns to normal.8,9
. a( C, ?/ L: Y# v# YThere are conflicting reports and controversy
; R2 W W, w6 U' o1 }1 M( m: \7 kover the effect of early androgen exposure on adult+ N8 b+ O+ T: @
penile length.10,11 Some reports suggest subnormal+ M; ]. Y$ U z- F. k5 d# o! k
adult penile length, apparently because of downreg-
7 h0 u' K8 |! M) `ulation of androgen receptor number.10,12 However,
2 W' a& r/ v. v- j( t: M2 e; k6 I& `) QSutherland et al13 did not find a correlation between
* p% G) w; u3 F0 \childhood testosterone exposure and reduced adult
$ Z. T% n: N H9 u5 `5 ppenile length in clinical studies." R2 \$ F; I7 T
Nonetheless, we do not believe our patient is
5 [7 a: M/ c1 P- b: N4 Igoing to experience any of the untoward effects from. \8 @: g( r& w
testosterone exposure as mentioned earlier because
3 I Y/ N9 L$ U+ t: M2 Vthe exposure was not for a prolonged period of time.
; f* i }+ s6 k6 ?Although the bone age was advanced at the time of
1 h+ `; d- M, m# |; N9 {! vdiagnosis, the child had a normal growth velocity at
! x+ [3 Z$ S: i3 {9 othe follow-up visit. It is hoped that his final adult9 d2 x( V& J1 a+ c3 p
height will not be affected.
6 h3 _( Y! z4 M! E; X7 M5 ^Although rarely reported, the widespread avail-% n( a" j) g7 |( n; d
ability of androgen products in our society may& u* @' ?+ L, r& |. z0 n
indeed cause more virilization in male or female# P; D( F' \ t$ g% E) Q2 V
children than one would realize. Exposure to andro-5 E, K m7 J, t8 ?9 l# P
gen products must be considered and specific ques-
n- v3 r% R9 L0 ytioning about the use of a testosterone product or
# N4 l8 I% h8 z, T/ M2 v, zgel should be asked of the family members during
$ s6 D+ B* ] a& v0 Hthe evaluation of any children who present with vir-
' j6 c" _$ n: d$ i3 bilization or peripheral precocious puberty. The diag-
: p" n* v+ y0 N: J- P, h- P/ E- Vnosis can be established by just a few tests and by
7 B6 z0 |2 J# s0 U4 _+ |appropriate history. The inability to obtain such a
4 a( m- X1 F9 J8 j1 d6 i' Ehistory, or failure to ask the specific questions, may7 c* B9 e0 d) b) E
result in extensive, unnecessary, and expensive
& U) U7 S2 y. s) jinvestigation. The primary care physician should be
0 C3 e2 G" @- e. J: m0 x/ u' Gaware of this fact, because most of these children
- D. W2 |$ c- D/ V5 z0 rmay initially present in their practice. The Physicians’& ]0 W7 T% y& A2 Q5 c% h
Desk Reference and package insert should also put a7 o3 ~- ]# A- G' V& b- g
warning about the virilizing effect on a male or
# Q3 y! x: \0 wfemale child who might come in contact with some-
7 o: V8 l, n) F; k! Hone using any of these products.
8 V( Q) `2 W5 ], q/ N; y) iReferences
$ W) y. L: o* I$ |! Q6 f* F1. Styne DM. The testes: disorder of sexual differentiation
0 f. G0 b4 u xand puberty in the male. In: Sperling MA, ed. Pediatric3 ] S2 h, ~ q4 t
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 g$ q5 A2 c. _- y% \. C: X* | d+ M! K2002: 565-628.
7 P: ]4 W' q& R2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
; ~* s& g1 Q* c, kpuberty in children with tumours of the suprasellar pineal |
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