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Sexual Precocity in a 16-Month-Old* Y; \1 x9 d; b/ w3 @8 @; S
Boy Induced by Indirect Topical
% N4 ] O ~+ ~6 n0 ~) r$ N* OExposure to Testosterone
/ W$ H$ O/ W9 V% w1 BSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 g" A$ }6 k! J9 band Kenneth R. Rettig, MD1) a. J I( @% o7 \
Clinical Pediatrics l" m1 {9 S! S3 p- s- |6 @* s; ~1 Z
Volume 46 Number 6
: P: Z3 m9 f' t# X- g$ OJuly 2007 540-543
% X) F# G8 J- \% h4 w! n0 N, |© 2007 Sage Publications! w/ P. G) v; ~ ?( Z
10.1177/00099228062966518 X7 |% C- h4 i
http://clp.sagepub.com
. d: |/ _' y4 T8 f9 A5 dhosted at
) y& [* k. w4 ^& i" N7 [& g* Phttp://online.sagepub.com5 X9 I9 \6 {. K- T$ M# ^ f
Precocious puberty in boys, central or peripheral,
' m& \, b! ?& z+ n; }6 T& f8 Pis a significant concern for physicians. Central
$ m3 E$ d a" Sprecocious puberty (CPP), which is mediated
. V; b) G/ s+ q5 Kthrough the hypothalamic pituitary gonadal axis, has4 l1 k2 E. R/ f; Z8 Q
a higher incidence of organic central nervous system) p1 Y) M" T$ m7 s$ t
lesions in boys.1,2 Virilization in boys, as manifested
# X _. @8 L3 j) X& `4 `by enlargement of the penis, development of pubic
, b" W" O; l! @) A; L6 \) F# ehair, and facial acne without enlargement of testi-
% B- t+ y# `! k$ `1 r8 x. ]cles, suggests peripheral or pseudopuberty.1-3 We
1 i* i: [$ T, L |report a 16-month-old boy who presented with the: d' L3 H- T( I
enlargement of the phallus and pubic hair develop-
( C/ ?3 I1 O) G6 X z4 @ment without testicular enlargement, which was due
4 |- W0 l3 g2 n2 \+ h$ w# Nto the unintentional exposure to androgen gel used by7 ?9 C I3 ^: \$ k
the father. The family initially concealed this infor-
, A' X& t; |8 R( H/ V- H- T; y8 |* kmation, resulting in an extensive work-up for this( {7 z; S9 ~5 R; d% K
child. Given the widespread and easy availability of
, m' l& n' y( q0 e( {$ Itestosterone gel and cream, we believe this is proba-0 r9 O Q/ ?) L# X
bly more common than the rare case report in the" W- }" d) M0 j7 ~2 J% x. i; t
literature.4
% s. T# l& @/ \0 M KPatient Report
5 E7 z4 Q% _1 ~$ y$ D) V" VA 16-month-old white child was referred to the
+ `, ?1 e. U; Kendocrine clinic by his pediatrician with the concern
) |) r2 K f6 X7 ]8 i* Vof early sexual development. His mother noticed7 o5 q& Q! w- ]9 s1 m, h) G
light colored pubic hair development when he was
! D! j1 C8 r) P2 i- xFrom the 1Division of Pediatric Endocrinology, 2University of
' u+ y3 h) J3 q. S# }South Alabama Medical Center, Mobile, Alabama.( m9 e4 o F$ \5 ]! [' f6 u
Address correspondence to: Samar K. Bhowmick, MD, FACE,! w9 b! W+ p M( d
Professor of Pediatrics, University of South Alabama, College of7 d# @/ J* A, j h- Y% ~: A
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 ]/ t) i. ?% s! G% me-mail: [email protected]." p. d* x; U; K0 _$ I* H
about 6 to 7 months old, which progressively became) V+ W( ^* ~7 A, {8 J( ]( j8 O# @
darker. She was also concerned about the enlarge-+ X! l) v" ^. z& U5 T
ment of his penis and frequent erections. The child
# U; N7 A. u7 m5 uwas the product of a full-term normal delivery, with
9 G% @* t1 H% Ka birth weight of 7 lb 14 oz, and birth length of
9 u! y& e( O& z0 A$ m* ?/ X% ~2 P20 inches. He was breast-fed throughout the first year
) a3 q- w: @" `6 Gof life and was still receiving breast milk along with
% ~8 I2 J8 R) {" l: `solid food. He had no hospitalizations or surgery,
- S5 j, M+ q6 H3 z& ]' I& Pand his psychosocial and psychomotor development
4 Q6 w- p2 j2 l0 G c7 Hwas age appropriate.
6 g! [( U. D0 p; B& N8 r6 d: uThe family history was remarkable for the father,
& {" \- r& k! x, ywho was diagnosed with hypothyroidism at age 16,
+ Y9 N4 [/ M% o% C. i# x4 `$ Iwhich was treated with thyroxine. The father’s
$ Y1 L5 r) y) h& Cheight was 6 feet, and he went through a somewhat
! ~& b1 ?" q2 r5 h* e: zearly puberty and had stopped growing by age 14.. l) c0 y T2 Q" `( {
The father denied taking any other medication. The
1 ^% [! ]' T. G" P. ]% K) I I7 Tchild’s mother was in good health. Her menarche0 X0 r5 m/ U& x* V3 W! l
was at 11 years of age, and her height was at 5 feet
& @: t) ?" `+ S. N+ t, h+ f4 D5 inches. There was no other family history of pre-; j/ ]4 X- v" o/ }- l9 Z! n
cocious sexual development in the first-degree rela-
0 v% ~ H/ C( Z9 t. ?tives. There were no siblings.
2 a4 ?& j( ~' ~ SPhysical Examination
$ k4 H* P4 S+ q" g, l* J0 k0 QThe physical examination revealed a very active,
9 C5 ?! {# E; Dplayful, and healthy boy. The vital signs documented3 ~$ ^( U6 R9 D/ r; J: y
a blood pressure of 85/50 mm Hg, his length was
$ w" O4 R& K3 Q: D* [. s90 cm (>97th percentile), and his weight was 14.4 kg
X& [$ H6 U; k9 a8 h1 l(also >97th percentile). The observed yearly growth
! p+ N( G" G1 ^4 B, Vvelocity was 30 cm (12 inches). The examination of
, `% N9 G, ^! E; v$ J- l' m; h6 ~$ Pthe neck revealed no thyroid enlargement.2 i+ s8 p/ b6 j7 P/ W
The genitourinary examination was remarkable for
) y; O8 p* \3 n+ m( D0 Aenlargement of the penis, with a stretched length of
- _8 c/ m6 \2 U/ {8 cm and a width of 2 cm. The glans penis was very well
0 p# h; w- Q* |8 kdeveloped. The pubic hair was Tanner II, mostly around7 ?4 D& T2 f/ O! O% p* B; h4 C0 Y/ \
5401 ?0 W. \! u# O0 g9 o
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
7 ]$ e" L% [" j% M) O4 xthe base of the phallus and was dark and curled. The1 n- D Q- b. N
testicular volume was prepubertal at 2 mL each.( M( L. m- g6 U2 G, @9 J. T
The skin was moist and smooth and somewhat
4 a3 z# _$ i0 F9 y7 _oily. No axillary hair was noted. There were no# C9 \" o* U+ y/ p" B/ ~- A
abnormal skin pigmentations or café-au-lait spots.
- b+ [) R; U+ O* A, b' I! e! m KNeurologic evaluation showed deep tendon reflex 2+) ?5 _- H/ S1 v4 j0 m' B+ ^. P( x
bilateral and symmetrical. There was no suggestion9 ~1 M! \% b. U, Z. x$ e2 I
of papilledema.
% o, z3 @ A! N1 f$ q1 wLaboratory Evaluation3 @2 Z/ X4 K( ?5 i) }) a
The bone age was consistent with 28 months by
- I+ i+ w8 B6 m4 t, G. ~& i" Qusing the standard of Greulich and Pyle at a chrono-
2 Z# D, ^3 I2 l* nlogic age of 16 months (advanced).5 Chromosomal9 C$ K+ W) V/ [7 m, c* I
karyotype was 46XY. The thyroid function test8 A+ X ?- Y, D6 q0 ^9 i
showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 ]3 _% C Z9 [ S" S# E/ J& R, Q3 y9 R
lating hormone level was 1.3 µIU/mL (both normal).% ]' i% n2 o4 T1 q
The concentrations of serum electrolytes, blood
8 t# D3 ?$ p6 e3 V) T+ F9 Nurea nitrogen, creatinine, and calcium all were
4 a& A" L, ^: L6 r( d! lwithin normal range for his age. The concentration3 H1 Z$ V1 |" P$ x# s; m e
of serum 17-hydroxyprogesterone was 16 ng/dL6 V* Q! z4 | ~* F. L5 Z
(normal, 3 to 90 ng/dL), androstenedione was 20. r, Q% f1 c/ _$ ?/ |
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: |: t% \) I5 i jterone was 38 ng/dL (normal, 50 to 760 ng/dL),( `: S4 e6 U9 p3 ?
desoxycorticosterone was 4.3 ng/dL (normal, 7 to7 D5 w5 t. _% U7 ] x
49ng/dL), 11-desoxycortisol (specific compound S)
: Q c8 t; Y }# i1 N: @% mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ [0 }) B# M& i: c: \/ X
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 X2 ?/ t7 K3 V3 ]5 z9 l
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
+ x% C j8 R. q: X4 Dand β-human chorionic gonadotropin was less than5 M+ P* b7 c# ?$ F8 V! g
5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ r1 ~- B5 ?) h/ h! ustimulating hormone and leuteinizing hormone
s" K3 y. m( M0 d+ v7 G( j! U9 }concentrations were less than 0.05 mIU/mL0 W0 H" k/ Y% T
(prepubertal).
6 F; c# B* H' _) n; x, O+ XThe parents were notified about the laboratory
7 |5 ?- n5 C, J/ K+ y# Mresults and were informed that all of the tests were; N+ m( S3 N% P
normal except the testosterone level was high. The
. b0 J: c9 N. h9 Vfollow-up visit was arranged within a few weeks to; _2 G, }( c4 x2 k5 ]) v- F s' J
obtain testicular and abdominal sonograms; how-
4 Y) y$ a$ [8 \8 r3 `4 `) _ever, the family did not return for 4 months.
! H( X! z% D* M" p1 @# T8 WPhysical examination at this time revealed that the; S; q5 }' q6 P% _7 `/ c4 ]4 G
child had grown 2.5 cm in 4 months and had gained) w8 V' v5 ?# W
2 kg of weight. Physical examination remained/ n/ ~- U2 R+ y% V1 `9 X
unchanged. Surprisingly, the pubic hair almost com-0 v: h: O5 f5 Y3 ?9 j! k, Y4 O
pletely disappeared except for a few vellous hairs at8 K2 T4 y% e: m; H1 C/ T
the base of the phallus. Testicular volume was still 29 x- N, d H- t& B9 O# ]
mL, and the size of the penis remained unchanged.
' h2 ~4 t; o. X6 w* L* |2 qThe mother also said that the boy was no longer hav-( j, Y% K3 a% N% \
ing frequent erections.
) n9 A* d- Q7 f2 s7 l5 BBoth parents were again questioned about use of$ r: c1 o: B* b0 l5 y
any ointment/creams that they may have applied to
' e/ g& r* U, {( Kthe child’s skin. This time the father admitted the
! W0 o$ T) g wTopical Testosterone Exposure / Bhowmick et al 5418 L; ^8 K' _- a4 n$ m; W
use of testosterone gel twice daily that he was apply-# U& X' R# }. [$ h2 r7 ^
ing over his own shoulders, chest, and back area for
; l' s/ D" D( W! |3 L" Za year. The father also revealed he was embarrassed
1 y( y! ]% e$ C3 w1 \. sto disclose that he was using a testosterone gel pre-
# W) u* n$ B- I( v! i# Wscribed by his family physician for decreased libido' s1 \* m2 L( g/ J" _8 g
secondary to depression.
6 D, y, E4 j S) v! T( b1 mThe child slept in the same bed with parents.
$ ?$ @) u! m" ~% I4 N3 a( F' ?: j$ LThe father would hug the baby and hold him on his' s& {9 m2 C" j
chest for a considerable period of time, causing sig-7 P/ F' D' }& c% t
nificant bare skin contact between baby and father.
8 l! T0 d+ t7 v! m1 r+ i1 @$ H: TThe father also admitted that after the phone call,! z. m4 F: ~$ f$ y. E
when he learned the testosterone level in the baby
: T$ x4 D8 n8 y! g! m ]% Uwas high, he then read the product information) P F# C* J6 h7 k8 o
packet and concluded that it was most likely the rea-
( @+ l3 T6 \' h" yson for the child’s virilization. At that time, they- S* s: u$ v& {- t" D- A: n
decided to put the baby in a separate bed, and the% n* `/ c8 G7 d; M0 T J
father was not hugging him with bare skin and had
9 N& V- Y7 V: ^; V1 F Zbeen using protective clothing. A repeat testosterone* s; x8 P* {3 _! {( ]5 ^
test was ordered, but the family did not go to the
8 F J& e N$ Y0 xlaboratory to obtain the test.
/ e4 Z6 b( t6 n. fDiscussion6 M J9 N; C# Z- M: u. Z4 }6 I
Precocious puberty in boys is defined as secondary
+ v3 h! \& E: k' V9 Usexual development before 9 years of age.1,4" y% d: F4 i% v1 v5 Z# s
Precocious puberty is termed as central (true) when
5 w5 W! v4 f7 Dit is caused by the premature activation of hypo-: S7 m# C4 _2 k7 j( ]: B
thalamic pituitary gonadal axis. CPP is more com- n& u5 a2 y5 \! q) z' C) l
mon in girls than in boys.1,3 Most boys with CPP
, v( v$ C$ k3 S. z7 d4 ]5 Emay have a central nervous system lesion that is. l" l# o8 f6 C4 P3 _# ~- b2 v
responsible for the early activation of the hypothal-6 U- G, \% Q0 P" U5 g q
amic pituitary gonadal axis.1-3 Thus, greater empha-; g( p- Q' Q5 X$ ?6 ?. X
sis has been given to neuroradiologic imaging in1 r6 W. ^+ x1 S( P/ v* g
boys with precocious puberty. In addition to viril-" [! t% x& e7 ]% w8 o
ization, the clinical hallmark of CPP is the symmet-
# W, o, f6 Y8 S: nrical testicular growth secondary to stimulation by8 v6 L& M" m5 F0 p+ M- l' Q5 P* e
gonadotropins.1,32 t9 \; ^/ z( Y
Gonadotropin-independent peripheral preco-
$ k5 m3 B( [6 L& Z* I: u: b/ \1 jcious puberty in boys also results from inappropriate
2 B' {' k/ |2 |$ G+ Tandrogenic stimulation from either endogenous or% m5 @( P2 O! e3 t$ Q6 c7 g
exogenous sources, nonpituitary gonadotropin stim-& g3 ]- T" c" M( ^
ulation, and rare activating mutations.3 Virilizing
& b, ]4 {4 K* B, \6 p/ ~; V) s1 ncongenital adrenal hyperplasia producing excessive
% L& Q j% k: o* ]( a4 _! kadrenal androgens is a common cause of precocious8 J3 ~+ A2 P) T3 T+ j
puberty in boys.3,4: c4 K: Z5 T- ~" u! Y% n/ X
The most common form of congenital adrenal
% o) w C% X! I h( v4 Rhyperplasia is the 21-hydroxylase enzyme deficiency.+ Q0 Q4 B/ m; k3 H# t
The 11-β hydroxylase deficiency may also result in' ]; W, ]$ k$ Q5 J# k+ O
excessive adrenal androgen production, and rarely," ]+ R$ J" \1 T* p9 z
an adrenal tumor may also cause adrenal androgen* L5 F4 v- |# v
excess.1,33 J# @, j' X* ~! I8 n5 ?$ C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 E5 U4 @# I( j542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- F2 Q2 u- ?" S3 bA unique entity of male-limited gonadotropin-' s! b, |0 s" \& Z9 G9 u# E
independent precocious puberty, which is also known
Y. t" d& ^& l4 X% e0 `as testotoxicosis, may cause precocious puberty at a
9 W* S h# X' [1 Y% V# V& Tvery young age. The physical findings in these boys+ f$ Z; n, f* I
with this disorder are full pubertal development,
- Z4 h! e0 L4 @including bilateral testicular growth, similar to boys
( o/ ~$ Z1 ^7 ewith CPP. The gonadotropin levels in this disorder
7 Y5 K+ `5 O9 r: n8 _9 `: @are suppressed to prepubertal levels and do not show
: F$ g+ K* [$ `/ N! O7 F+ N! Opubertal response of gonadotropin after gonadotropin-# O+ E1 f$ J3 q9 S3 {# E9 Y
releasing hormone stimulation. This is a sex-linked) D% ]8 P" S9 j2 |/ c
autosomal dominant disorder that affects only
# a H# ?. T9 |) P r R n [males; therefore, other male members of the family' N( q; G$ A" S, j. `' K4 D
may have similar precocious puberty.3
; u- h* w- J$ Q9 J4 L+ \1 @5 z3 ^- pIn our patient, physical examination was incon-
0 z8 M1 g3 m0 P9 f- Asistent with true precocious puberty since his testi-
4 ~! E. S9 P I2 k+ x- d& zcles were prepubertal in size. However, testotoxicosis
7 `! o- V3 t4 Z5 N$ Y" Pwas in the differential diagnosis because his father
, @" n$ K( K/ ^5 s6 l, bstarted puberty somewhat early, and occasionally,6 r/ Q. R3 z5 I1 ?: k
testicular enlargement is not that evident in the
5 p8 W" e! u- V9 ?! D: kbeginning of this process.1 In the absence of a neg-
9 k. T! E( c# vative initial history of androgen exposure, our% c$ y5 f- y6 c. C6 S, q
biggest concern was virilizing adrenal hyperplasia,1 C5 p' [% L) f$ h
either 21-hydroxylase deficiency or 11-β hydroxylase) ~/ B" O7 x' X3 K
deficiency. Those diagnoses were excluded by find-& m; n+ W( C% q4 v4 u) b- a
ing the normal level of adrenal steroids.: |. l' g1 S8 {4 ^8 T7 ?0 {* z
The diagnosis of exogenous androgens was strongly
9 S n+ d& l$ P( B9 g1 ?8 @suspected in a follow-up visit after 4 months because
) d7 B. J! {" d0 B5 g5 tthe physical examination revealed the complete disap-
& B! H3 Q$ O9 ]- d4 Kpearance of pubic hair, normal growth velocity, and
9 z) T4 M3 E& Z$ n2 ?decreased erections. The father admitted using a testos-( n$ K. l2 m, ~0 m
terone gel, which he concealed at first visit. He was- O- L% j5 x6 l2 I& u- b
using it rather frequently, twice a day. The Physicians’
" o0 `& S0 J- ADesk Reference, or package insert of this product, gel or6 ]; Z" s# p+ o, W# o. _" ?
cream, cautions about dermal testosterone transfer to
# `9 t$ x/ a0 @1 a, h2 R$ zunprotected females through direct skin exposure.7 }, D+ T* }9 R/ D
Serum testosterone level was found to be 2 times the
9 c* C }! W7 ]+ Fbaseline value in those females who were exposed to
; h+ J* }9 G, ^9 @- geven 15 minutes of direct skin contact with their male
; {! |3 g" o, b) i- \( }5 @. l0 jpartners.6 However, when a shirt covered the applica-
& O1 V8 Z, }: h" Qtion site, this testosterone transfer was prevented.
" N) E! L: D9 m# qOur patient’s testosterone level was 60 ng/mL,
( P, M9 q1 X) }7 nwhich was clearly high. Some studies suggest that% _0 X' {( Y' O! {
dermal conversion of testosterone to dihydrotestos-% L; m$ S4 }" n
terone, which is a more potent metabolite, is more2 y9 @# B# [ @6 U
active in young children exposed to testosterone0 Q4 _/ R- d% p
exogenously7; however, we did not measure a dihy-
7 U! X0 G- O0 Ldrotestosterone level in our patient. In addition to
: l/ A5 e) S( c8 C. q% dvirilization, exposure to exogenous testosterone in
+ q( L" M; G7 F% @children results in an increase in growth velocity and/ r5 ?# ~ E2 }/ ~( w
advanced bone age, as seen in our patient.
8 }$ d* N' m0 i# p, J4 PThe long-term effect of androgen exposure during
+ R' S3 D5 f% u" Qearly childhood on pubertal development and final
, g- J: E; W1 oadult height are not fully known and always remain
% V9 M& ?5 B1 F" L" Na concern. Children treated with short-term testos-" Z, e) f: W8 g7 W- T; r9 u7 p" I
terone injection or topical androgen may exhibit some; t q: _" Y1 Q! B, @
acceleration of the skeletal maturation; however, after p7 @7 ?, U5 S, o! w2 ?7 [
cessation of treatment, the rate of bone maturation7 V: i5 {& d; ^# J) _
decelerates and gradually returns to normal.8,9
N9 x# S" ` H4 P3 L8 aThere are conflicting reports and controversy0 Z; T9 }, r4 I! @8 R9 y
over the effect of early androgen exposure on adult
% ]6 [1 U: j6 o* Hpenile length.10,11 Some reports suggest subnormal0 L1 @, y' ^5 y! J+ w
adult penile length, apparently because of downreg-
! \7 u6 E3 x3 r* t5 {8 d2 f* Z# Julation of androgen receptor number.10,12 However,8 m. n% S( \2 a* K4 C, Q# C
Sutherland et al13 did not find a correlation between
- J: R/ Q, O! u- T) A. z& b8 ychildhood testosterone exposure and reduced adult
9 g9 v* ?/ x. |; ]penile length in clinical studies.
( K5 \, H! Q# [5 A. x2 I, qNonetheless, we do not believe our patient is$ t. h! j+ l2 m: g: Q9 w' u. u: {
going to experience any of the untoward effects from, r1 S- Z, R8 C/ o- V7 W8 h
testosterone exposure as mentioned earlier because
5 D- u9 T( T8 `9 F2 }" Rthe exposure was not for a prolonged period of time.
- G/ x0 ], G! ^" pAlthough the bone age was advanced at the time of5 Z0 m, S2 E4 H% ~- h
diagnosis, the child had a normal growth velocity at9 B" l6 K1 C- ^! a, _$ p- J
the follow-up visit. It is hoped that his final adult
( ^1 |; y) ]; n1 ]2 z4 D- Aheight will not be affected.
" `7 d+ `& _- d7 c3 N" C% JAlthough rarely reported, the widespread avail-
0 T6 k# m( F; w* K0 Iability of androgen products in our society may
! o, J* [6 W0 Z" }: [; gindeed cause more virilization in male or female
: S" v. P7 Q$ J3 P3 x1 vchildren than one would realize. Exposure to andro-' ^+ h& S/ \0 D" Q Q7 b
gen products must be considered and specific ques-
) J3 v8 o" W5 b6 Z' ~7 E& `tioning about the use of a testosterone product or
# j9 s/ K5 `0 k! g- igel should be asked of the family members during* {0 N9 I8 {3 w5 N
the evaluation of any children who present with vir-( I- v- t8 ?( x. I( l4 A) K
ilization or peripheral precocious puberty. The diag-0 f& y* Z/ O+ _; g' x: D
nosis can be established by just a few tests and by: B# ?4 M" o: z& b
appropriate history. The inability to obtain such a3 G; r8 y( \4 z9 g- g; c
history, or failure to ask the specific questions, may" t3 R: {# l5 ~6 d: p
result in extensive, unnecessary, and expensive# ]1 L0 M% c; w
investigation. The primary care physician should be
7 U& A3 h2 D% Aaware of this fact, because most of these children
7 C. ~6 t% K* |1 o! t) ^may initially present in their practice. The Physicians’
! Y3 y' i3 E, @Desk Reference and package insert should also put a
/ O# @) V i& {9 X3 K9 Awarning about the virilizing effect on a male or
0 w. [6 {+ W1 Q4 D% h: g" @female child who might come in contact with some-
: b+ C0 s: U- C7 gone using any of these products.$ A0 F3 h1 v; }$ _1 e
References9 H$ J# c8 p: L* p; I+ J/ m3 a
1. Styne DM. The testes: disorder of sexual differentiation8 g# O4 K9 M9 M( Q& v3 R- m8 {, y' p* I
and puberty in the male. In: Sperling MA, ed. Pediatric
: ~6 t; _5 q8 YEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; F) G0 R2 \' Y2 ^4 f, q2002: 565-628./ W8 j0 b# O. n: R
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& J. r. E1 w1 x; r% } q
puberty in children with tumours of the suprasellar pineal |
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