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Sexual Precocity in a 16-Month-Old
# x# D5 n- C- v8 p2 n( nBoy Induced by Indirect Topical6 Y+ {) d, o9 r: x+ `
Exposure to Testosterone3 T7 q. `4 i0 c1 J$ U" L
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. B5 p- | w0 X( E( I5 c" G: n
and Kenneth R. Rettig, MD16 N1 N0 l" F- t( [/ }$ K& I2 [
Clinical Pediatrics
8 X1 T, |1 @* Z9 u4 X( r" kVolume 46 Number 6
0 v9 ^7 ^8 F" b. K. Y' ZJuly 2007 540-5439 q+ c8 `9 G% `8 y8 m5 l+ M
© 2007 Sage Publications/ h( j7 c( I# H4 W1 E3 \
10.1177/0009922806296651
. D5 D9 h' ]5 Rhttp://clp.sagepub.com
- [& T* C1 P. s" i/ z8 r/ Q; bhosted at) p4 a0 @# i3 m5 _
http://online.sagepub.com
4 [, | \3 G* `3 V+ i1 Q% yPrecocious puberty in boys, central or peripheral,+ B7 C1 @8 c& G! F. j2 v2 E( w
is a significant concern for physicians. Central
! j: i; d2 y9 X* f0 Jprecocious puberty (CPP), which is mediated
c! R6 v4 J% D0 athrough the hypothalamic pituitary gonadal axis, has
! l3 Z3 F& q+ B* U! Ea higher incidence of organic central nervous system
; _& P' } t2 R# Q9 _0 }" g. b9 z$ Tlesions in boys.1,2 Virilization in boys, as manifested
6 @; d; L) c& ^5 @8 ~; C( Hby enlargement of the penis, development of pubic8 I a! }. G, [% h
hair, and facial acne without enlargement of testi- O) g0 ~% ^; z I+ z* ]) Q3 {( ^% K
cles, suggests peripheral or pseudopuberty.1-3 We
' O: N8 }4 J; Kreport a 16-month-old boy who presented with the( c) h, g5 |4 ~0 R w2 m( S% F: R% ~
enlargement of the phallus and pubic hair develop-& E6 w/ Z0 v) f
ment without testicular enlargement, which was due
6 G' ~# G% Y+ eto the unintentional exposure to androgen gel used by
F* T! L& g0 N) e3 W& Bthe father. The family initially concealed this infor-# V$ U; ]* G' n* s& w3 m
mation, resulting in an extensive work-up for this" U' T: ]/ {9 ~/ g0 `$ w/ M
child. Given the widespread and easy availability of
2 m, n0 L* C2 S5 ^# Mtestosterone gel and cream, we believe this is proba- }/ K. p6 a3 _: F1 Z; f
bly more common than the rare case report in the
' I4 \( `. @& o p9 Rliterature.4
; h$ G' k0 m9 H5 ?Patient Report
) q! d. C" q5 B* M9 ]' L; o* YA 16-month-old white child was referred to the
- f) a& X: H8 U; J8 oendocrine clinic by his pediatrician with the concern; c* A& w% W) o$ G ~; C
of early sexual development. His mother noticed- @5 f3 i' U8 j9 b8 k6 p
light colored pubic hair development when he was
) c- @- ~6 T7 a' O" s' wFrom the 1Division of Pediatric Endocrinology, 2University of
( h/ s3 G0 U5 zSouth Alabama Medical Center, Mobile, Alabama.
8 S( k; [+ K" w3 k, @4 N3 U9 NAddress correspondence to: Samar K. Bhowmick, MD, FACE,* X0 R* P9 h' @/ M X2 }8 D
Professor of Pediatrics, University of South Alabama, College of
8 p: W: P0 W0 ^9 r0 u; {0 oMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;0 h" H% o4 @7 S {% ]1 V+ _
e-mail: [email protected].
: ^# c# _# V5 L7 r# t0 [about 6 to 7 months old, which progressively became: h: e6 U+ J+ \! `6 W# {4 ^* d
darker. She was also concerned about the enlarge-
?3 d6 ~, s. H% [4 kment of his penis and frequent erections. The child
8 V7 Y2 h2 J, p$ H Y# u4 h5 z! Cwas the product of a full-term normal delivery, with! U! A6 L" M' F6 D( }$ q
a birth weight of 7 lb 14 oz, and birth length of5 b$ b: j- e0 Q. K. H; b7 w
20 inches. He was breast-fed throughout the first year
# y0 ^7 n }, S: d4 D2 ~, }of life and was still receiving breast milk along with
) ^( {8 Q: ^4 d+ ~# \, [solid food. He had no hospitalizations or surgery,- e+ _; _; a. |+ c8 v- @
and his psychosocial and psychomotor development
+ X+ A/ `# n t3 C, \. q8 m6 `was age appropriate.
8 g) Z7 Z2 z" XThe family history was remarkable for the father,
% [4 X' f% J2 R7 s3 }who was diagnosed with hypothyroidism at age 16,
/ m% S5 [, r' i! ?which was treated with thyroxine. The father’s
: m0 |' p2 n( _5 Eheight was 6 feet, and he went through a somewhat( e" w, q8 P- r% u3 C4 a( ^
early puberty and had stopped growing by age 14./ H& w/ w% D# S; h" A
The father denied taking any other medication. The7 A- B$ l1 D* U
child’s mother was in good health. Her menarche$ Z. ^8 F6 Y! [4 c9 g1 U
was at 11 years of age, and her height was at 5 feet& h! J) P8 H2 L" i- Z7 Q; z9 @
5 inches. There was no other family history of pre-
4 c q. B. F$ ^2 ]; i- e% Ccocious sexual development in the first-degree rela-9 E8 f7 s4 D3 w2 ]/ y& h
tives. There were no siblings.0 H9 E- J- k5 N; p" U: w
Physical Examination
. `7 ?- A7 n1 d& |* ZThe physical examination revealed a very active,
, \% p5 c5 {' W5 ]playful, and healthy boy. The vital signs documented
4 B* Y! Q: x3 _$ Ea blood pressure of 85/50 mm Hg, his length was
# u7 y# q) j8 E3 y$ t6 a9 a90 cm (>97th percentile), and his weight was 14.4 kg
4 M: J- ~6 }; s0 }(also >97th percentile). The observed yearly growth2 D1 E# }- {5 q" [: G* m* G2 r
velocity was 30 cm (12 inches). The examination of) M& M a' j; Y: s g4 p# q
the neck revealed no thyroid enlargement.- E* J9 ~& n+ l
The genitourinary examination was remarkable for. D: `2 p' ~" f+ R2 I! D
enlargement of the penis, with a stretched length of% ]& h' ~ p6 r+ i0 ~: J' l
8 cm and a width of 2 cm. The glans penis was very well2 Y- s' \* {" _: O4 f. Z" I
developed. The pubic hair was Tanner II, mostly around
% g- }' l0 h; a: I2 h+ u/ Q540, c' e1 Q ^6 O5 M
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" y) S l% B& ?9 Y K
the base of the phallus and was dark and curled. The* T% i( i" F$ N$ V% C9 r
testicular volume was prepubertal at 2 mL each.
8 R+ {; V# G+ n- C/ w: O8 mThe skin was moist and smooth and somewhat
3 Z: o, c1 S* [2 A" Y+ k# Z" Poily. No axillary hair was noted. There were no
- {( l/ ~; [& A' q0 ]' [abnormal skin pigmentations or café-au-lait spots.
- k( r( I+ V6 S5 Z1 u. kNeurologic evaluation showed deep tendon reflex 2+" b0 _. z) i: \8 ]/ y
bilateral and symmetrical. There was no suggestion
3 W0 s6 }. R3 C4 wof papilledema.
3 s& t1 L8 C% I- Y& Q% Q' z0 t( r1 SLaboratory Evaluation
- h+ ]( v3 ?+ E: x% K- ?# KThe bone age was consistent with 28 months by
- h7 ]) a. w+ V S) Pusing the standard of Greulich and Pyle at a chrono-- C4 f$ t6 X' ]5 d7 ], H7 ?1 U
logic age of 16 months (advanced).5 Chromosomal3 Y" s8 k+ w: S0 W1 m9 m
karyotype was 46XY. The thyroid function test* g3 T7 u, d" k7 Z
showed a free T4 of 1.69 ng/dL, and thyroid stimu-# y- e- l& l7 P& U ~- X8 V0 A! s
lating hormone level was 1.3 µIU/mL (both normal).
* S3 O2 d) R, v( _1 RThe concentrations of serum electrolytes, blood+ h7 ^/ J: v; j1 O0 s4 S
urea nitrogen, creatinine, and calcium all were
% w4 z3 R% s f& }within normal range for his age. The concentration: S* i5 ]# T7 c4 N2 E7 N
of serum 17-hydroxyprogesterone was 16 ng/dL: _7 c5 E1 |) ~ z' n# D3 r
(normal, 3 to 90 ng/dL), androstenedione was 205 H+ k1 q8 n5 z7 l7 R$ ?/ r" x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 V2 V, E' T( v
terone was 38 ng/dL (normal, 50 to 760 ng/dL)," `4 y1 U# k6 s. N% [6 W: Y6 D* |
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
8 t5 }' N+ K R2 v3 Q, {& M49ng/dL), 11-desoxycortisol (specific compound S), y( S' l) y" F, w9 k
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ h4 G2 M# ?; Z% F# ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. _9 X' g; j/ f' i' a$ b9 M' L
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& r5 r; c" e- B% h4 V
and β-human chorionic gonadotropin was less than# l9 C+ f: a+ a, T
5 mIU/mL (normal <5 mIU/mL). Serum follicular
( \. o% j3 w+ R1 p2 O7 G) {- n/ astimulating hormone and leuteinizing hormone# A: Z* {& ?) `' q. V
concentrations were less than 0.05 mIU/mL' o& C R1 h# R
(prepubertal).
6 Y* p7 E* A: H. WThe parents were notified about the laboratory
: c0 S) s4 _. M' Y. Aresults and were informed that all of the tests were# |! n1 f4 @& G$ c( l7 V
normal except the testosterone level was high. The
) b- r8 l1 x+ g/ n8 ofollow-up visit was arranged within a few weeks to1 O, v0 c, ^4 k9 V
obtain testicular and abdominal sonograms; how-
+ ^( \$ c4 P! A r4 _1 E# sever, the family did not return for 4 months.
* w1 x& Y& K/ L: y0 M- {Physical examination at this time revealed that the
% j- O$ }* }% h# R2 s* [) r0 h1 p0 rchild had grown 2.5 cm in 4 months and had gained
/ k. B& D. D6 u2 kg of weight. Physical examination remained! D" H0 e* r' e4 U+ a1 v( G
unchanged. Surprisingly, the pubic hair almost com-
9 O8 i& W$ X" i$ gpletely disappeared except for a few vellous hairs at9 Y+ T E% V2 s9 _& f) C
the base of the phallus. Testicular volume was still 2) J) m5 Z& I9 P4 ]
mL, and the size of the penis remained unchanged.. }" v; J6 L! Q. D; k
The mother also said that the boy was no longer hav-8 W) i& [0 k/ g' E0 e" V0 K2 A
ing frequent erections.
; M& C8 I5 i4 O. CBoth parents were again questioned about use of
: E+ \6 d7 [; B7 O+ \2 y$ Dany ointment/creams that they may have applied to, _3 b* H. d! @% D( E
the child’s skin. This time the father admitted the" o) I7 M) t* j( h- U% x* z/ N3 ~
Topical Testosterone Exposure / Bhowmick et al 541) G0 U; A2 `6 ]1 |
use of testosterone gel twice daily that he was apply-9 e1 `2 a$ N% U' W% W; ^+ o
ing over his own shoulders, chest, and back area for/ ?2 y2 J. ` H5 K6 X/ z. `
a year. The father also revealed he was embarrassed
: Y T2 u: ]( g* Q6 t6 C9 `to disclose that he was using a testosterone gel pre-
7 F8 {3 T2 S! `2 }! k& Lscribed by his family physician for decreased libido( Z* a: u' E0 t1 K2 _& \
secondary to depression.
2 {8 G \ Y1 eThe child slept in the same bed with parents.
% c3 G0 ?7 P7 L% |8 B5 CThe father would hug the baby and hold him on his
& [) B6 l8 F( l* D3 ~3 q7 Gchest for a considerable period of time, causing sig-
8 `$ g: C; J8 ~6 a- U% x2 anificant bare skin contact between baby and father.
- W$ {$ H$ a- q7 \The father also admitted that after the phone call,
3 C+ `! F6 V- D9 ~) \$ g- P+ N Kwhen he learned the testosterone level in the baby" g X$ [ G: s) j T+ v1 d
was high, he then read the product information2 |+ S3 _5 l( A2 o& ]
packet and concluded that it was most likely the rea-( Y9 Z" j0 ~. @" Q
son for the child’s virilization. At that time, they4 S6 Z. R. D, i7 l" E7 _" ]
decided to put the baby in a separate bed, and the1 A6 y e) l" T1 Y+ v( u R
father was not hugging him with bare skin and had% i9 r( e7 u: n, `1 K+ a; {
been using protective clothing. A repeat testosterone
, C) i. q. j' r% o0 {5 p) vtest was ordered, but the family did not go to the
$ X# I+ D# P( n; A0 glaboratory to obtain the test.+ J0 R5 K% S" p- L4 ?' b% m
Discussion
9 y' ]) v4 W* o5 f( J% d9 ePrecocious puberty in boys is defined as secondary: e: Z3 l* @5 c
sexual development before 9 years of age.1,4$ n2 W8 c8 K' ~
Precocious puberty is termed as central (true) when6 M0 o% G) Q% J: {
it is caused by the premature activation of hypo-
* P3 L h! l: H kthalamic pituitary gonadal axis. CPP is more com- F2 Z4 P0 b9 z; }' W
mon in girls than in boys.1,3 Most boys with CPP
( ]2 f$ o2 v' y) v- _. i. w! zmay have a central nervous system lesion that is
& k+ S- C( x4 S" iresponsible for the early activation of the hypothal-
! l: ?: Q$ a7 p8 {5 Jamic pituitary gonadal axis.1-3 Thus, greater empha-
/ N L# h6 W* i6 F2 ^7 {8 G3 Wsis has been given to neuroradiologic imaging in8 R/ E* d! I' I3 b! u! N+ q
boys with precocious puberty. In addition to viril-
& N7 R" E+ Y& L/ T9 w" mization, the clinical hallmark of CPP is the symmet-
& S5 v+ j! J& x/ m! Erical testicular growth secondary to stimulation by
7 F. r7 ~0 S0 w- ygonadotropins.1,3! h- r, ~$ _2 k# O A
Gonadotropin-independent peripheral preco-) [ x6 z+ m$ X2 E
cious puberty in boys also results from inappropriate' P: l4 e) D ?' w m5 O
androgenic stimulation from either endogenous or4 f$ p7 ]+ ?) e4 ]/ H1 @7 j0 [
exogenous sources, nonpituitary gonadotropin stim-; j: @/ S, Y! H. {0 L' X
ulation, and rare activating mutations.3 Virilizing+ j9 {6 ~( k0 f: L9 j
congenital adrenal hyperplasia producing excessive; t: u6 m+ ]" ?3 _* x
adrenal androgens is a common cause of precocious+ }. F, ]( j$ [: G E
puberty in boys.3,4! i( f3 I+ D3 @0 {0 @; [# `
The most common form of congenital adrenal6 ]/ }2 S0 M O6 c% G+ w( Q
hyperplasia is the 21-hydroxylase enzyme deficiency.
6 K& W R/ v: @& n; WThe 11-β hydroxylase deficiency may also result in0 l9 y# P& k' a0 z
excessive adrenal androgen production, and rarely,
8 I5 n* r7 l( Z; r: Z) s% t' _5 han adrenal tumor may also cause adrenal androgen8 x$ L( e: ~' s/ M8 U
excess.1,3
1 ^, E# {( R. n! o7 aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ f; h X3 G# [5 `. K7 U% K
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ v! }/ K4 {- |. L$ A; j3 F. i% lA unique entity of male-limited gonadotropin-
/ _; ^& H) R4 `independent precocious puberty, which is also known& ]$ M8 ]9 X# _% ]2 Q3 m8 H$ q
as testotoxicosis, may cause precocious puberty at a) V7 Q5 z6 B& Z3 [7 K% }
very young age. The physical findings in these boys0 }0 q8 E# U6 `, V( K
with this disorder are full pubertal development,
" l) Q9 L- F$ x/ l, g5 H% Jincluding bilateral testicular growth, similar to boys7 @+ X2 U% ?8 ~2 S: ]
with CPP. The gonadotropin levels in this disorder) w" G9 ?* C( q5 ^7 H/ c
are suppressed to prepubertal levels and do not show0 o l. i0 b' O5 R# n( P
pubertal response of gonadotropin after gonadotropin-
$ g; q: V) k5 Vreleasing hormone stimulation. This is a sex-linked
' q* H; y. E* k. n$ Z; [, k5 G" gautosomal dominant disorder that affects only
8 h& j! b" |" N2 t: Wmales; therefore, other male members of the family
) f0 `5 g5 i# u% Qmay have similar precocious puberty.33 T% [' ?3 Q% K L$ B2 S
In our patient, physical examination was incon-
$ I1 p$ u# p- Qsistent with true precocious puberty since his testi-' E$ H# s* m- U: W4 o
cles were prepubertal in size. However, testotoxicosis2 p/ r6 m0 Z2 e2 Q7 `: y
was in the differential diagnosis because his father0 q1 y! J* X! M. l2 f8 j
started puberty somewhat early, and occasionally,) U y/ B- g2 x0 F
testicular enlargement is not that evident in the5 \% l1 D. m4 L) G$ E, E
beginning of this process.1 In the absence of a neg-) K! G. l0 q8 y9 w
ative initial history of androgen exposure, our. ]* C+ ]/ [0 @+ s0 a- c, `$ z& v$ E
biggest concern was virilizing adrenal hyperplasia,
, O w: ^( Q( R( ?either 21-hydroxylase deficiency or 11-β hydroxylase
5 F$ s# W& O4 ^7 y8 q7 o Ndeficiency. Those diagnoses were excluded by find-; Q0 q5 S' Q) h, z. M
ing the normal level of adrenal steroids.- K- Q# J( J' P8 q
The diagnosis of exogenous androgens was strongly# I/ x5 z4 G6 |* w3 F: [: f
suspected in a follow-up visit after 4 months because
, x# N7 s1 T1 V# [1 p% _) e+ Rthe physical examination revealed the complete disap-
( n/ t; |4 f9 Q/ f0 h4 ~# gpearance of pubic hair, normal growth velocity, and4 T: n/ U) z4 h* L7 u+ M
decreased erections. The father admitted using a testos-5 C$ ]/ l% T2 m& p* y+ K! m+ i
terone gel, which he concealed at first visit. He was
. q- b# }' ` s, `% Gusing it rather frequently, twice a day. The Physicians’. A5 \% r% p- T- y! c
Desk Reference, or package insert of this product, gel or
) X* F8 K. |& R- ?& Z. rcream, cautions about dermal testosterone transfer to
: z' ^9 I5 x+ l1 d: ~unprotected females through direct skin exposure.8 N+ I6 a) D3 [9 b. g( I! K, ?
Serum testosterone level was found to be 2 times the5 T+ j5 q+ l( i& @1 ?( g8 P
baseline value in those females who were exposed to
: a% O+ P+ ]) c7 N; weven 15 minutes of direct skin contact with their male7 h# e4 }% ] U& Q' U- ]+ ~! ^" W
partners.6 However, when a shirt covered the applica-
+ {8 t- T2 ]" J( C8 \* btion site, this testosterone transfer was prevented.& U1 X$ I5 g- ]" B6 G4 B
Our patient’s testosterone level was 60 ng/mL,2 b& ~3 [2 [7 U) N
which was clearly high. Some studies suggest that
# ~6 M7 ]0 c& z6 o5 ~. adermal conversion of testosterone to dihydrotestos-
7 ^& v* `2 q# ?0 @ I/ yterone, which is a more potent metabolite, is more
% ^1 j+ D. z. c+ z0 _% k, A2 sactive in young children exposed to testosterone
' r2 R; v9 P# O& V4 d* Nexogenously7; however, we did not measure a dihy-1 E( T* e* W) z
drotestosterone level in our patient. In addition to
7 A9 M) L6 E) g6 rvirilization, exposure to exogenous testosterone in
% j" p3 z/ O; n- Z6 N) s, Ychildren results in an increase in growth velocity and
2 p* F, E" Q1 \ |advanced bone age, as seen in our patient.
1 G, I% c( U6 v1 VThe long-term effect of androgen exposure during6 n$ L+ P, \2 ?: r
early childhood on pubertal development and final
6 y* F! B+ T+ q/ z2 }adult height are not fully known and always remain. w; z I8 j. [* \7 }$ ~
a concern. Children treated with short-term testos-
: l$ J5 z+ G* j& u, jterone injection or topical androgen may exhibit some0 d# w/ _+ R# O
acceleration of the skeletal maturation; however, after, s5 E6 }$ Y) `- y. t
cessation of treatment, the rate of bone maturation
( e( k* r! k6 L) y1 sdecelerates and gradually returns to normal.8,9
* W: T' r! Q3 I* S) U$ kThere are conflicting reports and controversy
# O; H$ H( Z4 O& Kover the effect of early androgen exposure on adult# U3 K( G$ A3 X
penile length.10,11 Some reports suggest subnormal
$ Q4 V7 c Y* V8 q( s- radult penile length, apparently because of downreg-
6 J( u3 L2 X& [1 P) N' v& sulation of androgen receptor number.10,12 However,* k8 H. r$ A. o( F
Sutherland et al13 did not find a correlation between" }' u* }% f5 m% c+ c/ N* P1 I
childhood testosterone exposure and reduced adult. h& K4 s. u1 m; t) L t
penile length in clinical studies.# N+ |6 v0 Y7 H: x' R" c
Nonetheless, we do not believe our patient is
$ ~" R4 g: k1 ?9 F% y! qgoing to experience any of the untoward effects from
* B( F8 [, _' Otestosterone exposure as mentioned earlier because
! r9 s& b; t. U! I% a: \* ithe exposure was not for a prolonged period of time. j' p: R, u) Z) L, V. i
Although the bone age was advanced at the time of
1 G: u* }( ?7 R* G4 C8 Odiagnosis, the child had a normal growth velocity at
; k3 o _2 a+ ?+ J7 W* m' zthe follow-up visit. It is hoped that his final adult
0 Q- m8 i+ ]7 q, Z6 qheight will not be affected.6 e* D3 g) T8 p
Although rarely reported, the widespread avail-
# @- D; _! Z, z8 n& Wability of androgen products in our society may" U( @4 f" p" ~1 s# Z4 Q
indeed cause more virilization in male or female' n/ M0 D4 K3 y
children than one would realize. Exposure to andro- L, \0 G0 C' v& }9 _! B" f( E
gen products must be considered and specific ques-, c- U* C/ n1 V4 W& \
tioning about the use of a testosterone product or% e) B& _* Y' B% W0 l. ]) ~" z
gel should be asked of the family members during8 W/ a m! E) _, @% D: I6 C5 ~8 h
the evaluation of any children who present with vir-
' k) R1 P. V, b y: A Z. T {/ tilization or peripheral precocious puberty. The diag-
) ?3 _% C9 U* w, K$ Knosis can be established by just a few tests and by8 }) y, k- ?8 D& c# i6 d
appropriate history. The inability to obtain such a: W: K3 k' ]+ }, |& Y
history, or failure to ask the specific questions, may- w9 e4 [+ M+ B J$ F
result in extensive, unnecessary, and expensive
$ c1 x& f5 g2 d y/ v* B9 Minvestigation. The primary care physician should be5 p a' L& H0 n. T: ]
aware of this fact, because most of these children7 L' D- ^2 m$ ?" V" M; {
may initially present in their practice. The Physicians’
6 t9 ` S9 m D, j. W. zDesk Reference and package insert should also put a. H. [6 I# y: p) Z B
warning about the virilizing effect on a male or0 _9 F V( e$ H J3 c
female child who might come in contact with some-( _( s* T) t) }0 G3 B
one using any of these products.
/ @( \+ B; G8 f1 F3 mReferences
. B! c+ L; ^. P& K1. Styne DM. The testes: disorder of sexual differentiation
. _, Z$ ^9 e* ^6 Q" a& }4 [# t B+ ~% tand puberty in the male. In: Sperling MA, ed. Pediatric
4 j) |" m, `1 v; M- r. SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- F- I. N) e6 L! ]7 y7 d S) [
2002: 565-628.
7 H( _- a7 A; [6 ~4 W2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious( `3 u/ e) i2 H- m, M/ E+ p. D- R
puberty in children with tumours of the suprasellar pineal |
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