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Sexual Precocity in a 16-Month-Old
$ E& I) f. W+ O! d* l% d1 zBoy Induced by Indirect Topical% W3 F* J+ L. \- U1 G6 }
Exposure to Testosterone
( a! ?/ B6 O: t( e7 HSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! f# v, l+ z% z( s
and Kenneth R. Rettig, MD1
0 H+ E9 [5 Y7 X' X; H/ }Clinical Pediatrics
. O+ y6 d# v0 H/ E1 H/ eVolume 46 Number 6
T3 `7 W: Q6 {( eJuly 2007 540-543
0 f/ I9 }6 Z3 y: c' J1 D© 2007 Sage Publications
( a) x" M. G" s; o$ ~5 ]/ n10.1177/0009922806296651
9 T& `1 J4 S9 u% A( T/ K- rhttp://clp.sagepub.com
8 y/ G- A# V% `8 Yhosted at
5 D+ O3 |- Y. C6 ~. ?3 | Qhttp://online.sagepub.com9 c# @2 X! A& U, k1 @4 U
Precocious puberty in boys, central or peripheral,
. A# ]6 R, X( T4 z- ais a significant concern for physicians. Central
# D2 A8 D- p2 L) P$ tprecocious puberty (CPP), which is mediated
" v6 z1 B9 W) v2 V( R6 Othrough the hypothalamic pituitary gonadal axis, has
6 t, \/ r/ ^& @a higher incidence of organic central nervous system; ]* Q' s3 R( g( l) o u+ Z
lesions in boys.1,2 Virilization in boys, as manifested {' Z/ Z5 X6 E# c4 M. D" P$ \
by enlargement of the penis, development of pubic/ i0 E3 o; @: b: U W& A% G; T
hair, and facial acne without enlargement of testi-
+ x, p& a, |: r$ d. o7 Vcles, suggests peripheral or pseudopuberty.1-3 We
6 x4 k* ]* j/ areport a 16-month-old boy who presented with the: F4 n1 N. A" }6 `
enlargement of the phallus and pubic hair develop-
# a o( \! [, N k! jment without testicular enlargement, which was due
- Z- o, W1 N$ p1 S7 M7 D) @to the unintentional exposure to androgen gel used by
* P. r7 R4 g# q) Gthe father. The family initially concealed this infor-
' e9 n p- w: \ }mation, resulting in an extensive work-up for this. B; L }8 c1 o z7 t+ w- R
child. Given the widespread and easy availability of
" M4 i; |* l7 t+ ~7 atestosterone gel and cream, we believe this is proba-
2 @4 P% Y, u: I- w q0 @5 xbly more common than the rare case report in the) ?- z# l" p4 N4 _
literature.4
7 l9 z5 x8 Q- @; R8 _Patient Report
% Y/ g4 x% r3 U* q0 \8 I7 A0 c8 SA 16-month-old white child was referred to the6 K, Y0 |) N W$ D
endocrine clinic by his pediatrician with the concern; a+ p, x( a6 H6 g
of early sexual development. His mother noticed
: i* k+ l8 ^: vlight colored pubic hair development when he was
9 h, N4 A5 ^3 Q. DFrom the 1Division of Pediatric Endocrinology, 2University of8 ^7 [* ^+ k+ J( @# C3 z1 K
South Alabama Medical Center, Mobile, Alabama.
. v" K. o3 [2 ?- [& i7 l) I' \) e' b6 ^Address correspondence to: Samar K. Bhowmick, MD, FACE,
1 Z: ^" i$ ^7 i; MProfessor of Pediatrics, University of South Alabama, College of
$ Q+ L% ?9 K, O+ GMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- E. M, p0 c& w! y& [
e-mail: [email protected].) ^# g( f! A* s/ w7 I7 M: a
about 6 to 7 months old, which progressively became
2 Q+ y7 J( @0 x7 b( t9 |darker. She was also concerned about the enlarge-$ C# J& y7 C4 a
ment of his penis and frequent erections. The child2 ] j; P6 Q+ Y4 o! v8 p, t
was the product of a full-term normal delivery, with
( X* V: E8 @# ^1 za birth weight of 7 lb 14 oz, and birth length of. _7 ~% u( A8 w; K- Y8 m. Q
20 inches. He was breast-fed throughout the first year3 _3 L* C; D# B& v6 H
of life and was still receiving breast milk along with
7 ^$ a5 k! R, N/ a/ H ^- R% n# Qsolid food. He had no hospitalizations or surgery,( e' }# `4 a- H9 L1 M" S
and his psychosocial and psychomotor development* ?) L& f8 f% [ S/ u
was age appropriate.
: M( L. w( N; w4 `% l0 U! x' xThe family history was remarkable for the father,% f; h* H) o( q3 N
who was diagnosed with hypothyroidism at age 16,7 h9 p! f, t" e: _8 [/ i+ h. T
which was treated with thyroxine. The father’s
) \1 j* |! W8 s- `height was 6 feet, and he went through a somewhat0 j& c7 N4 y2 q1 X5 [5 m( D
early puberty and had stopped growing by age 14.% Z3 [! \, F7 X8 E# n
The father denied taking any other medication. The
% _+ t5 Q4 B6 |1 _2 @child’s mother was in good health. Her menarche
/ w: @4 n4 U! p: m9 U* s7 awas at 11 years of age, and her height was at 5 feet& `1 m+ D0 g/ z* C' k; E& y; J3 c
5 inches. There was no other family history of pre-
" m+ S$ K0 |3 ` _' ~& {cocious sexual development in the first-degree rela-
3 _; L4 V( z/ Y) ztives. There were no siblings.: P! u. D6 F3 H7 F% ~( D
Physical Examination8 U0 q! }* E7 W r& I3 w& }% ?
The physical examination revealed a very active,7 e$ n1 V- G3 b" Q5 t
playful, and healthy boy. The vital signs documented
4 a @0 x$ e$ X8 q0 Z$ La blood pressure of 85/50 mm Hg, his length was
4 C" R! L0 P7 x" L90 cm (>97th percentile), and his weight was 14.4 kg
' L) p' V% K8 [(also >97th percentile). The observed yearly growth+ l1 G% H/ |6 K6 n5 N
velocity was 30 cm (12 inches). The examination of" T- |! K2 P. h% L' _2 Z6 D
the neck revealed no thyroid enlargement.
. E" \9 y Y$ MThe genitourinary examination was remarkable for
- J+ F/ C( |" Denlargement of the penis, with a stretched length of; _8 K2 }: [& V: L: n
8 cm and a width of 2 cm. The glans penis was very well
3 @% X5 }# J. Ddeveloped. The pubic hair was Tanner II, mostly around
$ w: u. p0 p, Y$ c540
5 |& k6 ~/ ^! M! N: x8 G5 n* sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( P+ b0 P; Z7 M. d) |# @- w4 xthe base of the phallus and was dark and curled. The
3 p T9 p( V1 K4 Atesticular volume was prepubertal at 2 mL each.
' j3 W2 V' H: @9 b3 @7 nThe skin was moist and smooth and somewhat
: J; B& |7 w. ^3 P, M# K( Yoily. No axillary hair was noted. There were no2 C4 C) o4 u. d+ }- ~# s' U
abnormal skin pigmentations or café-au-lait spots.- L, g1 Y- q. b/ ]
Neurologic evaluation showed deep tendon reflex 2+- G M8 R1 Y6 N
bilateral and symmetrical. There was no suggestion" U8 p% J" O V/ o
of papilledema.# W# Y; d8 q# v) w; b' D3 X& `
Laboratory Evaluation& `5 V8 |8 D( d9 N
The bone age was consistent with 28 months by3 [; z( L, w& j1 R( ~
using the standard of Greulich and Pyle at a chrono-' F1 D- T1 u6 G8 x8 }
logic age of 16 months (advanced).5 Chromosomal. Z$ c% \; q3 G: C/ q4 K- ^
karyotype was 46XY. The thyroid function test
3 A/ ?! B q6 {( V5 d5 F' `" I ~showed a free T4 of 1.69 ng/dL, and thyroid stimu-
# K- n( u: L* E6 t: Ulating hormone level was 1.3 µIU/mL (both normal).( m9 [& q- E0 K: a0 m) V9 d9 x
The concentrations of serum electrolytes, blood
( i* M. g' X" T- E% k$ y; Purea nitrogen, creatinine, and calcium all were9 C$ X* |( A: E) U/ u0 v
within normal range for his age. The concentration8 A! R! z, o& F N" D
of serum 17-hydroxyprogesterone was 16 ng/dL
: j L0 h: t. w, u. @! _- J(normal, 3 to 90 ng/dL), androstenedione was 20
2 i% Q, r6 E% ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-" F2 S! n+ \8 ?) Y6 _
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
, M! f! f- B/ h q" tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
2 m7 x3 v# }) y. m49ng/dL), 11-desoxycortisol (specific compound S), b3 n7 a2 ]/ K6 w% m
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# A, _" f0 G2 Q# R, L, ?tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 W' }1 ~, Z+ K6 x+ E$ b. ktestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ c! X, O9 h3 F( A. O& H4 q/ F9 zand β-human chorionic gonadotropin was less than
2 l0 n3 O' H4 A F$ G; u5 mIU/mL (normal <5 mIU/mL). Serum follicular( l" T4 e2 G- t( c" x
stimulating hormone and leuteinizing hormone C2 I2 Q4 J$ d: I& t0 C
concentrations were less than 0.05 mIU/mL
' X/ O) M6 t+ ^# _" C(prepubertal).) A0 V: R$ D8 v, n- }
The parents were notified about the laboratory6 T6 e$ ?1 u1 |' U+ M5 A
results and were informed that all of the tests were
B( N) P2 W( g' c) g6 ynormal except the testosterone level was high. The. j) t5 a9 t/ R [! k+ b
follow-up visit was arranged within a few weeks to
7 S2 f0 B& s; V0 X2 H+ Q* Hobtain testicular and abdominal sonograms; how-$ n, y4 z1 L' p/ i! ?. A/ r
ever, the family did not return for 4 months.
4 X G# a7 X: I9 U6 `Physical examination at this time revealed that the
0 h! a. u9 [4 c' @; {: {3 B9 zchild had grown 2.5 cm in 4 months and had gained
/ Q0 o6 K% z8 e( w2 kg of weight. Physical examination remained
" m- D8 B' E+ |% z# ~3 R6 qunchanged. Surprisingly, the pubic hair almost com-4 R0 I% V0 f/ c/ S [0 b$ Z
pletely disappeared except for a few vellous hairs at7 M' c# i2 j! I- }# E2 t
the base of the phallus. Testicular volume was still 2
/ j1 P$ Q& Q! Q5 n% emL, and the size of the penis remained unchanged.
+ H. ?1 h% B; `+ U* e9 O, | ]$ ?The mother also said that the boy was no longer hav-
5 b M" a; L' V, s" Ning frequent erections.' h1 y/ ^# n" H8 e `# [' p
Both parents were again questioned about use of3 v; i9 l$ ^7 ?" N @( i
any ointment/creams that they may have applied to* ]& ^7 x: K0 `3 A) E7 D
the child’s skin. This time the father admitted the
9 F5 }" J8 G' U3 {Topical Testosterone Exposure / Bhowmick et al 541+ E+ g" l* @3 i" a
use of testosterone gel twice daily that he was apply-
: \0 b0 y4 ]' j$ Z( uing over his own shoulders, chest, and back area for
8 I! f& C9 U7 I K7 m! s, W( ha year. The father also revealed he was embarrassed* \' t- h0 l+ o( i2 }$ o
to disclose that he was using a testosterone gel pre-2 v' Z) J7 `0 }, K
scribed by his family physician for decreased libido" j* r4 v; Q* Y- J9 s' o
secondary to depression.
# a0 w& ]: j$ y' K+ ?9 XThe child slept in the same bed with parents.
2 }+ f' n: [" L, }0 I! QThe father would hug the baby and hold him on his
/ s& W$ n" y; q% d: }$ ?chest for a considerable period of time, causing sig-/ _8 B" X/ N- |! Q+ }' `; O/ G
nificant bare skin contact between baby and father.
$ l/ [ |2 Q2 Q, S- R; y5 zThe father also admitted that after the phone call,
( z0 J0 S+ l" \7 ^$ _" z6 Mwhen he learned the testosterone level in the baby, H$ L, |2 H* x3 q/ V6 |. d
was high, he then read the product information
( X% u; W4 m7 O, dpacket and concluded that it was most likely the rea-/ e P# D' A4 I1 _: N. ^9 ^/ R% d
son for the child’s virilization. At that time, they- a$ v0 i" e. [: ], F( x- S
decided to put the baby in a separate bed, and the
# N5 y4 M8 _) g! g1 Bfather was not hugging him with bare skin and had5 Q9 j$ S% ~5 \$ L: @5 W
been using protective clothing. A repeat testosterone
# j1 {- z2 o& t% Ytest was ordered, but the family did not go to the1 N( D. S, |, E2 u& [, {0 ]
laboratory to obtain the test.& B6 ^- t- R( I" f% ]
Discussion
% h, _) }& H& h6 T; b- `7 _, _Precocious puberty in boys is defined as secondary/ ^$ D9 X3 Z* Z" k/ @1 I9 _
sexual development before 9 years of age.1,4
" d& X+ N& b( JPrecocious puberty is termed as central (true) when
! ?- O2 g' Y/ Kit is caused by the premature activation of hypo-6 J: s \( B5 E( N6 ^
thalamic pituitary gonadal axis. CPP is more com-
6 ?* S' X4 S2 ]mon in girls than in boys.1,3 Most boys with CPP) r( Y- L, c; o( M! g
may have a central nervous system lesion that is' N- A! {* |& Q5 j+ Y( o* @0 ?
responsible for the early activation of the hypothal-
% W4 O0 c4 V) M6 l1 a* k( g8 eamic pituitary gonadal axis.1-3 Thus, greater empha-# Z+ X& R# D7 u$ L
sis has been given to neuroradiologic imaging in3 C5 H, x" s) A9 E5 _
boys with precocious puberty. In addition to viril-
% d" b2 ]4 Y9 T" ]2 \ization, the clinical hallmark of CPP is the symmet-" i* r% D+ W j" k6 E/ s* z5 W: E
rical testicular growth secondary to stimulation by+ ]; S' l7 S7 T% u
gonadotropins.1,31 C- S$ y8 w0 c# O4 G
Gonadotropin-independent peripheral preco-
) P/ F" ~% D: x+ w& q O4 scious puberty in boys also results from inappropriate7 e% e& [! A3 f; R+ Q
androgenic stimulation from either endogenous or
. b( ]) Q* I2 r. p$ Eexogenous sources, nonpituitary gonadotropin stim-# G& I7 J8 _* v# Z: y
ulation, and rare activating mutations.3 Virilizing N2 N$ u! u4 w- `/ n9 ^' P
congenital adrenal hyperplasia producing excessive: {- S( w$ r7 H" j+ Y$ Q% r( p
adrenal androgens is a common cause of precocious8 }- p3 j- i2 D4 g+ S
puberty in boys.3,4* m ~" p k5 a5 y% a/ d
The most common form of congenital adrenal
$ Z8 ]% I. M1 `" s+ Dhyperplasia is the 21-hydroxylase enzyme deficiency.
! b) u$ N% ]0 o. D- H" rThe 11-β hydroxylase deficiency may also result in4 W. { x8 @9 S. O+ M% D3 v
excessive adrenal androgen production, and rarely,* P, I+ e+ ^8 A5 u8 D: S( i4 N
an adrenal tumor may also cause adrenal androgen* m Z( P( Z* Z/ R( r5 ?
excess.1,3+ }& p% x+ V( w" ?5 y5 O
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ ^* W9 q( s5 |" r5 S, i
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007) w, g5 e0 |! i1 k% k8 B
A unique entity of male-limited gonadotropin-9 v8 W) Y0 H- r
independent precocious puberty, which is also known
1 Y o$ }1 t Has testotoxicosis, may cause precocious puberty at a; d4 Z9 g; G8 O8 c% s h0 Q) `
very young age. The physical findings in these boys3 O1 S6 z# i% t3 C
with this disorder are full pubertal development,
0 u7 u2 j0 Q, d1 f5 Rincluding bilateral testicular growth, similar to boys0 O' [: ~' f4 S" b* \# X! D8 X
with CPP. The gonadotropin levels in this disorder8 m0 I6 u- Z0 t Y9 X, X
are suppressed to prepubertal levels and do not show
2 O* \: M" k1 ?. X5 A0 m% Npubertal response of gonadotropin after gonadotropin-# Q" D: Q4 Q" T M+ P- S) b
releasing hormone stimulation. This is a sex-linked2 D. _3 U: i8 n8 d' p M
autosomal dominant disorder that affects only) }/ r0 L" j0 {. D1 q, H) y
males; therefore, other male members of the family
9 c' J/ e5 e4 q! z4 w! U; Imay have similar precocious puberty.3& H, \6 D. D0 d4 `& S9 z
In our patient, physical examination was incon-4 C$ y% S# I8 W* R7 r
sistent with true precocious puberty since his testi-
8 U( R2 S7 g( n( Q- N/ z$ ?cles were prepubertal in size. However, testotoxicosis+ k7 a0 o9 W: S# I1 D* |
was in the differential diagnosis because his father
: f1 |# n8 R% e8 J; T2 L: Y) J# kstarted puberty somewhat early, and occasionally,
, H) q4 Z0 \6 o9 S+ t# ztesticular enlargement is not that evident in the) Q' p+ a7 S' w6 J
beginning of this process.1 In the absence of a neg-
! a A* @2 u3 I6 B% Xative initial history of androgen exposure, our! N0 G$ [: T+ A7 ?
biggest concern was virilizing adrenal hyperplasia,5 ]4 [: [3 W w8 }0 |
either 21-hydroxylase deficiency or 11-β hydroxylase
: n7 c1 l1 m; C& J: L W; {deficiency. Those diagnoses were excluded by find-6 D6 {/ W0 \3 }: X; l$ u1 F
ing the normal level of adrenal steroids.) n1 j1 Y' b, _1 W7 b1 D- v/ R
The diagnosis of exogenous androgens was strongly- u [. p- j6 ^' s7 h _
suspected in a follow-up visit after 4 months because2 m( v( u' S: n9 U/ u% K1 ^
the physical examination revealed the complete disap-( [1 P5 |( h* V( a
pearance of pubic hair, normal growth velocity, and8 K8 I5 B! d& w: }* t* |/ u; B& q
decreased erections. The father admitted using a testos-; j" w# x) C+ w/ j8 R# p
terone gel, which he concealed at first visit. He was
1 V& }# O/ S9 T6 p4 `using it rather frequently, twice a day. The Physicians’1 S+ z6 Q( M, S* Z* `/ F' B
Desk Reference, or package insert of this product, gel or3 J* L% z; \' o: w2 h' z
cream, cautions about dermal testosterone transfer to
) S- s. P2 w6 I) Junprotected females through direct skin exposure.
7 e- S, e" O! T l4 _Serum testosterone level was found to be 2 times the
- z! D5 l2 ~9 e) r" Abaseline value in those females who were exposed to8 \9 M: P1 Y7 g; j
even 15 minutes of direct skin contact with their male
5 j0 f/ V% f( `# o, tpartners.6 However, when a shirt covered the applica-
; ?1 x. o$ B1 E1 T; F5 stion site, this testosterone transfer was prevented.* S' r' h$ p0 c$ U: d3 w7 T
Our patient’s testosterone level was 60 ng/mL,
8 r8 V, _3 a( x1 k4 J1 w/ r' Fwhich was clearly high. Some studies suggest that
5 Y" X( f0 g7 rdermal conversion of testosterone to dihydrotestos-$ p* O* o, W1 K% M
terone, which is a more potent metabolite, is more1 q+ B; n* Z# P3 B( p
active in young children exposed to testosterone
( e1 Y' _ y( T8 xexogenously7; however, we did not measure a dihy-
( j6 f' \% A( J& i" R3 vdrotestosterone level in our patient. In addition to. N. A: Z2 p+ a: |$ @
virilization, exposure to exogenous testosterone in
: z3 l8 O8 I& h3 ^+ [% ~5 ~children results in an increase in growth velocity and- w4 e# c4 ] s# j
advanced bone age, as seen in our patient.' k: i1 ?7 X) E1 ]% {* N1 ]
The long-term effect of androgen exposure during$ o5 r5 R. p: S
early childhood on pubertal development and final& V. v! \. D0 s3 Y7 p0 M7 W
adult height are not fully known and always remain
" F0 | |' f# V( a. e' G7 a; Y2 _a concern. Children treated with short-term testos-) a$ z+ c9 t% f) I; Q: E& V
terone injection or topical androgen may exhibit some
( {" G9 A6 W' J/ R _/ y1 hacceleration of the skeletal maturation; however, after
n" @' v/ z+ {' t- w: s, |3 w! ?cessation of treatment, the rate of bone maturation
1 S- f5 C5 R- C4 n# ~decelerates and gradually returns to normal.8,9' N/ @/ |0 X! a/ j
There are conflicting reports and controversy
' Z3 A/ g" M* B2 h) |% Gover the effect of early androgen exposure on adult4 u. W6 G2 Y' X1 C% g! w7 k' Y
penile length.10,11 Some reports suggest subnormal$ A: Q% O% j8 {2 i. L- t8 X
adult penile length, apparently because of downreg-
1 m& |. L5 R9 h' Hulation of androgen receptor number.10,12 However,
8 I$ I* L3 N- xSutherland et al13 did not find a correlation between" i& y% V% G8 v; }9 C
childhood testosterone exposure and reduced adult% |' J: [% D5 L* o8 T" _0 u9 g3 K E* W
penile length in clinical studies.. G- F8 q. v: x1 C7 b! e
Nonetheless, we do not believe our patient is
4 E" g Y# I8 ~# jgoing to experience any of the untoward effects from
9 K, D E" @. F/ g4 ltestosterone exposure as mentioned earlier because
( P! h* r/ M, d O( r( c6 H* q9 Vthe exposure was not for a prolonged period of time.& K: `* ] l8 w% j5 E1 {9 }
Although the bone age was advanced at the time of
5 i& H- e/ b: y, k% x3 _% Rdiagnosis, the child had a normal growth velocity at
/ s! @$ @1 X4 {, j0 s. T' m, ?0 `/ z) lthe follow-up visit. It is hoped that his final adult0 o+ @9 [/ D$ u% j9 v" I6 }
height will not be affected.5 l( f% n( i" {7 `3 m
Although rarely reported, the widespread avail- f. p6 `# ]7 F7 H: [. X$ _2 ?# @
ability of androgen products in our society may$ V( n, `" w: _& J/ d
indeed cause more virilization in male or female- J( r" m9 r. |& |7 w
children than one would realize. Exposure to andro-* A( l, v. m+ a' S0 n# t' P: Z5 K
gen products must be considered and specific ques-
) s' ?; e: E: I# k5 _/ _tioning about the use of a testosterone product or- N8 ], W$ v( o; U/ a
gel should be asked of the family members during( R- y3 [7 @; L- @7 b' |# E
the evaluation of any children who present with vir-
- x9 e2 g- G& Xilization or peripheral precocious puberty. The diag-- x" V) i) o# D- K3 ^9 j( e3 \
nosis can be established by just a few tests and by$ \. a. I# ^3 ^6 H# F& z$ d
appropriate history. The inability to obtain such a
D9 s6 a4 k0 V9 q0 b' Q* q" ~history, or failure to ask the specific questions, may
% ]' y( y. n" s; |7 e# a+ `result in extensive, unnecessary, and expensive
% n; a* j# _. j7 r. ^3 [2 ninvestigation. The primary care physician should be
+ m* ^* G* t( e' ~# p) v) r0 caware of this fact, because most of these children, z, K# D- R/ S) ~+ [/ h: c% g- b
may initially present in their practice. The Physicians’
' G8 s# {0 j# i' t& I8 K4 mDesk Reference and package insert should also put a0 Z: ^, F) s9 o! _
warning about the virilizing effect on a male or
/ f9 A# l0 t* K9 H2 F0 @female child who might come in contact with some-
- E( Q& v7 ?" P' xone using any of these products.
; U N7 n) Z; u5 {- F. {7 SReferences
; _# n+ S, W/ J* U- C) y: r" f+ p1. Styne DM. The testes: disorder of sexual differentiation
3 Y H3 Y a$ L v( Qand puberty in the male. In: Sperling MA, ed. Pediatric, s Q' d) x8 ]9 k& J! V, {
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# R3 ?+ U2 S: W. @( g1 K1 Q2002: 565-628. k. L; {$ ^6 K( p$ Y* b
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: B/ k& D2 d5 Z4 _0 v
puberty in children with tumours of the suprasellar pineal |
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