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Sexual Precocity in a 16-Month-Old
* e; k" l+ i& [* |% F( o: ABoy Induced by Indirect Topical/ s- g4 K; b7 r. K
Exposure to Testosterone' }; |" s3 Q6 H) @% w1 v
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,29 c0 J# U2 S- Q2 F& c8 Z a
and Kenneth R. Rettig, MD12 V9 Q" T# T" O
Clinical Pediatrics0 z" q9 o) m- i8 F( K2 S
Volume 46 Number 6
+ N* R. X- Y) T& h. r% }1 y4 A( S% tJuly 2007 540-543
" g3 i; j& `8 J6 X0 _* }© 2007 Sage Publications
7 X4 u. o" M4 d* g- d: S% ]* O# F10.1177/0009922806296651' G( A. E4 W9 F
http://clp.sagepub.com/ ~6 A9 I C% B' @' U: Y4 \
hosted at
7 U2 u* \9 A6 L% s, vhttp://online.sagepub.com: S1 M T7 K0 n+ p' F+ i. l
Precocious puberty in boys, central or peripheral,
* h9 D0 [3 |: F4 ois a significant concern for physicians. Central' a. x: p9 k9 J9 ]0 Q. E+ v
precocious puberty (CPP), which is mediated$ [2 x4 [. D; J$ ]
through the hypothalamic pituitary gonadal axis, has
5 p% ^# |0 i" P: Ma higher incidence of organic central nervous system; ?; t# d: z6 W5 S, S
lesions in boys.1,2 Virilization in boys, as manifested
: d- V5 ~) \2 J2 fby enlargement of the penis, development of pubic9 M8 g8 l% f. k! r- n
hair, and facial acne without enlargement of testi-
h( k$ K! K \cles, suggests peripheral or pseudopuberty.1-3 We
8 l, w2 g; h. ^* Q2 e- Ereport a 16-month-old boy who presented with the
& A% y: i, u6 G5 i6 g' y1 p3 |enlargement of the phallus and pubic hair develop-
( V- S# l3 K- X6 p3 C: @ment without testicular enlargement, which was due
+ r; o4 p- V/ ]( L8 R3 ^to the unintentional exposure to androgen gel used by9 z3 ^) p+ O- A& T4 _ G' ^
the father. The family initially concealed this infor-# B& B1 V$ {) \5 ?
mation, resulting in an extensive work-up for this8 V1 [5 W0 o. `6 Q" v7 }
child. Given the widespread and easy availability of
% m: K8 w1 f1 L9 c% p2 `testosterone gel and cream, we believe this is proba-3 A3 V; [6 m( b! Q# G- e
bly more common than the rare case report in the
9 Y- _. ^2 n& V9 C# y9 d: Aliterature.4
6 e- {7 ]4 c- \# d1 o0 G- _Patient Report# F% u7 L: {+ a
A 16-month-old white child was referred to the
$ k; y" c$ \% sendocrine clinic by his pediatrician with the concern
3 |/ T4 n! A9 R- y" v) |0 kof early sexual development. His mother noticed
& e2 O/ z& M+ n4 D- D2 i, Nlight colored pubic hair development when he was1 v7 z7 N S$ A
From the 1Division of Pediatric Endocrinology, 2University of$ t5 {+ F! A# i& I, R# i) ^
South Alabama Medical Center, Mobile, Alabama.- @- Y; t4 _+ B9 A( ^+ o
Address correspondence to: Samar K. Bhowmick, MD, FACE,
' `* P0 q7 ]0 t" r2 WProfessor of Pediatrics, University of South Alabama, College of
, u3 P* u; x: Y( o, cMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
6 |( H( S5 B7 D* r; a/ E; ]+ Ie-mail: [email protected].2 I& ^; s- V2 E: b
about 6 to 7 months old, which progressively became5 A8 \3 F& v' W/ r8 b
darker. She was also concerned about the enlarge-" f& S$ i4 q. H5 i
ment of his penis and frequent erections. The child c0 V/ a+ ~) Q3 j7 N
was the product of a full-term normal delivery, with
F" t- v% U w. p+ X& v3 r& Va birth weight of 7 lb 14 oz, and birth length of
) E. {5 e" r( t5 o. a+ {3 g! w20 inches. He was breast-fed throughout the first year7 m1 b g$ E9 E. n
of life and was still receiving breast milk along with
. {6 M) D' [4 _. usolid food. He had no hospitalizations or surgery,# X) I$ e6 ?) T: i+ h$ f) O
and his psychosocial and psychomotor development) G2 Y o, o0 Q! ]& F2 [; @2 T
was age appropriate.
2 D' x/ y' s5 aThe family history was remarkable for the father,
& ^' y* T7 d |% wwho was diagnosed with hypothyroidism at age 16,4 ^9 k, v# p+ }% W
which was treated with thyroxine. The father’s2 V: f, S5 R% f8 ?5 j' X
height was 6 feet, and he went through a somewhat
5 f. r0 t) J. _3 Mearly puberty and had stopped growing by age 14.- f' h$ S/ i6 R5 |! H' |% H% b
The father denied taking any other medication. The
1 l5 ~' M: |9 I! u: j) f% l# xchild’s mother was in good health. Her menarche
, k, G. u [3 |4 g8 E' Y( E6 j' Rwas at 11 years of age, and her height was at 5 feet2 n/ E3 d3 W0 T
5 inches. There was no other family history of pre-
L% v5 \+ u. ^6 m9 k+ ^" Xcocious sexual development in the first-degree rela-
/ v- {6 h1 Q, r5 _4 otives. There were no siblings.
1 q# l& v) x5 t" E# M8 qPhysical Examination
! F8 |, I5 c# S! I" t) m9 R( iThe physical examination revealed a very active,
5 t+ Q+ B0 ]$ c. \1 U1 }' _playful, and healthy boy. The vital signs documented s' c5 k }2 S( H5 e
a blood pressure of 85/50 mm Hg, his length was
4 ^! D+ R& S/ W3 G' [90 cm (>97th percentile), and his weight was 14.4 kg
% d! s0 J# f. t* b(also >97th percentile). The observed yearly growth
, K1 @/ D6 [( \! Y% fvelocity was 30 cm (12 inches). The examination of
0 v+ O2 Q# b/ C7 k+ X$ ?the neck revealed no thyroid enlargement.+ t2 v# w2 \4 N: C1 [
The genitourinary examination was remarkable for; {" l, P& g& e: S( I7 h
enlargement of the penis, with a stretched length of8 v }6 u" D8 Q$ S4 {
8 cm and a width of 2 cm. The glans penis was very well% e( ?: g0 o1 w
developed. The pubic hair was Tanner II, mostly around$ z% i- X3 h! S/ |- x
540
$ ~0 Q& I( j L7 |8 i, Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 k5 u3 y* B. m$ M1 z2 R, a2 A0 f
the base of the phallus and was dark and curled. The
2 r6 z7 ~$ |/ ~testicular volume was prepubertal at 2 mL each.: A. i5 G4 @( b& P
The skin was moist and smooth and somewhat# x) l/ I. p2 U& G8 }0 M
oily. No axillary hair was noted. There were no
3 U0 [3 d s5 n, j* D" mabnormal skin pigmentations or café-au-lait spots.; H" _1 V1 `5 ~* c# R
Neurologic evaluation showed deep tendon reflex 2+
* M& p; C# S7 V7 }8 e5 G1 G4 H4 Vbilateral and symmetrical. There was no suggestion
% f y2 X. G5 F, }! R# wof papilledema.
, i% F5 q' Y2 Y* q) KLaboratory Evaluation" e! ^! C p, _7 @1 [0 Q9 U. S
The bone age was consistent with 28 months by
8 J& x( k. c2 E/ F+ p7 a4 f2 husing the standard of Greulich and Pyle at a chrono- E ]& P4 d# R: G
logic age of 16 months (advanced).5 Chromosomal, p( j# u! r7 u: ?
karyotype was 46XY. The thyroid function test3 X+ z. ]1 z8 j+ E0 B; ]! h
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% Z1 D3 ]1 { u0 |lating hormone level was 1.3 µIU/mL (both normal).' x$ O! B0 q: i& }, _8 \
The concentrations of serum electrolytes, blood
( D* n: p& U3 Qurea nitrogen, creatinine, and calcium all were( N+ J9 m% g4 [
within normal range for his age. The concentration
5 _) C" f1 }& O+ b! Iof serum 17-hydroxyprogesterone was 16 ng/dL
+ F* \" s. j% T(normal, 3 to 90 ng/dL), androstenedione was 20* x' ?& W1 p8 u9 `
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" D4 k. C& L6 Y7 ^& G" M* g% n$ `, Dterone was 38 ng/dL (normal, 50 to 760 ng/dL),
& O4 }+ W+ z/ F/ Y9 Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to B& h) C0 @7 O' c
49ng/dL), 11-desoxycortisol (specific compound S)
- U4 e3 ?. i3 d: Gwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-& |. }; h% P& E I' I* x
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' t& j8 E/ U8 R0 g# _
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 X& A, A5 L- W; r# I$ ~3 nand β-human chorionic gonadotropin was less than' \2 t/ U! ~- o4 e- Y% d
5 mIU/mL (normal <5 mIU/mL). Serum follicular8 J; ~* [- n* t; ]1 n9 ~5 T
stimulating hormone and leuteinizing hormone1 Q. b" Q' e, F( Q( |
concentrations were less than 0.05 mIU/mL
: s+ i2 x. Y9 m K4 u(prepubertal).
, z. B0 q8 T# G6 A: eThe parents were notified about the laboratory
2 u) d6 L/ ]. b' H0 p* [results and were informed that all of the tests were
; M' h6 R7 \5 ]& A3 tnormal except the testosterone level was high. The. a. V( B; R1 b A/ t7 }1 N
follow-up visit was arranged within a few weeks to0 v5 B5 b' N0 B- z. d" ]
obtain testicular and abdominal sonograms; how-
5 V! J+ Q1 G) h; p- G1 j' Cever, the family did not return for 4 months.1 s1 R3 b7 W; `
Physical examination at this time revealed that the& ]+ x! y0 D8 X/ i
child had grown 2.5 cm in 4 months and had gained5 G2 O/ G& O# P& `4 J' a- B
2 kg of weight. Physical examination remained* z9 ]' ^8 I* N/ n2 J
unchanged. Surprisingly, the pubic hair almost com-3 e7 {/ x* a! p6 j
pletely disappeared except for a few vellous hairs at
; @% M4 A: d, n7 N5 T( [the base of the phallus. Testicular volume was still 2
1 }* x5 \- W ], l- v, Z9 ]7 TmL, and the size of the penis remained unchanged.* F8 Q( F) w: g6 _. ]
The mother also said that the boy was no longer hav-, l+ X- m7 {5 y$ W$ @
ing frequent erections.1 r- }9 c9 ?- k) o& w
Both parents were again questioned about use of6 K) s* j1 m( y1 i- O+ l0 Z, e' z
any ointment/creams that they may have applied to
2 E* I9 w6 C" B6 p8 S. `the child’s skin. This time the father admitted the
0 X/ k/ D. ^, ?0 jTopical Testosterone Exposure / Bhowmick et al 541
1 T9 R, v/ h' w8 w E3 Luse of testosterone gel twice daily that he was apply-
% Z0 V, c; H% h* K ling over his own shoulders, chest, and back area for: z# ? l% W! G# m& f3 e
a year. The father also revealed he was embarrassed/ I( T; U. @7 ^- a6 C% }7 @
to disclose that he was using a testosterone gel pre- l6 M9 g8 C+ v4 P; X7 ~, w ~
scribed by his family physician for decreased libido7 `+ d! O+ W1 j% B+ h6 m" Y2 d
secondary to depression.& \+ c J9 w0 u- q1 H0 E) }1 K Q
The child slept in the same bed with parents.
0 W& y% `$ H0 h$ B1 a" o N6 r& V, hThe father would hug the baby and hold him on his
5 D# \$ j( n8 j8 \# }' F$ xchest for a considerable period of time, causing sig-
) j8 Q1 \& h! ]7 L$ znificant bare skin contact between baby and father.
0 f; R& k P. `% tThe father also admitted that after the phone call,0 |, @% o, l) g5 R/ W; Q& E
when he learned the testosterone level in the baby
% z9 {3 q3 e5 a+ Nwas high, he then read the product information) C4 ^" p9 S9 M4 J2 J% G
packet and concluded that it was most likely the rea-+ Y C* M% R" q! ]7 q
son for the child’s virilization. At that time, they
" ?+ ?2 P* j0 x* h" z! Jdecided to put the baby in a separate bed, and the6 f- O+ X3 e! L' ?1 g2 F) z/ f
father was not hugging him with bare skin and had) ? J; Q+ j( b6 H
been using protective clothing. A repeat testosterone2 I0 ~0 ~$ `: d0 _
test was ordered, but the family did not go to the9 e; R: d- x6 V. b% g0 |+ n$ J
laboratory to obtain the test.$ I& v/ e, d( W3 I' @$ [7 c
Discussion. t% C' C% r2 V% X2 F5 s4 f' y: `
Precocious puberty in boys is defined as secondary$ ]2 X; y% }; P8 {1 M* `, D
sexual development before 9 years of age.1,4
" F- A& d2 j2 f1 T2 ^Precocious puberty is termed as central (true) when
, t) h0 u& s5 E# z+ |- Dit is caused by the premature activation of hypo-
' l7 J! K W5 k, e7 |thalamic pituitary gonadal axis. CPP is more com-8 a% W% t) \: ]+ z }4 F* r/ m) U
mon in girls than in boys.1,3 Most boys with CPP
9 M) F7 U5 E' Z& H9 Q: L3 gmay have a central nervous system lesion that is$ P8 w; h, y) z* O% o7 h
responsible for the early activation of the hypothal-( D+ d0 h9 H0 e! H3 i3 k
amic pituitary gonadal axis.1-3 Thus, greater empha-
+ \9 `8 }' }8 u0 Q; n4 j7 {sis has been given to neuroradiologic imaging in1 {9 B0 x; S. a2 j& e
boys with precocious puberty. In addition to viril-
$ J, o/ |$ J# L: s, jization, the clinical hallmark of CPP is the symmet-
' ?) U5 `/ V4 [$ H$ l9 P# Z) z' ~rical testicular growth secondary to stimulation by4 ]* N: c* `7 [/ K0 {& H
gonadotropins.1,3
+ R) T- R p, S( C/ I4 aGonadotropin-independent peripheral preco-6 a: w* Z6 ^5 z/ h- l1 n
cious puberty in boys also results from inappropriate
7 Q4 L/ S) G) f9 Y1 l) U" dandrogenic stimulation from either endogenous or0 x0 d: m8 y* {# V. v4 n4 N
exogenous sources, nonpituitary gonadotropin stim-
, B: ?$ Z2 X! Z; b% _ulation, and rare activating mutations.3 Virilizing0 f1 ]' m+ \6 p$ T
congenital adrenal hyperplasia producing excessive
* T5 h. X' ~; \: K$ Iadrenal androgens is a common cause of precocious
8 k, j3 i/ X/ t5 c0 I% } Vpuberty in boys.3,4
$ _/ P3 O7 c4 z- ~, i9 SThe most common form of congenital adrenal
! q, R/ w) G; M6 D9 Thyperplasia is the 21-hydroxylase enzyme deficiency.
0 @4 r$ c5 _) z( IThe 11-β hydroxylase deficiency may also result in) l& |9 X1 b% E- E p e! ~
excessive adrenal androgen production, and rarely,, L: R' i4 X/ N
an adrenal tumor may also cause adrenal androgen* [1 e& _; S9 [% C
excess.1,3/ T8 D4 [. ^) e% P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 P4 g6 ?# a T& A4 M; Z' o542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ W6 {: [1 u5 j$ B: `2 f7 { G
A unique entity of male-limited gonadotropin-4 G0 j4 P- [( \3 e' E4 |4 k
independent precocious puberty, which is also known/ I4 e. g5 N2 G
as testotoxicosis, may cause precocious puberty at a
' b! x; z# y# N9 b$ C% `3 t4 bvery young age. The physical findings in these boys
& M) J- x& M! X: P, k% n; w8 ^with this disorder are full pubertal development,! E2 L. N# V. E, Q" n" x# h
including bilateral testicular growth, similar to boys) ?6 `% D( N( a
with CPP. The gonadotropin levels in this disorder
1 ~( p8 b( i. ^. K: Y* C7 X9 S+ E3 X- pare suppressed to prepubertal levels and do not show1 V) n* n6 n3 r5 X& }( g: O
pubertal response of gonadotropin after gonadotropin-6 u' g- ]3 K3 X! n
releasing hormone stimulation. This is a sex-linked8 F3 ?1 g0 H$ |# m5 E
autosomal dominant disorder that affects only
! [) z/ |" |" m7 T3 j P: p- omales; therefore, other male members of the family
# \6 T" V0 d- _$ A- y: Tmay have similar precocious puberty.3
7 k# j. Z' h! N7 b( RIn our patient, physical examination was incon-
( J5 ~, B5 L' A3 \; Tsistent with true precocious puberty since his testi-! O& O8 R, Z d: [
cles were prepubertal in size. However, testotoxicosis
+ z* [% r+ T& d- V$ Zwas in the differential diagnosis because his father: U6 q$ C2 Z, N- [+ C# |' S. k
started puberty somewhat early, and occasionally,5 J) _: _4 ?' I7 V
testicular enlargement is not that evident in the( g8 }* o/ ^5 Y1 B: u; X/ p$ w8 W0 y
beginning of this process.1 In the absence of a neg-
2 W% T. v9 x$ X2 V. }ative initial history of androgen exposure, our
4 O; x4 B4 I9 C6 Hbiggest concern was virilizing adrenal hyperplasia,
5 S$ I% |2 R' G$ P8 B5 Feither 21-hydroxylase deficiency or 11-β hydroxylase
4 c) V. Y$ k! bdeficiency. Those diagnoses were excluded by find-
# |( g, T; f. `% }ing the normal level of adrenal steroids.7 s5 j: e) X6 i: v( O* h" o" a
The diagnosis of exogenous androgens was strongly) H. R+ J! \! W2 f6 z4 y; p- I
suspected in a follow-up visit after 4 months because2 |# h; N( Q% v
the physical examination revealed the complete disap-
) T( T! j5 U% j2 b6 B! S5 cpearance of pubic hair, normal growth velocity, and r6 L8 N" j% A& D1 [ z
decreased erections. The father admitted using a testos-
' I4 j& F9 j# Y: B( Aterone gel, which he concealed at first visit. He was
2 }8 I& [) }2 ~" `using it rather frequently, twice a day. The Physicians’
+ ?# O, r* {! f9 ^9 k) r A; HDesk Reference, or package insert of this product, gel or/ n8 Z1 V$ X) }) }% X8 \# P/ p
cream, cautions about dermal testosterone transfer to
1 U9 T! t7 K: h1 R& Z! Cunprotected females through direct skin exposure.
; Z/ i$ |9 m5 B8 k/ s* X! \Serum testosterone level was found to be 2 times the
6 ^3 O h6 K1 G l* Z0 V! j- {$ rbaseline value in those females who were exposed to9 D% C$ j7 N" B/ U* [* Z2 V( P* x
even 15 minutes of direct skin contact with their male6 s2 ^/ O; v( `* Q- }
partners.6 However, when a shirt covered the applica- K# H3 m7 h, v1 g1 C. k% \/ ~
tion site, this testosterone transfer was prevented.; M5 p$ h8 _ t& ?
Our patient’s testosterone level was 60 ng/mL,
6 Y K$ m' m' l) Vwhich was clearly high. Some studies suggest that5 i2 ^. G2 ^, L- p: x# p
dermal conversion of testosterone to dihydrotestos-" u2 J% J9 H7 ^$ |/ e0 l
terone, which is a more potent metabolite, is more# y; Y* T8 F% M9 v; }2 b, o, ^
active in young children exposed to testosterone
& X% E6 k" j( Q+ zexogenously7; however, we did not measure a dihy- _% w: P/ |# v' c
drotestosterone level in our patient. In addition to7 X5 T" I- E/ ]. g! ?+ b
virilization, exposure to exogenous testosterone in! O7 }$ O: p" F) b/ i" J
children results in an increase in growth velocity and
& F! B# t1 X3 e9 J( radvanced bone age, as seen in our patient.' I( \( K$ h& Y! G, V6 P0 B
The long-term effect of androgen exposure during+ m/ ~ {0 C! [1 |- P
early childhood on pubertal development and final
! H; T& y% Y4 f+ i; _adult height are not fully known and always remain
% ^: D8 f1 ~" E6 Y% N- E# H% I! ja concern. Children treated with short-term testos-1 ^: P; B: g5 S" t I8 i- p
terone injection or topical androgen may exhibit some
" O0 W) f0 q6 M sacceleration of the skeletal maturation; however, after
$ L/ j; |6 I! Q1 Jcessation of treatment, the rate of bone maturation
( G/ v+ l! r! w7 D5 {7 A6 x+ ^- idecelerates and gradually returns to normal.8,9
! o7 o! P* d8 C; y, VThere are conflicting reports and controversy1 p, F5 o: X9 g- V Q
over the effect of early androgen exposure on adult
( p' q+ E! f+ R5 I8 |penile length.10,11 Some reports suggest subnormal$ a. n! `! \7 r$ _# e& d6 X
adult penile length, apparently because of downreg-
3 J# r3 O6 m+ k( Z9 M7 v4 V1 b- ]5 Iulation of androgen receptor number.10,12 However, E! r3 L+ [$ I' x- e8 l$ I0 z
Sutherland et al13 did not find a correlation between
$ ?' v* b) v4 S% ]+ nchildhood testosterone exposure and reduced adult
+ a9 l' c: k s. T' [penile length in clinical studies.+ p7 i4 q' i {4 f
Nonetheless, we do not believe our patient is
; H0 c- u9 h; I4 q! |going to experience any of the untoward effects from
m% k0 m$ T- w8 w8 }testosterone exposure as mentioned earlier because$ |4 b' B8 ^3 F% ^1 ?% b: _
the exposure was not for a prolonged period of time.
6 b! [1 D/ K9 n3 Q. KAlthough the bone age was advanced at the time of' U, E, G& J& E, |
diagnosis, the child had a normal growth velocity at
$ g4 v3 G9 w9 C0 S5 D. @the follow-up visit. It is hoped that his final adult
~; w4 B' W+ u: M; G( ?height will not be affected.
& P2 q- p( H3 V/ vAlthough rarely reported, the widespread avail-
; Q5 o2 x1 W5 i9 }( pability of androgen products in our society may+ z- Y+ O4 ]2 w: C
indeed cause more virilization in male or female& `% y" v. l* @% O
children than one would realize. Exposure to andro-
0 J& R1 ]2 m2 V' r. {8 ogen products must be considered and specific ques-* l' n% ~2 X: P1 _6 G5 ^- |# W! ^: m
tioning about the use of a testosterone product or2 E& ~6 {) u2 J2 Z/ h
gel should be asked of the family members during
! q9 e; k* }$ N* v- dthe evaluation of any children who present with vir-# ^9 a1 \+ t" L S
ilization or peripheral precocious puberty. The diag-9 \* J, Z6 M: E. _) E* r
nosis can be established by just a few tests and by
* J, C: z* a& u0 b+ f( ^appropriate history. The inability to obtain such a' g9 H. O' O" K" m0 C9 [0 R
history, or failure to ask the specific questions, may) _3 p& t1 ~$ d8 Z* Q
result in extensive, unnecessary, and expensive
1 k+ X7 C0 s1 g: V9 {investigation. The primary care physician should be
$ I+ s, `' _0 e2 [: C" q* Eaware of this fact, because most of these children
6 D& W O% u; `" d9 X7 @1 B0 O" {+ [3 dmay initially present in their practice. The Physicians’
D* P' H1 Z5 t' p8 ]4 H( J8 J- pDesk Reference and package insert should also put a$ u( A P4 ?! }% _8 T# F U
warning about the virilizing effect on a male or% C8 E h& e. V- u% F
female child who might come in contact with some-3 D4 E: G+ U# C9 R
one using any of these products.
9 v% W2 y0 s2 I7 D$ yReferences) s$ O+ ~5 p3 }
1. Styne DM. The testes: disorder of sexual differentiation
- _7 v3 ~) b6 d3 vand puberty in the male. In: Sperling MA, ed. Pediatric4 D6 f0 O1 [! s
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 p. p4 S1 b" r# j p2002: 565-628.
6 H; }9 F/ A& v2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
9 \. p+ W$ \4 F& Qpuberty in children with tumours of the suprasellar pineal |
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