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Sexual Precocity in a 16-Month-Old
. ]3 m- h3 n8 ]4 k3 G6 X( S$ dBoy Induced by Indirect Topical( g2 y$ o2 M4 m' a; o. | b/ \, i
Exposure to Testosterone9 z, S6 {+ B B8 x. x# f
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2% E7 [1 P9 l1 C* ^! R% u+ d$ Y
and Kenneth R. Rettig, MD1
R% t- ]" T4 mClinical Pediatrics; l. p+ ]6 m& a8 l9 E9 v
Volume 46 Number 6
o/ {8 w/ Q2 U7 o# N+ t0 g8 OJuly 2007 540-543
1 m6 R4 J/ `6 r© 2007 Sage Publications4 d8 [& j9 e: p# s( s+ x
10.1177/0009922806296651
5 D: H' |; N3 N1 ahttp://clp.sagepub.com2 z' Z# {3 y) z
hosted at
' Q$ n! ~' o. p- l( |& Ahttp://online.sagepub.com' V- X. J4 x/ R9 u# a
Precocious puberty in boys, central or peripheral,9 k5 u3 [! A) N9 |2 [7 b& j& Z
is a significant concern for physicians. Central0 s7 H9 ]* m4 E, x, |$ q$ p9 A8 h
precocious puberty (CPP), which is mediated
8 W6 w& c# X4 S7 x' F- t! B2 n$ Ithrough the hypothalamic pituitary gonadal axis, has
) ], S, a5 W( U& Ma higher incidence of organic central nervous system
$ t( A( W' _ Y; [& ~2 F5 g6 a& q4 xlesions in boys.1,2 Virilization in boys, as manifested
& N* m8 O/ M6 pby enlargement of the penis, development of pubic
1 N: z4 [% v7 C7 f+ A: {$ Dhair, and facial acne without enlargement of testi-9 r* H d$ x7 P) k9 o
cles, suggests peripheral or pseudopuberty.1-3 We
' L! E& ]+ k; t( G* ` G+ Q7 Ureport a 16-month-old boy who presented with the+ P# @0 J% _7 T: e
enlargement of the phallus and pubic hair develop-1 n& ^/ D% Z X2 G0 o, M, V
ment without testicular enlargement, which was due% C/ r" L" U4 ^+ M
to the unintentional exposure to androgen gel used by/ j/ \- x$ g# u' p% o/ I( N
the father. The family initially concealed this infor-- ` t2 J1 y1 r# Z( i; \. j
mation, resulting in an extensive work-up for this
5 F% n+ p6 L2 a* ?: R/ Cchild. Given the widespread and easy availability of
) h. x' M) t, x! ~8 xtestosterone gel and cream, we believe this is proba-
: Z/ {7 K- c% w" wbly more common than the rare case report in the
. j& U! T9 z9 N- ~+ p# i- N: sliterature.4+ e& G/ G' S) ]) @! h5 j2 `
Patient Report
1 o7 a9 U; V# n% QA 16-month-old white child was referred to the; n6 `% V6 L7 t8 }
endocrine clinic by his pediatrician with the concern
, X& F/ r6 s% W# V- Y% {of early sexual development. His mother noticed* K( `3 f# j x5 x6 ~
light colored pubic hair development when he was
4 |; P4 |( d* f1 s4 w2 J0 _/ qFrom the 1Division of Pediatric Endocrinology, 2University of4 T8 g m* L* m" z$ V- E3 \
South Alabama Medical Center, Mobile, Alabama.
3 _5 K8 W w7 M: X9 O7 zAddress correspondence to: Samar K. Bhowmick, MD, FACE,
; H& @/ o- J' n6 C9 G! `% W1 _Professor of Pediatrics, University of South Alabama, College of( Q# n- j4 W# x
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 J3 i- `9 p7 [2 R1 T/ C) |
e-mail: [email protected].
( N6 t% [& f0 S# c" Vabout 6 to 7 months old, which progressively became
6 D T/ E0 V0 [$ L# u4 Zdarker. She was also concerned about the enlarge-# C: Y5 m% \" E( v- u$ n- V
ment of his penis and frequent erections. The child
. X# e6 @, X d$ @8 Swas the product of a full-term normal delivery, with. S8 C3 t8 ?& v, X1 ?. U
a birth weight of 7 lb 14 oz, and birth length of
; z4 t( T$ v" @: k" o20 inches. He was breast-fed throughout the first year$ i9 M' F7 U! j" ]
of life and was still receiving breast milk along with
$ A" d0 k5 }! y8 H" Zsolid food. He had no hospitalizations or surgery,
6 k: e* Y. ^3 `and his psychosocial and psychomotor development, G) }9 a* c o. p" n2 \
was age appropriate.
- Z' V! t7 L) f5 y* M3 R* j2 VThe family history was remarkable for the father,
3 |% [/ P1 m& S8 q+ X' T9 B. Twho was diagnosed with hypothyroidism at age 16,
& I2 S; k% Q: A* v! w! s$ Twhich was treated with thyroxine. The father’s" M5 U" G4 b# ]/ D' P+ R& g
height was 6 feet, and he went through a somewhat
5 S! M& ]+ I1 h' S3 H6 J) W7 d* Bearly puberty and had stopped growing by age 14.
# ~7 l7 ]3 c; P% ]# ?! p) a; e, KThe father denied taking any other medication. The- q9 b) X. D) l9 }, w: Q$ I, \
child’s mother was in good health. Her menarche# a& [7 G Z* U! w
was at 11 years of age, and her height was at 5 feet
% P4 [* ^+ T: {8 T5 inches. There was no other family history of pre-: _- }% i; z) v( {
cocious sexual development in the first-degree rela-
2 a. S2 @& y3 N% X) K3 ztives. There were no siblings.
$ F/ Q# ^% }" o: q7 P; n9 ^% CPhysical Examination9 v4 K' n6 _( N! `$ M
The physical examination revealed a very active,
4 j) n0 T! U; d3 o3 K0 r; m* rplayful, and healthy boy. The vital signs documented
; X! i0 E3 O+ Ja blood pressure of 85/50 mm Hg, his length was! m, U2 D! T1 T4 {% L
90 cm (>97th percentile), and his weight was 14.4 kg
4 H6 e' n J* p8 [* p% G(also >97th percentile). The observed yearly growth0 j/ o1 n5 e; P1 |+ a4 @: f
velocity was 30 cm (12 inches). The examination of! I0 w7 w, a' o* v, ?; l, t2 ?
the neck revealed no thyroid enlargement.
* q+ N8 u7 @- M, x) ~The genitourinary examination was remarkable for
, z2 W* G0 M' m! j$ aenlargement of the penis, with a stretched length of
+ F& T# V7 d7 S- C5 N1 C& V8 cm and a width of 2 cm. The glans penis was very well
6 [. u8 I8 M) N9 \4 vdeveloped. The pubic hair was Tanner II, mostly around
# _' M" t, W9 ~5400 B' x' P$ }8 m1 ~" h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
m$ E! }! I' f% T+ R; T$ I" {the base of the phallus and was dark and curled. The
$ A6 n Z+ C5 z u; u5 ], ytesticular volume was prepubertal at 2 mL each.
& x# Z! `" K+ l1 k9 HThe skin was moist and smooth and somewhat
, ?, H n7 x. ^& F9 k7 Woily. No axillary hair was noted. There were no O& Q. L! M" v: p) I+ X8 L9 j
abnormal skin pigmentations or café-au-lait spots.' d8 f7 a# h$ F# u
Neurologic evaluation showed deep tendon reflex 2+4 b$ m" s' C0 d1 x- y3 [8 X
bilateral and symmetrical. There was no suggestion1 x/ ^$ _" V. U' f) H6 [
of papilledema.9 e% [1 [3 N$ E; m$ Q+ u5 p/ }
Laboratory Evaluation. @% L" F* W# j: F
The bone age was consistent with 28 months by
; ~+ |8 Z1 m( ^7 q Z" G2 susing the standard of Greulich and Pyle at a chrono-! w) H) {( A6 t1 @2 M2 L
logic age of 16 months (advanced).5 Chromosomal
% e5 q- M9 B3 G U6 ~' k4 Ekaryotype was 46XY. The thyroid function test
2 O4 ~8 S- `0 J7 D+ j8 _# l, gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 t6 F- K5 ^$ l* N. Jlating hormone level was 1.3 µIU/mL (both normal).6 D# t' ^' f: a7 O ~$ Q2 D
The concentrations of serum electrolytes, blood* L& A# {% o- ?2 w
urea nitrogen, creatinine, and calcium all were: D9 z" a9 N1 F7 F2 ]
within normal range for his age. The concentration
- }2 {( s H2 O2 N& [1 S: W7 qof serum 17-hydroxyprogesterone was 16 ng/dL
2 a3 {! H; B& r4 X: b7 ^(normal, 3 to 90 ng/dL), androstenedione was 20
& E. w. B. V) }, Sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; Q+ m7 M5 k, M0 ]. \terone was 38 ng/dL (normal, 50 to 760 ng/dL),
# L6 Q! ]* p+ q+ X* Zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to' F0 h; B1 e6 L4 ?0 G0 {
49ng/dL), 11-desoxycortisol (specific compound S)
3 y/ b# l! u4 ~" r* Hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-0 W% A- Y2 e+ `% \4 @% K: E
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 d+ S T: O0 O0 V; p0 `testosterone was 60 ng/dL (normal <3 to 10 ng/dL),2 ]. F! e; N; ? E2 x3 g9 c
and β-human chorionic gonadotropin was less than" T" V4 ?' v6 E7 N* Q- R8 l
5 mIU/mL (normal <5 mIU/mL). Serum follicular$ i% ?4 C7 @# X( a
stimulating hormone and leuteinizing hormone
" `; a4 C4 ^& w, }. [' v( P9 Jconcentrations were less than 0.05 mIU/mL$ ?1 m. i. V" e8 V, O* m
(prepubertal).
' J3 q( V/ d& a# c, M/ oThe parents were notified about the laboratory4 u5 w/ T/ B; U' z0 k m$ y
results and were informed that all of the tests were
( G0 V* C4 U! J" X v6 Qnormal except the testosterone level was high. The
8 U6 F4 y+ N: d% h0 Z7 G6 wfollow-up visit was arranged within a few weeks to- D* o/ n3 L. K% |
obtain testicular and abdominal sonograms; how-
' o9 k: ~0 t: u L8 X8 j; k7 f* jever, the family did not return for 4 months.! ^$ A. o' t" s5 Q7 B
Physical examination at this time revealed that the
+ h. @1 v3 [- R E8 Jchild had grown 2.5 cm in 4 months and had gained
' \/ q( I: K# ~' P' E8 A$ s; T2 kg of weight. Physical examination remained+ z* [7 i/ b9 N& p2 m0 s4 b9 Y! Z. ?
unchanged. Surprisingly, the pubic hair almost com-% D$ M* X7 Y. Y9 j5 C
pletely disappeared except for a few vellous hairs at g- K' k- G; S9 R3 J. _4 r3 H* |/ V
the base of the phallus. Testicular volume was still 2
[! N: `6 k' L4 @mL, and the size of the penis remained unchanged.) {/ J. {6 d6 z( j Q! O
The mother also said that the boy was no longer hav-6 R# u' S; N$ }7 h2 N1 D* M
ing frequent erections.
( A4 v6 `# v1 ~' e& z E& rBoth parents were again questioned about use of
9 e6 E, }/ K5 e7 C! J/ `% Many ointment/creams that they may have applied to; g5 H }. A G; T# X7 i4 S2 B8 _
the child’s skin. This time the father admitted the, ~9 ~# m) S4 u- {$ V% I8 l! n- g
Topical Testosterone Exposure / Bhowmick et al 541 a; V- ? ^/ y
use of testosterone gel twice daily that he was apply-
; ~3 c7 n T7 `ing over his own shoulders, chest, and back area for- u; b2 f1 U) ?* @7 W8 c9 ^ o7 M4 b
a year. The father also revealed he was embarrassed
F. {2 [5 k# c0 o( Nto disclose that he was using a testosterone gel pre-( w5 x* b; z& `7 x+ G
scribed by his family physician for decreased libido
1 Y3 H# ?8 r) ?: i5 Esecondary to depression.5 J% s; y( A, a( }# \- t: }
The child slept in the same bed with parents.
9 p, Z. b9 S0 I, |% P( EThe father would hug the baby and hold him on his
0 Z0 M8 z3 O8 A7 j; S* Pchest for a considerable period of time, causing sig-
+ a {4 X; |- k4 v, B/ V& Hnificant bare skin contact between baby and father. f& \6 g! V/ N& c6 K% ~
The father also admitted that after the phone call,
3 l& Y! w% D M- }$ n, vwhen he learned the testosterone level in the baby
$ U' l) F* |; G3 cwas high, he then read the product information
) _- O2 s% ]" x- Y# N, E: \packet and concluded that it was most likely the rea-
( u. d! d* @% g7 ~* {+ e& ?& fson for the child’s virilization. At that time, they0 ]" V9 s3 r. X- `8 R
decided to put the baby in a separate bed, and the( M5 B- U, u0 Y+ w! S9 ~, o
father was not hugging him with bare skin and had
1 `7 e6 A' V6 L6 F! q h' Xbeen using protective clothing. A repeat testosterone0 c& y3 P. a. }: H
test was ordered, but the family did not go to the
( g% M; P& W$ U9 n2 Alaboratory to obtain the test.3 b3 ?# o& e Z) O! {8 q* D. |
Discussion! h. r/ a% Y8 T6 L* L( ~
Precocious puberty in boys is defined as secondary( R+ i. c" \1 \! Z1 E
sexual development before 9 years of age.1,4( [, r4 f( L7 a/ i
Precocious puberty is termed as central (true) when; ?$ Z7 Y- W% P4 e, [5 X, P* V
it is caused by the premature activation of hypo-
6 g! E8 U7 E* x8 |- _8 b, f0 Dthalamic pituitary gonadal axis. CPP is more com-$ H$ H4 c# m( Y3 E
mon in girls than in boys.1,3 Most boys with CPP3 {/ e5 B: z* o% c; s ]* R% R
may have a central nervous system lesion that is9 W5 G4 b9 k5 N" V2 [7 g# V
responsible for the early activation of the hypothal-
) Q+ V5 N6 g3 P+ _0 F+ F0 e! tamic pituitary gonadal axis.1-3 Thus, greater empha-
& m6 Q; ]# q0 V' Z* O Y8 jsis has been given to neuroradiologic imaging in# J* O) p. { B
boys with precocious puberty. In addition to viril-
( n5 g) ~7 ?) g: g; R. uization, the clinical hallmark of CPP is the symmet-4 y3 u8 k0 R1 _9 S; m- k _
rical testicular growth secondary to stimulation by+ l' A+ K" \3 k: ^
gonadotropins.1,37 {% m5 W8 Z N. X. _
Gonadotropin-independent peripheral preco-7 E, D4 y( c, E& o' K; c( j5 _
cious puberty in boys also results from inappropriate
2 X! s2 S/ u' f; J( p% p- F/ L. iandrogenic stimulation from either endogenous or) y2 c8 V$ W+ h6 R, M) A$ N/ M
exogenous sources, nonpituitary gonadotropin stim-
) G- S6 {- B6 V2 m9 S2 C, W$ wulation, and rare activating mutations.3 Virilizing
2 v+ }! ^- x8 ]( H, B) ]4 h, ]$ i. wcongenital adrenal hyperplasia producing excessive
! l1 L4 Y7 i2 v3 Xadrenal androgens is a common cause of precocious. t9 J* C0 v+ ~- ~7 s
puberty in boys.3,44 T q1 J( m' r5 C0 b1 g
The most common form of congenital adrenal$ l% M" B, B2 P1 z' v
hyperplasia is the 21-hydroxylase enzyme deficiency.
4 y' W5 f( z: J: A1 |The 11-β hydroxylase deficiency may also result in
# ]& m( u" q) {! d" X& \3 Z) |% s! }excessive adrenal androgen production, and rarely,* } H) i. H/ Q0 N
an adrenal tumor may also cause adrenal androgen- J: }* y0 ~6 i" {
excess.1,3
" e( |" u" q$ |! K. d) P) y5 yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" g3 x: p1 Q5 A2 i3 P
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! p% f3 P% z- @; b
A unique entity of male-limited gonadotropin-, _5 E- t, ?# c& |
independent precocious puberty, which is also known
$ x. o) L( _" p6 gas testotoxicosis, may cause precocious puberty at a, \: W9 ^( A' Z. a
very young age. The physical findings in these boys7 z2 X5 T# k- I( m5 s% E
with this disorder are full pubertal development,9 k4 v" p0 h" M$ ?
including bilateral testicular growth, similar to boys6 g# z2 F9 B- W/ U! [$ R
with CPP. The gonadotropin levels in this disorder
4 G z1 X _" D+ z$ Lare suppressed to prepubertal levels and do not show
+ u+ D5 ?" {, Apubertal response of gonadotropin after gonadotropin-3 M" F8 C/ N: J0 D
releasing hormone stimulation. This is a sex-linked4 O, Z' e( v3 [5 G
autosomal dominant disorder that affects only9 e3 V2 ^* L* b8 j9 @
males; therefore, other male members of the family) T; |% L+ }' R
may have similar precocious puberty.3
- ?6 B1 z& R" ^5 XIn our patient, physical examination was incon-
( @7 f& G4 c7 x. B |( qsistent with true precocious puberty since his testi-
- V* ^+ n7 x# G8 X. }cles were prepubertal in size. However, testotoxicosis' X0 }9 Y! v* k2 f4 m, Q5 f
was in the differential diagnosis because his father
) U; T8 K9 d2 ~7 ?2 ~started puberty somewhat early, and occasionally,
* w6 ?" t8 q* f/ gtesticular enlargement is not that evident in the
# ~0 F: O4 f% w( p2 Ubeginning of this process.1 In the absence of a neg-& z8 z9 m/ \/ w: r+ ^( y
ative initial history of androgen exposure, our
' ~2 _- j7 {% hbiggest concern was virilizing adrenal hyperplasia,
) [6 S8 N# Z. \either 21-hydroxylase deficiency or 11-β hydroxylase
% [* Q# ^$ U# l5 o$ _ B: Pdeficiency. Those diagnoses were excluded by find-. t: L& p4 R' v Q4 z. h# x. b
ing the normal level of adrenal steroids.
$ x. P/ Q( O: X3 m( H: ~+ [' o# xThe diagnosis of exogenous androgens was strongly1 T% W4 a( U! H' f, j+ O, f* N! V
suspected in a follow-up visit after 4 months because7 Y8 M- k% }) |9 T
the physical examination revealed the complete disap-
4 y9 g \/ K- L @6 fpearance of pubic hair, normal growth velocity, and
6 m* p, X: h6 }8 \7 h l7 ndecreased erections. The father admitted using a testos-; u! A4 l1 x# R1 U% ~2 j8 _$ z
terone gel, which he concealed at first visit. He was; _2 t& _5 K, y6 \( |
using it rather frequently, twice a day. The Physicians’
: l8 W3 n0 _: m, \# S% `* ~! H. ADesk Reference, or package insert of this product, gel or4 s" P1 p/ a6 `. p" g6 O, e; H
cream, cautions about dermal testosterone transfer to
0 z) H- L* z' S6 N. V/ F1 sunprotected females through direct skin exposure.9 U% J# @+ ^' n
Serum testosterone level was found to be 2 times the
% o3 D; [, y# V9 ubaseline value in those females who were exposed to3 L' K, W' h: G, H+ R4 Z3 P( q
even 15 minutes of direct skin contact with their male
6 C* k' {# [( lpartners.6 However, when a shirt covered the applica-( i4 M" T% Z* \4 s9 v( D
tion site, this testosterone transfer was prevented.8 M0 b6 Z& L1 \5 _- H9 w% h
Our patient’s testosterone level was 60 ng/mL,
; Y, \0 f9 y; Q& {which was clearly high. Some studies suggest that
( G( k4 h+ s) l fdermal conversion of testosterone to dihydrotestos-- ^/ J1 }" X% C0 f
terone, which is a more potent metabolite, is more
. u% X; t7 f4 t+ J0 s2 dactive in young children exposed to testosterone; D7 ^) b' }2 n0 w+ a0 u
exogenously7; however, we did not measure a dihy-1 m9 S3 g' n. z7 Y8 P0 q( w
drotestosterone level in our patient. In addition to) ^5 Y; t7 o$ m, K. y9 Y q0 L
virilization, exposure to exogenous testosterone in' q4 s+ ]/ `; N/ Q# c$ x
children results in an increase in growth velocity and
0 N5 k. u$ m8 E/ h( n2 F% O) ?advanced bone age, as seen in our patient.3 w y8 P; E8 o& F8 c# n6 u
The long-term effect of androgen exposure during y6 f/ r( R/ v* d9 z
early childhood on pubertal development and final
6 g0 y0 p8 K& w% [9 Vadult height are not fully known and always remain4 d& S/ [8 Y: p F" ^
a concern. Children treated with short-term testos-
, E; R" y1 A; ~3 ~6 a" h. cterone injection or topical androgen may exhibit some# v3 u6 P; l% |0 |1 }+ D; f
acceleration of the skeletal maturation; however, after
8 ~- ?2 g/ ]' E0 d" z8 Jcessation of treatment, the rate of bone maturation6 T0 z; b9 @6 `3 F3 n! T3 P F' U
decelerates and gradually returns to normal.8,9+ y/ X+ a( K# a+ T% S) \
There are conflicting reports and controversy" T. m6 ~8 Y1 {, l( d
over the effect of early androgen exposure on adult: x0 U3 x! W( s' |( T5 k5 i
penile length.10,11 Some reports suggest subnormal# D, A+ `# c& `
adult penile length, apparently because of downreg-
( Y! i2 r5 k+ O1 d1 z6 y! eulation of androgen receptor number.10,12 However,
z! J) ]6 H$ h. H+ @Sutherland et al13 did not find a correlation between" ~) M3 ]' l; |
childhood testosterone exposure and reduced adult F0 T: j! b9 T1 |' C
penile length in clinical studies.
5 M. Q; x6 j u5 y* s$ e8 }; `Nonetheless, we do not believe our patient is: v/ E- p& T3 y- J4 |- c! {) H
going to experience any of the untoward effects from$ L [8 l Z5 {1 L; e: g6 |
testosterone exposure as mentioned earlier because
* ^- W u" Y* v/ _: Wthe exposure was not for a prolonged period of time.
3 j( g8 j2 Q3 ?" ^Although the bone age was advanced at the time of! t3 Z8 t! [$ {) g' @
diagnosis, the child had a normal growth velocity at' R9 e/ s+ W# p
the follow-up visit. It is hoped that his final adult
4 m4 w, w% v! S; D2 ?3 ^height will not be affected.( `$ `/ m2 W) e- v! z7 }
Although rarely reported, the widespread avail-# l" q) i0 o9 i1 m% i" |) g2 f
ability of androgen products in our society may
2 ?: i. T+ D7 W1 d1 y+ _ hindeed cause more virilization in male or female; b9 T3 b- A$ h3 U- R
children than one would realize. Exposure to andro-
7 q+ W) G% G/ K9 C U( z2 ]gen products must be considered and specific ques-
^/ a4 o* V6 F1 @, Utioning about the use of a testosterone product or
0 o1 K2 Q* n, {& b0 jgel should be asked of the family members during! x3 s3 e" p/ g6 D$ z' B
the evaluation of any children who present with vir-4 y8 l9 A2 N, ^, `4 Q. o! H" F
ilization or peripheral precocious puberty. The diag-$ a W4 {# L0 K: t# p* ]% U
nosis can be established by just a few tests and by
& f% E8 z9 f% B- W# K) t* Nappropriate history. The inability to obtain such a& v+ h9 s6 @0 P+ j
history, or failure to ask the specific questions, may0 t, w7 J3 J3 F! w2 m
result in extensive, unnecessary, and expensive6 Q7 M" r3 H0 S( o+ G$ C7 B
investigation. The primary care physician should be
3 r& J2 A. b& ?& E% X# A, D3 oaware of this fact, because most of these children$ T( d! O, E0 b6 K% [
may initially present in their practice. The Physicians’5 w5 @& u* H$ S U3 \6 M
Desk Reference and package insert should also put a- [' E- U! \# g1 I: a4 a' S$ s: p8 g
warning about the virilizing effect on a male or3 U' T) E3 B$ P: b) i& m* R1 F- f( |' S
female child who might come in contact with some-
; Z9 c7 I, r( l2 N$ {0 gone using any of these products.- W0 i4 [$ {2 I, U3 Q8 x) p" V
References
4 L4 c4 J v$ r2 B" Q* Z6 @1. Styne DM. The testes: disorder of sexual differentiation
6 |7 M7 r, ^ T5 T: W- f' K" tand puberty in the male. In: Sperling MA, ed. Pediatric
2 o: X8 u t2 e3 S/ ]Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;# t) w% e' q1 O+ w; r! H
2002: 565-628.
3 F: b/ C9 V/ o- k2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% U/ [: r$ g3 o3 O' X }puberty in children with tumours of the suprasellar pineal |
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