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Sexual Precocity in a 16-Month-Old
5 c' d7 J" E# M+ p( H9 sBoy Induced by Indirect Topical
2 j- F! {% X: t+ m! \6 g' a- Y9 zExposure to Testosterone
6 G0 B: g3 _& h: R: O. rSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- T7 S7 ^! p6 i: mand Kenneth R. Rettig, MD1
1 D" d* [" b& B) b' ~0 W H4 p7 dClinical Pediatrics
* m2 W2 t4 o( p) I% ^$ oVolume 46 Number 6
: \. t1 V% O; m8 TJuly 2007 540-543' p+ K! C- v: E. a% K
© 2007 Sage Publications
7 _* s* g% H" O z6 Z! |10.1177/0009922806296651+ x8 w" I, b% S
http://clp.sagepub.com, c0 O, A, ]' n) Z% w3 [" m: U$ l) ]
hosted at: X# }8 i" {# k$ A& z' s6 V* v
http://online.sagepub.com- p; ~& x% C1 F0 J- {1 y
Precocious puberty in boys, central or peripheral,
- f9 P* P. e8 D ^( ^is a significant concern for physicians. Central
4 L1 w2 P& u, R: C- oprecocious puberty (CPP), which is mediated3 C6 m: m7 Z; _' d+ Y
through the hypothalamic pituitary gonadal axis, has
" g+ G) e& c6 _a higher incidence of organic central nervous system# ]. @$ Y8 M: \; B, j r
lesions in boys.1,2 Virilization in boys, as manifested
9 w0 t3 F P6 ?( \2 Qby enlargement of the penis, development of pubic. L# J K: ~$ `' H" a
hair, and facial acne without enlargement of testi-2 T! c0 w4 I" F/ B3 ^* p$ ^
cles, suggests peripheral or pseudopuberty.1-3 We" a0 O& ]" M) t# d) X8 v& P
report a 16-month-old boy who presented with the
( ^- g+ L1 ~7 E% ]- D8 Genlargement of the phallus and pubic hair develop-
$ y8 J x+ h: f" x8 a( |. gment without testicular enlargement, which was due$ x9 J6 k+ V) ]* F4 n; m9 Q5 h
to the unintentional exposure to androgen gel used by
, U5 A l# Q& N+ K( B$ q9 W2 uthe father. The family initially concealed this infor-5 P5 e4 E3 Y4 M4 `; F
mation, resulting in an extensive work-up for this. t2 H: g) {& N1 A8 i2 w
child. Given the widespread and easy availability of& P4 N, O, [4 e* y" y d! o
testosterone gel and cream, we believe this is proba-1 X1 J3 o4 i6 ~7 ~0 ^
bly more common than the rare case report in the, k1 E, {+ b" S8 a2 I6 e+ w- [1 X# X8 `
literature.44 j9 w' M4 B- J- a3 s
Patient Report
7 | |( s# @6 Z. \5 q' P% h( x% DA 16-month-old white child was referred to the
! `( H) q0 ~! x% N2 i0 z" F1 A2 aendocrine clinic by his pediatrician with the concern0 B# j, j* A) `1 k5 }2 ?
of early sexual development. His mother noticed
- M: u# M2 B7 G9 K, }light colored pubic hair development when he was" f0 b6 o" F+ G9 E9 q. A0 n
From the 1Division of Pediatric Endocrinology, 2University of
; e3 x& g5 H# `South Alabama Medical Center, Mobile, Alabama.
' S# Z) E; p) J# U yAddress correspondence to: Samar K. Bhowmick, MD, FACE,, L3 Y9 M2 W& R3 `( O: g+ q
Professor of Pediatrics, University of South Alabama, College of5 Q( y! X, s4 h( U9 ?- i6 u
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* h) e1 W: Q) M
e-mail: [email protected].
# r. ], i' @( Gabout 6 to 7 months old, which progressively became t+ H- w4 m0 g9 _
darker. She was also concerned about the enlarge-
6 j% C" s( N8 }# f$ }ment of his penis and frequent erections. The child
# Y/ f' o5 l5 I; E: N, S& Qwas the product of a full-term normal delivery, with a7 T7 s' u+ n% l8 ^; ^
a birth weight of 7 lb 14 oz, and birth length of% _9 n9 r4 X8 [2 o# _4 W$ h
20 inches. He was breast-fed throughout the first year# w3 K+ r$ Q5 p* T+ a$ t2 m& h7 J
of life and was still receiving breast milk along with& I* J: F" C+ `& n* d z& m+ I" w, \
solid food. He had no hospitalizations or surgery,4 n' E# }5 V2 Z. a# [! b' W/ A
and his psychosocial and psychomotor development& Y" P7 O% f1 p# l- |/ O' P
was age appropriate.1 i8 X2 ^/ W% W7 w2 Q; ]1 z5 C+ R
The family history was remarkable for the father,# E# e" s5 e, e9 J* z9 ?6 \
who was diagnosed with hypothyroidism at age 16,
; H0 Z" b( ?9 y" r$ Vwhich was treated with thyroxine. The father’s1 u3 N; g+ R% U# }
height was 6 feet, and he went through a somewhat
( `6 z! t) O4 s; a7 K, Gearly puberty and had stopped growing by age 14.' P' k1 q v+ G4 P: X
The father denied taking any other medication. The
- A7 V, b" X* schild’s mother was in good health. Her menarche) e! |; r' L$ }; f$ `
was at 11 years of age, and her height was at 5 feet# @* w. F* k4 g$ n ~% B" l0 K( B% H7 X
5 inches. There was no other family history of pre-
, N+ v* d( S# ?: ^( Y; Vcocious sexual development in the first-degree rela-
' A! R; ^+ p* h8 T f. Qtives. There were no siblings.
, I2 j W2 \+ h4 k. `9 y NPhysical Examination) S# o# H" s$ Z4 D1 o3 Z% P+ g
The physical examination revealed a very active,3 k7 f* M( k" I( ~' p# ^; r) a
playful, and healthy boy. The vital signs documented
6 m) D7 K( d& ~8 `2 Ia blood pressure of 85/50 mm Hg, his length was
. Y9 d, P, U- \1 P/ p! z90 cm (>97th percentile), and his weight was 14.4 kg" K, T; _0 L6 k. X$ P
(also >97th percentile). The observed yearly growth
6 b( U' B$ i5 s6 u! M% M. p# avelocity was 30 cm (12 inches). The examination of- k* [6 z& `% j! {7 [' Y8 k2 x
the neck revealed no thyroid enlargement.4 U! _7 g, W4 s& Y
The genitourinary examination was remarkable for% e- x/ ^, s, Q! t
enlargement of the penis, with a stretched length of
0 M! ], y, X7 l5 u9 k: ~8 cm and a width of 2 cm. The glans penis was very well* y* x* S' m" B' P" f: n2 s1 {
developed. The pubic hair was Tanner II, mostly around: ?% d3 I) ~% \
540
0 j' y+ \% J; b9 Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 X! X: t! K8 T! x0 ]* Ythe base of the phallus and was dark and curled. The" Q8 Q+ W1 S' }+ | w* L
testicular volume was prepubertal at 2 mL each.
* t! H! G# L% |4 ^The skin was moist and smooth and somewhat6 a5 L$ ?& u2 z8 E! s
oily. No axillary hair was noted. There were no; t6 W+ O5 @& m: J! A$ z7 C
abnormal skin pigmentations or café-au-lait spots.
0 B5 D5 L% x7 A8 h, E( wNeurologic evaluation showed deep tendon reflex 2+
' Z9 w* b) l* U3 x* U( Ybilateral and symmetrical. There was no suggestion
$ c) Y( d$ q( Sof papilledema.8 K* g9 _" G" g# Z5 R
Laboratory Evaluation$ b2 V- l* Z; I0 \6 o) x) x
The bone age was consistent with 28 months by$ z1 S. K& N8 s3 M
using the standard of Greulich and Pyle at a chrono-( t. r8 ~* T% O* p
logic age of 16 months (advanced).5 Chromosomal! f% J$ w, c J
karyotype was 46XY. The thyroid function test
: O( D4 `2 z2 r3 x7 a1 V" {showed a free T4 of 1.69 ng/dL, and thyroid stimu-$ {# {4 R6 n2 X( |7 z, r
lating hormone level was 1.3 µIU/mL (both normal).
, T8 d" v0 W/ @9 K. Y( bThe concentrations of serum electrolytes, blood
* G7 |. `2 f. j& n" d# Wurea nitrogen, creatinine, and calcium all were* y" T. ^* C# E2 K3 p
within normal range for his age. The concentration
3 u8 k4 d3 c1 g% u5 ~% w: J3 Zof serum 17-hydroxyprogesterone was 16 ng/dL' [6 k. a) w+ p- s. k6 e: N
(normal, 3 to 90 ng/dL), androstenedione was 20
# B, D( i* k' C# l8 N% f6 wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ y- h3 w, U& O4 M" ^terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 q- Z0 U% l; d& @desoxycorticosterone was 4.3 ng/dL (normal, 7 to" B: i0 u/ t, u
49ng/dL), 11-desoxycortisol (specific compound S)8 O( k! l* D- d% t* i8 \
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 y: s4 N$ y6 k0 A. A2 i6 O" T7 i* P" N
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 m5 [+ l" P& E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 Y3 B G. u' T; v
and β-human chorionic gonadotropin was less than
' ~1 p/ U0 M; g3 J& F5 mIU/mL (normal <5 mIU/mL). Serum follicular
1 B% l# H" u- ^, T0 bstimulating hormone and leuteinizing hormone2 T: v* q1 X, `
concentrations were less than 0.05 mIU/mL. l' n5 L$ n' `0 n$ v+ T9 x5 D5 L
(prepubertal).
! ?6 f9 P0 R3 V7 l' \The parents were notified about the laboratory3 A/ |0 T& K( k5 g5 E8 l" ?
results and were informed that all of the tests were
5 R6 Z- ]2 w `/ G* Knormal except the testosterone level was high. The
5 o/ _5 ]1 f U1 o" a. v Y& Efollow-up visit was arranged within a few weeks to1 P2 ]4 g7 T8 P% j. M& w& }' r; A
obtain testicular and abdominal sonograms; how-
9 [! k7 I4 L, G7 }ever, the family did not return for 4 months.1 i! {6 b+ Q) x) S" l
Physical examination at this time revealed that the( T" t: N F2 o) r9 Q3 a/ }4 x* s
child had grown 2.5 cm in 4 months and had gained7 \: z l& D* ~9 p o
2 kg of weight. Physical examination remained
/ o* l( s/ W" m0 J3 c! Wunchanged. Surprisingly, the pubic hair almost com-
3 Z- [% F- m" `( y& apletely disappeared except for a few vellous hairs at
3 ]8 p% m5 S1 o) K' o# U2 Ethe base of the phallus. Testicular volume was still 2
3 I" n5 M k( y8 t$ amL, and the size of the penis remained unchanged.- T& }/ P% n8 I
The mother also said that the boy was no longer hav-) \1 J! a! Z( q7 k$ B
ing frequent erections.
6 K' m# \0 f+ S8 o, c Y% V& `Both parents were again questioned about use of6 M! `/ X- S9 f3 ^6 e1 A6 N
any ointment/creams that they may have applied to% n! o; B: s6 k. q. P) v+ g2 i
the child’s skin. This time the father admitted the- C. `& x% |& Q- ]" W
Topical Testosterone Exposure / Bhowmick et al 541
4 L' h- H; E3 u4 y( T* Yuse of testosterone gel twice daily that he was apply-
( X/ |9 e# N" [* @' Y/ q4 ^; _9 y2 E* ming over his own shoulders, chest, and back area for
8 @/ I% W0 A$ j! o4 r% c. r1 za year. The father also revealed he was embarrassed! f+ x$ @' O0 l
to disclose that he was using a testosterone gel pre-' b+ i5 H3 c( F- S' Q% J
scribed by his family physician for decreased libido
& Y' f' Y; `. I c. |2 ?. isecondary to depression.
5 c2 c. f% f H" h8 I' s2 ?The child slept in the same bed with parents.
4 c. \5 g' |/ l( @) ~- K! R- aThe father would hug the baby and hold him on his
: z* P, @7 _ q# a$ `chest for a considerable period of time, causing sig-
/ U3 N# i) r' |; ?! }* dnificant bare skin contact between baby and father.
8 i% q4 }$ n% |0 n* @The father also admitted that after the phone call,1 k( @* r- ]8 h3 ^
when he learned the testosterone level in the baby' @8 O1 [% K$ y0 ^0 r3 b
was high, he then read the product information
5 J' A3 V; E; e4 n% O8 U/ ^packet and concluded that it was most likely the rea-0 v7 T- j$ ^( K3 o# B. T
son for the child’s virilization. At that time, they. E8 s7 O9 a$ B" c
decided to put the baby in a separate bed, and the
+ n4 n+ J( E/ s" y8 z" tfather was not hugging him with bare skin and had4 g) y+ \0 m3 o, h8 \9 M6 U
been using protective clothing. A repeat testosterone& m* [8 B* G# l& T; v
test was ordered, but the family did not go to the; @! W( j0 \5 @, v: r
laboratory to obtain the test.
3 D; b3 L2 @ _" F2 e( UDiscussion; O; _0 P3 L Y, I7 f) F& t7 Y
Precocious puberty in boys is defined as secondary
& H$ h( w4 `/ [& s7 G4 bsexual development before 9 years of age.1,4- S9 a' O3 p4 W. k, W
Precocious puberty is termed as central (true) when
- D+ S( L# o. w7 q5 x2 o. t0 a4 X; zit is caused by the premature activation of hypo-
4 M" K" F w9 K, p& @thalamic pituitary gonadal axis. CPP is more com-
9 `/ N) z3 Z7 n/ l! k# Vmon in girls than in boys.1,3 Most boys with CPP7 A! i! Z& B0 Y6 T/ _" I% |
may have a central nervous system lesion that is
6 i3 c" p& {; R% X7 Y: Nresponsible for the early activation of the hypothal-
1 {8 q3 ^" e" }* t* T9 pamic pituitary gonadal axis.1-3 Thus, greater empha-8 B) _- f0 F; D0 j
sis has been given to neuroradiologic imaging in
+ l8 D1 J6 \& u; h0 }% _, ~- wboys with precocious puberty. In addition to viril-% l- q3 A% l. b9 E2 J) `9 x
ization, the clinical hallmark of CPP is the symmet-
4 ~) f* t$ ?! Q1 G' Orical testicular growth secondary to stimulation by- q' S3 V5 |, H: m
gonadotropins.1,3( y. Q6 M v6 D6 f
Gonadotropin-independent peripheral preco-. U1 E3 T3 g2 n2 _
cious puberty in boys also results from inappropriate) K9 U7 j5 ]+ t& T( R
androgenic stimulation from either endogenous or
3 A$ F _. @+ ]2 I- o7 X2 ?exogenous sources, nonpituitary gonadotropin stim-
0 u; y( ]+ ]$ r6 N9 S) |5 N4 j, Dulation, and rare activating mutations.3 Virilizing. w+ p! R: L: h9 B
congenital adrenal hyperplasia producing excessive
1 ]# R% O6 S- i4 @) O# Tadrenal androgens is a common cause of precocious, n. \" A3 i. i# t
puberty in boys.3,4
! r# J4 m W7 `- W% T0 `The most common form of congenital adrenal
9 y. K8 e9 F' D! z5 N; ?; {- [hyperplasia is the 21-hydroxylase enzyme deficiency.
# N, ]9 N* S# oThe 11-β hydroxylase deficiency may also result in; d& l' _! j5 c4 ]
excessive adrenal androgen production, and rarely,
0 O9 o3 D+ g J$ o/ tan adrenal tumor may also cause adrenal androgen9 b5 \- y8 d" p( a# w }
excess.1,3/ ]. Z% S$ M; ?* K* E/ y, s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
# Y' a* M8 {/ T" T$ S542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 y5 z8 I0 B) Z, JA unique entity of male-limited gonadotropin-
v5 _" _9 X3 f. `independent precocious puberty, which is also known
5 F8 @' j' J( D( c) q+ t- Qas testotoxicosis, may cause precocious puberty at a7 A; C" g/ M2 q& e5 h: L I
very young age. The physical findings in these boys0 \* v) e7 f' a
with this disorder are full pubertal development,
! C% i W5 Q8 @) p3 F! Rincluding bilateral testicular growth, similar to boys
- X: @4 C. b: X/ i) l' }$ u9 {+ G9 Nwith CPP. The gonadotropin levels in this disorder' s% P0 y5 S2 Z4 A
are suppressed to prepubertal levels and do not show! W% G, n( L V# F
pubertal response of gonadotropin after gonadotropin-
6 L! G7 Q$ L% p+ Q4 Hreleasing hormone stimulation. This is a sex-linked
$ W) S$ Z3 V7 f: ?" ]autosomal dominant disorder that affects only
R$ l* f& Q, mmales; therefore, other male members of the family
3 Z L+ ~% C: m1 Imay have similar precocious puberty.3( F& U* [# C( B- s
In our patient, physical examination was incon-
# l1 E) K* O, O2 K0 e1 v- asistent with true precocious puberty since his testi-
# b# S2 F1 e6 @: B) m5 v. Pcles were prepubertal in size. However, testotoxicosis4 m( _0 w! J8 v1 F2 \4 E
was in the differential diagnosis because his father
1 K1 y+ w( i. }started puberty somewhat early, and occasionally,
: c" L, w% k2 D% I- Ftesticular enlargement is not that evident in the+ c) J4 X. E8 }9 s
beginning of this process.1 In the absence of a neg-
0 L, ~2 a5 ?6 l' Qative initial history of androgen exposure, our. l9 g% ^* s- k& l
biggest concern was virilizing adrenal hyperplasia,
/ {9 f+ U K$ f" v- feither 21-hydroxylase deficiency or 11-β hydroxylase% G' t+ T* I( Q8 j
deficiency. Those diagnoses were excluded by find-2 H$ S; e) z# ~. w2 N4 P0 H+ z5 q
ing the normal level of adrenal steroids.6 ?. U1 ]9 J! x5 e+ I" {
The diagnosis of exogenous androgens was strongly% ^* b/ l2 ^% F0 P5 s: i" X
suspected in a follow-up visit after 4 months because
* y- @2 m: ~6 V7 h3 s2 i4 d4 i* v- Xthe physical examination revealed the complete disap-
3 U4 J' H8 o7 }1 k2 ?5 Ppearance of pubic hair, normal growth velocity, and7 `* O* F5 V5 h7 J6 s B
decreased erections. The father admitted using a testos-
( K; V( M3 |! Hterone gel, which he concealed at first visit. He was
/ w& R) w! X: e4 cusing it rather frequently, twice a day. The Physicians’
$ B; m# J! v4 A- o8 tDesk Reference, or package insert of this product, gel or
8 X$ `6 i- ~+ l. hcream, cautions about dermal testosterone transfer to% W+ t+ c0 j+ D7 v F
unprotected females through direct skin exposure.! A# ^# h/ Z. U4 V8 b, h' W! Z& @% F
Serum testosterone level was found to be 2 times the* `5 Y3 [" l v1 }! l
baseline value in those females who were exposed to# t% {. l" B1 b+ Z% i3 K5 `- i
even 15 minutes of direct skin contact with their male. R% `2 y$ k2 x
partners.6 However, when a shirt covered the applica-
# E" J! v4 ~, ^2 w4 X1 ption site, this testosterone transfer was prevented.
' K) [4 `. g# W- {' @0 k8 f' ?Our patient’s testosterone level was 60 ng/mL,* Q4 {3 V) v' }; D6 \' o9 C
which was clearly high. Some studies suggest that: M7 R' U& t s
dermal conversion of testosterone to dihydrotestos-8 G7 x' H8 ?, p# @( d+ I/ r. o
terone, which is a more potent metabolite, is more
" n! `" X: x& J) P. factive in young children exposed to testosterone
* z0 n7 ]& W! e e9 Sexogenously7; however, we did not measure a dihy-
, r/ \& Y' v/ \' R+ O2 y Cdrotestosterone level in our patient. In addition to
# l8 u3 n S4 R$ i5 lvirilization, exposure to exogenous testosterone in
, X, s0 b3 d% k1 M" _4 ichildren results in an increase in growth velocity and
# W) D9 T f: p; x6 Iadvanced bone age, as seen in our patient.
+ Y7 A9 k$ y6 r3 QThe long-term effect of androgen exposure during
( b- q6 J( ]6 |5 oearly childhood on pubertal development and final( p, {1 ~4 Z o+ \! [3 _
adult height are not fully known and always remain
$ S8 I C: n: z: \7 N Da concern. Children treated with short-term testos-8 Q* z' w( Z( R
terone injection or topical androgen may exhibit some
" v$ y. O( b2 S' V5 X1 r5 Gacceleration of the skeletal maturation; however, after1 I% ~1 S: s( G* e4 t* M" l
cessation of treatment, the rate of bone maturation
# \* q' [7 a: d" l# a% Udecelerates and gradually returns to normal.8,9
. x. k7 R! p" K+ e6 ~There are conflicting reports and controversy" k, W/ l5 e& x* N+ y$ V- T
over the effect of early androgen exposure on adult) r2 J! y4 g% K! i5 f. U) j O
penile length.10,11 Some reports suggest subnormal
3 M+ p6 S0 W9 s7 ^( Z- R' xadult penile length, apparently because of downreg-
1 x, r, h" F0 f+ v% }ulation of androgen receptor number.10,12 However,1 H" h9 }6 q$ q C. R2 S ]7 J; w
Sutherland et al13 did not find a correlation between
# M2 R2 j5 v3 ]9 k3 G" j0 Schildhood testosterone exposure and reduced adult3 d q8 @: G6 H, c* m; B
penile length in clinical studies.
* O% k* Y3 B1 z' e1 A- P; GNonetheless, we do not believe our patient is
3 R$ F$ v7 Z& L) |. z8 i% w% Ngoing to experience any of the untoward effects from- K1 p% S& g5 N# { Y$ h
testosterone exposure as mentioned earlier because
- k8 t5 V1 U( F* rthe exposure was not for a prolonged period of time.! D+ d. h, q- ]) _- q e+ ^3 m Y9 N
Although the bone age was advanced at the time of
+ e Z( p; o8 @diagnosis, the child had a normal growth velocity at0 E3 X) j! r' S' o( y
the follow-up visit. It is hoped that his final adult
8 h# K: U8 l$ ~3 cheight will not be affected.
; i# X& i! _' z# K0 X/ eAlthough rarely reported, the widespread avail-0 V; O! P* ~3 n. n
ability of androgen products in our society may
$ l- `3 d# U E. H$ ^indeed cause more virilization in male or female) e! q! P) ?# _( r
children than one would realize. Exposure to andro-
/ s. S$ Q3 F7 t% V/ u0 \7 G% L) ^/ [gen products must be considered and specific ques-
1 P! ?0 n- D$ E. |& etioning about the use of a testosterone product or* U( m0 }( b: i# K5 A( B# ]' ?! D
gel should be asked of the family members during
3 A" e% \: E( ?& o6 a! N; e5 Qthe evaluation of any children who present with vir-
5 \# G& @( m/ b* v" f& W( |1 Dilization or peripheral precocious puberty. The diag-
8 P. ^4 Q1 B! g& r% b) A8 Nnosis can be established by just a few tests and by
7 W$ ]- V# w) X$ T0 p" Sappropriate history. The inability to obtain such a- A, O% s0 }; Y6 _1 }- J2 v
history, or failure to ask the specific questions, may$ t3 ^2 N3 Q7 a: A0 W# o
result in extensive, unnecessary, and expensive
7 G! B5 J: Q1 Y! d9 g) |investigation. The primary care physician should be
. h0 e" O* Z) L8 i2 d* }aware of this fact, because most of these children
( d9 m2 e: c+ n; vmay initially present in their practice. The Physicians’1 O' k3 M1 N" _9 [- C; ~
Desk Reference and package insert should also put a
% S2 U9 G0 t) Lwarning about the virilizing effect on a male or, U0 @6 a+ l; {3 R7 F4 R" r
female child who might come in contact with some-
1 c/ r* J4 v9 O, pone using any of these products.% l) W* ]6 c, ]( Z0 {, E4 Z& h# D
References+ c- g( Q; D% O2 D3 C# F1 `" W
1. Styne DM. The testes: disorder of sexual differentiation
$ H Y9 U" a# o3 _and puberty in the male. In: Sperling MA, ed. Pediatric5 Y/ O0 g4 X1 q# D
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
# X4 ?' V0 O$ ^9 R. l2002: 565-628.
+ S$ V5 c& }5 I! b7 X- d; {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& i, K2 h6 w* c7 v1 S1 cpuberty in children with tumours of the suprasellar pineal |
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