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Sexual Precocity in a 16-Month-Old
6 `( k3 D* f+ |5 ~1 d! ?9 gBoy Induced by Indirect Topical
4 K! \5 u" k2 M/ L# U. sExposure to Testosterone1 \# O! I' `2 W1 X
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,20 R3 M4 X, w0 G' ~3 L
and Kenneth R. Rettig, MD1
" B7 q; G! U" Z/ \8 A6 Q8 h, c8 DClinical Pediatrics4 y! _( @0 W }! b# M
Volume 46 Number 63 w2 [ L) _) E0 u' v8 m4 c" @
July 2007 540-543
7 `' W: t9 b7 |3 ]3 D" j" d8 r© 2007 Sage Publications
6 V) n+ j3 I5 y$ K; ]10.1177/0009922806296651
; a' O( _1 X+ Ghttp://clp.sagepub.com0 k5 K+ N, B9 a/ h/ |
hosted at( f$ `4 O% i9 N+ I: }! k$ J
http://online.sagepub.com" {0 j9 v8 `6 V; Q4 ^2 G2 \
Precocious puberty in boys, central or peripheral,
4 m2 L. @: x; Zis a significant concern for physicians. Central
5 a4 s p; Y2 j# \ bprecocious puberty (CPP), which is mediated
# F0 w& Z) u4 e# mthrough the hypothalamic pituitary gonadal axis, has
! s' i% K m$ ~" t0 |a higher incidence of organic central nervous system
5 B0 _/ @* c- R" Y3 b, c9 ]$ `lesions in boys.1,2 Virilization in boys, as manifested
' C' o' x# y' y3 \: M0 ~! uby enlargement of the penis, development of pubic
5 I. Q8 Z+ b5 g4 U$ G& h5 [7 \hair, and facial acne without enlargement of testi-
& @) }6 f" g; a) [) |cles, suggests peripheral or pseudopuberty.1-3 We
. D5 j( Q! N+ J+ A7 {1 b1 j6 rreport a 16-month-old boy who presented with the) U6 F6 B& B: H; r$ Z0 H/ b
enlargement of the phallus and pubic hair develop-' T" F; g) ?8 O) p
ment without testicular enlargement, which was due* o# c" q o9 s6 y
to the unintentional exposure to androgen gel used by% [- f( f& l; A6 l
the father. The family initially concealed this infor-
5 G$ A5 d5 B0 lmation, resulting in an extensive work-up for this$ S! p- D. B" u! h# o/ q5 ~7 o
child. Given the widespread and easy availability of
( I' k# D' A O" w( rtestosterone gel and cream, we believe this is proba-9 D( q @* v9 j
bly more common than the rare case report in the
6 v: p$ b$ d: F( hliterature.4
+ y+ @# U: Z( ]7 @. y# v( HPatient Report: G! h$ r# b* q- X0 _
A 16-month-old white child was referred to the6 J5 h6 \- h7 D# y! I- V w+ G" F
endocrine clinic by his pediatrician with the concern
, u1 i" v8 D; e1 sof early sexual development. His mother noticed
7 y' G! c) i; ?; ?' B3 Vlight colored pubic hair development when he was& a: n( Y* g( S- @ U
From the 1Division of Pediatric Endocrinology, 2University of. j3 [& L! G9 j4 W7 n+ m* W0 ?
South Alabama Medical Center, Mobile, Alabama.$ Z# y( q0 K7 }$ S0 _! ~0 C
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 c# }& } T% E9 N7 B( d2 B5 w7 h* qProfessor of Pediatrics, University of South Alabama, College of- K) [( ~8 v7 { @" ]0 T3 { K6 F
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 `- F. X& i D, T( s u) Q6 xe-mail: [email protected].
# j6 z7 W7 I' ]about 6 to 7 months old, which progressively became
! O8 p7 G6 n" }' E7 D7 W4 ?$ R' E, xdarker. She was also concerned about the enlarge-
+ T: R. x% V) L! l: jment of his penis and frequent erections. The child
5 n) r; f5 S0 C# V' Pwas the product of a full-term normal delivery, with
4 u. }3 ?; M! c! @a birth weight of 7 lb 14 oz, and birth length of
) y+ J, Y/ g9 l- r7 ?1 P) b20 inches. He was breast-fed throughout the first year
" n" q: m- t* B4 bof life and was still receiving breast milk along with$ f) N) q4 B% C6 M6 u
solid food. He had no hospitalizations or surgery,
+ T6 B& O9 b( T$ n2 q) ~* V1 Dand his psychosocial and psychomotor development* u! N1 V& ^2 J( H
was age appropriate.
2 C0 }' j# I+ ?1 mThe family history was remarkable for the father,
6 f Y% ]0 J# I! h: k& N. qwho was diagnosed with hypothyroidism at age 16,
" ~/ D* y) Y9 ^2 F3 L1 ywhich was treated with thyroxine. The father’s
# c& Z9 ? m& P% ? }4 P* Sheight was 6 feet, and he went through a somewhat5 h) Q$ g F3 T; F/ L
early puberty and had stopped growing by age 14.$ _& l* K, J! M* b0 x" B+ r" q# }
The father denied taking any other medication. The3 Y7 p3 h% _2 |; w. H3 o
child’s mother was in good health. Her menarche8 \/ [3 L& p. U, ^0 M; h
was at 11 years of age, and her height was at 5 feet) u. g- w" A$ k; k, H P: ?, i
5 inches. There was no other family history of pre-
5 n1 G' Y# N5 y3 bcocious sexual development in the first-degree rela-
4 `- C6 F. A1 q$ jtives. There were no siblings.
5 h* T' E6 i. Q: t3 |" ~ bPhysical Examination
5 b/ Y2 E9 ], O+ dThe physical examination revealed a very active,
" V b; t2 ]+ K3 Yplayful, and healthy boy. The vital signs documented" T n8 H; |, r) s
a blood pressure of 85/50 mm Hg, his length was# L# n# ^8 E( f! M
90 cm (>97th percentile), and his weight was 14.4 kg! j7 ~3 d6 a0 n* D3 P; ^8 A
(also >97th percentile). The observed yearly growth0 u1 h' X5 g, q6 [( B+ x
velocity was 30 cm (12 inches). The examination of
, c% e5 C. K9 {" vthe neck revealed no thyroid enlargement.$ S: f+ G. P2 P9 u$ x
The genitourinary examination was remarkable for
: C5 ~2 H6 V o, a% Xenlargement of the penis, with a stretched length of8 a2 x5 u- c c9 T% `. t
8 cm and a width of 2 cm. The glans penis was very well
1 y9 c1 ]! e; ~( ~% P2 Z5 g8 Tdeveloped. The pubic hair was Tanner II, mostly around% v' g' ]# Q! D5 j# o/ F- p
5402 G5 L9 s7 P7 b0 Y: }! w
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% n# a5 p. o) X7 `1 pthe base of the phallus and was dark and curled. The
/ }; b4 {: n8 m- a' s9 n( Ftesticular volume was prepubertal at 2 mL each.
]9 c# q/ ^5 iThe skin was moist and smooth and somewhat
) {0 L0 A) z! Y: B2 T; O2 loily. No axillary hair was noted. There were no% g' m& {: d2 K) z
abnormal skin pigmentations or café-au-lait spots.
, }' W2 |8 ^- M% Y3 h; hNeurologic evaluation showed deep tendon reflex 2+2 y% N' ]. ^% T# B
bilateral and symmetrical. There was no suggestion
. V4 P6 L1 o# r! Z2 ]4 F0 D( kof papilledema.
8 o9 i2 s! l0 T/ |Laboratory Evaluation
3 n- M( g3 N5 R: M, UThe bone age was consistent with 28 months by9 a) S, O- a5 S5 t- T) j
using the standard of Greulich and Pyle at a chrono-. j9 j! N6 J& @
logic age of 16 months (advanced).5 Chromosomal
, c8 ~5 `8 j2 W4 o3 u- `karyotype was 46XY. The thyroid function test$ x' b# k5 L4 F
showed a free T4 of 1.69 ng/dL, and thyroid stimu-! X9 G) L1 P0 }" r' j) \
lating hormone level was 1.3 µIU/mL (both normal).
% H4 L$ h$ H9 ~The concentrations of serum electrolytes, blood+ P9 w6 _3 A! r# O. c! \- D2 H; ]
urea nitrogen, creatinine, and calcium all were! D. W1 e. z3 B: O" z
within normal range for his age. The concentration
, t) ~7 s1 u1 W( A9 _5 Gof serum 17-hydroxyprogesterone was 16 ng/dL
5 R( ?9 m/ k% w& V(normal, 3 to 90 ng/dL), androstenedione was 20, s% }: j6 c$ l- C& l. `
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( S- }0 S; `/ D6 n$ T: Yterone was 38 ng/dL (normal, 50 to 760 ng/dL),, I# f8 d( y! H7 b: l
desoxycorticosterone was 4.3 ng/dL (normal, 7 to- C: o# g" T$ x Y2 t
49ng/dL), 11-desoxycortisol (specific compound S)
! L G0 R1 u: M- lwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 u& O* x+ C9 f7 j8 j4 N9 h* itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- }( t9 Q9 X$ B$ Ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 A8 f( b2 Z5 [2 dand β-human chorionic gonadotropin was less than
5 m; p8 `: O% Y) ~+ F) p o5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 i6 t2 Y+ t' r, F; L: E! v0 o8 Cstimulating hormone and leuteinizing hormone
5 ?6 C8 g* X2 N4 Sconcentrations were less than 0.05 mIU/mL
+ A6 s4 p, _+ E, `& z( Q7 X(prepubertal).7 ]* J& D, l0 z4 X( f; [2 i: h0 ^
The parents were notified about the laboratory
}) c/ H2 l, f- [results and were informed that all of the tests were, L$ h+ {5 \% S3 h& A8 c0 _
normal except the testosterone level was high. The
7 K: G. r5 m( F# S/ r0 Mfollow-up visit was arranged within a few weeks to
% v5 C6 ~8 f* W0 R1 {6 Aobtain testicular and abdominal sonograms; how-3 g# C6 S" \' k4 V# K! V
ever, the family did not return for 4 months.
6 J7 L6 o l' u! ~+ yPhysical examination at this time revealed that the% {4 J" K" K5 U3 w# G
child had grown 2.5 cm in 4 months and had gained
: a: O0 h' C4 m& }% i* n& W, Z2 kg of weight. Physical examination remained
; |- g0 k9 S9 @$ G; o$ {- p' r0 Funchanged. Surprisingly, the pubic hair almost com-, x/ n+ @5 o- [% ?4 H. r8 }# {( \
pletely disappeared except for a few vellous hairs at4 }6 ~+ m& W) m
the base of the phallus. Testicular volume was still 2
0 t* v( u; }4 k" t& W! [- V# y8 CmL, and the size of the penis remained unchanged.2 m# Y1 c" e* c5 i( [7 p b: t
The mother also said that the boy was no longer hav-0 B: J, O4 e2 {, `: V4 `" }' E
ing frequent erections.' G$ o- p# J: B% J
Both parents were again questioned about use of1 x1 q0 m: v6 X& I( s
any ointment/creams that they may have applied to
2 B/ g8 D' E5 g9 q4 U' U; F5 Sthe child’s skin. This time the father admitted the! B0 t& B, O# y+ ], }
Topical Testosterone Exposure / Bhowmick et al 541, U. X9 k$ E3 q' W5 b/ l1 O
use of testosterone gel twice daily that he was apply-
( w! U! u5 W8 n* Ying over his own shoulders, chest, and back area for
5 S) b. r j- k- L: T8 Ra year. The father also revealed he was embarrassed) f3 S Y4 {9 {: w; a& |4 D+ g" `
to disclose that he was using a testosterone gel pre-
n+ s0 S6 `6 Y; b2 m2 h5 H$ escribed by his family physician for decreased libido
* H8 ^6 @, v; Q$ Tsecondary to depression." Z, B( _! Y; E. ?0 g! Q
The child slept in the same bed with parents.
. Q+ B$ N+ h p! {: _4 n3 a% gThe father would hug the baby and hold him on his8 h/ j0 h1 C: x3 z
chest for a considerable period of time, causing sig-
, t# {, ?# G0 h' X( z+ P7 r0 Nnificant bare skin contact between baby and father.( y. v+ E+ O7 b& }4 J Y
The father also admitted that after the phone call,8 J& M6 T; P+ \! g* S
when he learned the testosterone level in the baby J. y, b& O! b4 g, H8 O! ^" e
was high, he then read the product information' ^9 W; _, a+ A- q/ w
packet and concluded that it was most likely the rea-
" z6 K4 X( _+ H: H+ y5 oson for the child’s virilization. At that time, they
C5 N: O2 k5 i" P# E: z) pdecided to put the baby in a separate bed, and the
9 y' q7 K" o' m& |8 ?' [7 ufather was not hugging him with bare skin and had
! D. n9 D) c$ V7 c- g& dbeen using protective clothing. A repeat testosterone2 X7 q) _/ k/ f
test was ordered, but the family did not go to the% E0 @6 N, l+ P9 k q7 ]
laboratory to obtain the test.
* v: c) S; j/ JDiscussion
/ O9 h; v9 O/ E5 d6 U VPrecocious puberty in boys is defined as secondary
, S2 D. x2 G$ h) c% @ x% [" wsexual development before 9 years of age.1,4" J& I* y, L# i/ \6 \ O% N
Precocious puberty is termed as central (true) when
8 ^$ X# I8 K7 A; J/ k2 ^; G4 _( N8 qit is caused by the premature activation of hypo-" e1 A6 G$ h+ _3 {6 t- m5 J# b
thalamic pituitary gonadal axis. CPP is more com-& J' E2 [6 A) S& A
mon in girls than in boys.1,3 Most boys with CPP
$ _ J; p1 G1 @9 c, Xmay have a central nervous system lesion that is
, y4 `1 i! V9 mresponsible for the early activation of the hypothal-
) g5 {! v# e3 Z! A# I' _6 g* x) |( Aamic pituitary gonadal axis.1-3 Thus, greater empha-
. Z/ P: ?- i2 r" E+ Dsis has been given to neuroradiologic imaging in
+ i. y; {6 z$ N/ i* |: V( gboys with precocious puberty. In addition to viril-
/ E4 ^+ k: P. U+ ^1 `* rization, the clinical hallmark of CPP is the symmet-3 r5 a7 Y- R# m4 |, B$ y# X
rical testicular growth secondary to stimulation by
8 W; Y8 p8 y: ]7 M6 Z9 d4 ^gonadotropins.1,3
% D! V8 h: n) v9 x* t( y, p/ _) nGonadotropin-independent peripheral preco-
& G8 }( m# v) A1 xcious puberty in boys also results from inappropriate/ s5 z* @& z6 o
androgenic stimulation from either endogenous or
+ @( C7 @3 l1 c1 k9 \3 Oexogenous sources, nonpituitary gonadotropin stim-
; [/ j- V+ O6 t) M' m) L" x6 j- lulation, and rare activating mutations.3 Virilizing- B: L: L/ P+ I9 B, d A4 P$ y+ ^2 E
congenital adrenal hyperplasia producing excessive: a2 _" ^! p6 @4 O( q! H
adrenal androgens is a common cause of precocious4 a# i3 H( y6 }; Y' v. Q& v
puberty in boys.3,4
( Q% T. C/ f& ^2 RThe most common form of congenital adrenal
/ ^' t$ S, v# ahyperplasia is the 21-hydroxylase enzyme deficiency.' \% Y( ]" v$ Q. O$ p
The 11-β hydroxylase deficiency may also result in3 F4 s5 n2 u: I5 W1 w! s, c' j
excessive adrenal androgen production, and rarely,
. E+ H! U; f5 Dan adrenal tumor may also cause adrenal androgen
9 b; r4 m! N, ]# o9 [5 X6 Kexcess.1,36 g$ a4 C8 [9 u0 S4 E0 W7 w. u, K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 k/ P4 {" E' y7 w+ m
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* D. K2 y1 V& o: e3 c5 F: E; v; @A unique entity of male-limited gonadotropin-
9 }( A1 _9 \. mindependent precocious puberty, which is also known
& i/ ~" s/ t$ s5 V% H/ Xas testotoxicosis, may cause precocious puberty at a6 v L% O( n& ^, B" p6 a. ]
very young age. The physical findings in these boys
9 l: K4 i* |* ~with this disorder are full pubertal development,
) ?7 k# y; U& Nincluding bilateral testicular growth, similar to boys
4 i( `8 e9 Z) C" G7 Y# h1 ~- D7 ywith CPP. The gonadotropin levels in this disorder
9 F" z* W; M0 w$ ^are suppressed to prepubertal levels and do not show& r, F7 i& X! p" O5 L: l2 I, F
pubertal response of gonadotropin after gonadotropin-
% T8 B7 I6 ?9 `0 S9 ereleasing hormone stimulation. This is a sex-linked
) B! v4 D3 t" v3 |* Pautosomal dominant disorder that affects only
" X ^! G0 C+ ]' h6 umales; therefore, other male members of the family
- Y6 l+ r9 @8 h# u$ G0 zmay have similar precocious puberty.3' B% |4 [) w( s
In our patient, physical examination was incon-# e. I! Y* ^- X0 u4 W7 [
sistent with true precocious puberty since his testi-7 z- I) E0 D1 q5 O. A, y
cles were prepubertal in size. However, testotoxicosis
1 {3 U, X% C1 B4 U1 |% {- T# R8 Gwas in the differential diagnosis because his father9 n* z- D, c/ [! L; w, n5 o& v
started puberty somewhat early, and occasionally,0 G+ R5 k5 D: f, C
testicular enlargement is not that evident in the4 O4 }9 r: \" b4 i% F
beginning of this process.1 In the absence of a neg-
) e; P, L( R# g& \" V# Vative initial history of androgen exposure, our- S9 g: D" z; y: w2 N' N1 _+ C% P
biggest concern was virilizing adrenal hyperplasia,# K$ f" u, ^ A. X6 [3 a
either 21-hydroxylase deficiency or 11-β hydroxylase4 l4 m% f; @* N: |
deficiency. Those diagnoses were excluded by find-8 ?! U9 I$ V, K) {4 N& B5 ^5 s
ing the normal level of adrenal steroids./ G2 B6 u6 m& o! c
The diagnosis of exogenous androgens was strongly
" ]" Q! C, N# F: ?$ ^$ K9 ]suspected in a follow-up visit after 4 months because c7 q- P- ~0 H) i$ h7 K
the physical examination revealed the complete disap-
0 b. X7 e0 a: R7 J, A3 q( V5 Lpearance of pubic hair, normal growth velocity, and
: m- `2 U$ b' q4 ]decreased erections. The father admitted using a testos-
4 k! [! q5 J4 iterone gel, which he concealed at first visit. He was+ f+ H _2 [3 Y. j1 q" ~
using it rather frequently, twice a day. The Physicians’
5 u i* D- x9 I. @Desk Reference, or package insert of this product, gel or
6 R4 Z# `. f# a% m. ^5 J wcream, cautions about dermal testosterone transfer to; B4 Q, b( D& g
unprotected females through direct skin exposure.% G: d. @4 C- ]4 D8 m p
Serum testosterone level was found to be 2 times the. L5 ^) j9 M, e% ~
baseline value in those females who were exposed to
6 @' z) H: Q7 |' J8 F) Keven 15 minutes of direct skin contact with their male
0 r( y( t" r9 \" |* kpartners.6 However, when a shirt covered the applica-: o) f8 F9 W7 s9 O
tion site, this testosterone transfer was prevented.3 C6 U; ?2 Q4 F
Our patient’s testosterone level was 60 ng/mL,6 d. C) o) h: F( ` y# U/ V$ P; R
which was clearly high. Some studies suggest that
" [. Y" g" g/ A5 zdermal conversion of testosterone to dihydrotestos-: n: f0 O2 _9 Q- b2 K
terone, which is a more potent metabolite, is more/ n* m( ]! {" \# m6 P
active in young children exposed to testosterone' W& F. v3 ~$ V( q1 B, }
exogenously7; however, we did not measure a dihy-
: s4 y9 z9 z# fdrotestosterone level in our patient. In addition to
1 t% `! o( b4 L8 o1 E2 L/ T6 P# fvirilization, exposure to exogenous testosterone in& V8 }+ }6 L. l4 C" l
children results in an increase in growth velocity and
, q! R _1 c6 a4 k/ M. ?% \advanced bone age, as seen in our patient.$ _6 P; T$ e# v7 o# @& _
The long-term effect of androgen exposure during& T+ I7 H( P+ {- F6 x
early childhood on pubertal development and final
# [; j% W, Y9 v2 _, Wadult height are not fully known and always remain! [7 o ?6 f* t( j
a concern. Children treated with short-term testos-
8 L6 l7 G) b$ _5 U, Y6 ~7 bterone injection or topical androgen may exhibit some
+ d( ]1 Y" t, p4 v( v1 v( ~acceleration of the skeletal maturation; however, after
" T& N8 A. O/ X, |- qcessation of treatment, the rate of bone maturation
8 j Y5 m, j6 i+ R8 gdecelerates and gradually returns to normal.8,94 ?5 a! x: G( h
There are conflicting reports and controversy3 N) n# s5 b# w; P: B
over the effect of early androgen exposure on adult
/ F5 A$ p) C; l$ d+ a4 _penile length.10,11 Some reports suggest subnormal6 ~, j5 E% Y, r& o
adult penile length, apparently because of downreg-
^* v. U& i7 g8 g# o* |2 rulation of androgen receptor number.10,12 However,4 p2 u; u0 \) ^$ ?, A/ K* u
Sutherland et al13 did not find a correlation between( D `6 f+ _! _
childhood testosterone exposure and reduced adult5 I* y, A* a- F/ S
penile length in clinical studies.. {5 Q6 a! v# U! Q3 Z6 p6 G: F, U+ ~
Nonetheless, we do not believe our patient is8 @- x/ c; Y M" n7 k/ R1 m
going to experience any of the untoward effects from/ y6 d4 R9 {! a) E7 R& G- t
testosterone exposure as mentioned earlier because
% V' x9 U9 m* a* Fthe exposure was not for a prolonged period of time.) A; y- G4 I' t) f9 m
Although the bone age was advanced at the time of
: P) `6 O' u1 ]- Jdiagnosis, the child had a normal growth velocity at
% y; V# ~! `5 s, Dthe follow-up visit. It is hoped that his final adult
2 ~# S1 v9 K' c) v5 L: Pheight will not be affected.9 X' s3 i3 E: n
Although rarely reported, the widespread avail-" l: `8 C4 x8 O/ o6 o
ability of androgen products in our society may) f* f. o4 _: M4 U. }
indeed cause more virilization in male or female( D# d# F' A% R2 f9 [
children than one would realize. Exposure to andro-5 g: y6 ]3 T* `; l
gen products must be considered and specific ques-0 K6 A) |' _( M% c! \4 l
tioning about the use of a testosterone product or0 U* _: \# e1 F0 @0 d
gel should be asked of the family members during
) w4 H9 |2 w% p0 [the evaluation of any children who present with vir-4 d. c- }( Q5 r/ I6 o: N( B
ilization or peripheral precocious puberty. The diag-
5 s; q" U3 T" a4 o2 `. q! y* anosis can be established by just a few tests and by7 y7 w* U3 I: U& X( k& z+ I$ V
appropriate history. The inability to obtain such a2 F( d, V' O, m* A& J/ I
history, or failure to ask the specific questions, may
! c: n# |$ G; R+ e) d3 g! [' Tresult in extensive, unnecessary, and expensive( s, m% @6 X; N/ l
investigation. The primary care physician should be
D5 l& S% ^+ w8 f6 zaware of this fact, because most of these children# Y- a0 |0 Y( E, W/ L
may initially present in their practice. The Physicians’
( G7 c+ V) i+ y' F1 K+ sDesk Reference and package insert should also put a4 e4 D4 `1 A) N/ |6 B* I. a
warning about the virilizing effect on a male or
% y; i( Y# Z* W: g {! zfemale child who might come in contact with some-
( c+ r# f7 P7 K& W2 Kone using any of these products.* w. C/ _& G7 D }' Z2 |$ T
References, H& {4 @1 }1 e( f! I
1. Styne DM. The testes: disorder of sexual differentiation
/ v" C9 O$ a7 X$ `" I' Vand puberty in the male. In: Sperling MA, ed. Pediatric
) V' K, L8 J2 a( mEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 f. i& M& M: y2002: 565-628.$ ~! |: r' G2 |' j& n- L- D& a
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ \5 ?: [$ k5 f% Epuberty in children with tumours of the suprasellar pineal |
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