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Sexual Precocity in a 16-Month-Old9 {/ p2 s+ K8 Z9 [/ S+ v3 ?) L
Boy Induced by Indirect Topical
2 ~7 d, r% S. m- mExposure to Testosterone2 \$ A1 E9 i0 h4 B& y0 M2 S
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 t5 a3 _1 u' P1 Q) Xand Kenneth R. Rettig, MD1
4 B( M1 f' S* l3 g9 B4 }Clinical Pediatrics
! _: L" @) D1 J- D* J) RVolume 46 Number 6
% L" r6 O9 I4 W4 ]- y& g9 Y3 HJuly 2007 540-543
0 V- g0 ~4 z( f. M/ @8 N© 2007 Sage Publications
$ k9 v2 p% c! b' c10.1177/0009922806296651
4 e" n# ?5 P5 w Z$ Q' b6 Vhttp://clp.sagepub.com: Q/ m# o/ }1 o- I1 D; P
hosted at
+ \1 h' M! }/ e- lhttp://online.sagepub.com
6 b" ? Z9 b0 ~; ]4 `! dPrecocious puberty in boys, central or peripheral,: y5 ]7 S! g4 i# d5 l5 X2 R
is a significant concern for physicians. Central/ I$ J' U! _4 |1 d0 X2 M
precocious puberty (CPP), which is mediated
& h; F# x+ P# w/ r% Gthrough the hypothalamic pituitary gonadal axis, has! Z. G* ~# q3 Y
a higher incidence of organic central nervous system- y+ C! e# u" s9 u3 b e) B
lesions in boys.1,2 Virilization in boys, as manifested
6 c8 y7 i9 R# A3 k: qby enlargement of the penis, development of pubic, V! [& Q5 Z2 C! K7 c' r" K
hair, and facial acne without enlargement of testi-
* x- u3 p) U! D3 a( s* }cles, suggests peripheral or pseudopuberty.1-3 We
" L T I8 @: B6 @: O9 yreport a 16-month-old boy who presented with the
7 @. ~( t% Z+ Z0 o& I, Penlargement of the phallus and pubic hair develop-& G8 `. o4 a3 Y! j" l& p" C
ment without testicular enlargement, which was due7 A# [. i: r- ^7 O% `$ ]( V
to the unintentional exposure to androgen gel used by( a4 g5 x, Y: b
the father. The family initially concealed this infor-
, a% F8 Y7 L b4 o% {mation, resulting in an extensive work-up for this& r, {3 ]! ]2 @" O
child. Given the widespread and easy availability of5 B+ q1 s% E: ^% F( B! i9 ~6 B
testosterone gel and cream, we believe this is proba-# I' C @/ i! ~7 {$ _) x
bly more common than the rare case report in the1 q! t2 V4 b% I& ?; ^
literature.4
+ U( }9 ~$ V! pPatient Report
5 s5 ^& v4 E7 U9 K+ f4 x" @A 16-month-old white child was referred to the9 b2 k6 D s4 K
endocrine clinic by his pediatrician with the concern9 }0 W% a$ @ v) R: d: b' q
of early sexual development. His mother noticed
0 }% A; W; I1 {: y- F1 U" ]* B6 Elight colored pubic hair development when he was
& B0 Z1 \9 D+ F" i/ p) ` m' QFrom the 1Division of Pediatric Endocrinology, 2University of
" G1 W9 B& `+ ?& s! \South Alabama Medical Center, Mobile, Alabama.- e1 u3 X+ N. b' t; D
Address correspondence to: Samar K. Bhowmick, MD, FACE,
* _" S' Q1 ?+ D+ v& N( PProfessor of Pediatrics, University of South Alabama, College of3 O* J7 {# L; p
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# ~; H- z9 @& u4 ^
e-mail: [email protected].
& r; t @: a/ jabout 6 to 7 months old, which progressively became
# q0 p3 _$ |4 q) Y& h! Bdarker. She was also concerned about the enlarge-
4 ^8 a7 j, p9 tment of his penis and frequent erections. The child- p7 K3 n# f* l
was the product of a full-term normal delivery, with5 u8 X% q w; f6 f* }) @3 h1 M
a birth weight of 7 lb 14 oz, and birth length of2 l+ x( ?2 x; t7 M
20 inches. He was breast-fed throughout the first year
: P. H7 y$ Y n* l" x$ l& ?% Wof life and was still receiving breast milk along with
: v$ P6 e/ O3 O5 qsolid food. He had no hospitalizations or surgery,4 S$ A2 r7 V! a
and his psychosocial and psychomotor development8 o F- q {/ R3 f. A: ~
was age appropriate.8 d' o/ e: {2 Q% Y4 F, o# Y
The family history was remarkable for the father,' i3 i! t. M% i
who was diagnosed with hypothyroidism at age 16,$ I2 c! J) o( |
which was treated with thyroxine. The father’s: K" v( t. x" G7 ?
height was 6 feet, and he went through a somewhat+ O7 r8 i- _# i4 O$ H* `
early puberty and had stopped growing by age 14.8 m5 @7 h1 a& F" N* r; `0 a# K9 L
The father denied taking any other medication. The) D" P8 l/ j. c u5 i
child’s mother was in good health. Her menarche
; U; s! Y! W* a, A5 m$ W6 kwas at 11 years of age, and her height was at 5 feet
% K. e7 K8 z! K3 n% ?5 inches. There was no other family history of pre-8 x9 \/ M& _, i; c
cocious sexual development in the first-degree rela-. c5 L& h5 U% n+ a* T
tives. There were no siblings.
4 s8 M- k: j4 JPhysical Examination
9 P0 U& X6 F) D6 QThe physical examination revealed a very active," a& f7 V4 v% @7 p* X5 q+ r/ N
playful, and healthy boy. The vital signs documented8 k/ G m1 J' a
a blood pressure of 85/50 mm Hg, his length was f/ r! o0 T, o- ?+ U; o
90 cm (>97th percentile), and his weight was 14.4 kg
; f5 |, r6 G' d% p2 O(also >97th percentile). The observed yearly growth
: Z' `2 A# `4 J" g5 l! V$ Pvelocity was 30 cm (12 inches). The examination of
2 Z( \8 ]" ^) {. V& l3 hthe neck revealed no thyroid enlargement.
5 O$ P2 c9 D5 y5 L+ Y% c5 w5 H( D5 P3 MThe genitourinary examination was remarkable for
7 {) w5 c# l2 l' c0 G% E1 denlargement of the penis, with a stretched length of
) r4 U( K5 b' H3 }, s! @% ?8 v- Z V8 cm and a width of 2 cm. The glans penis was very well
0 B ?; I! U5 t: {, X! I5 ]developed. The pubic hair was Tanner II, mostly around8 L. U" \' x6 U# `
5404 m" j2 L+ `3 o1 P- x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' W; l, y1 N& w# Q
the base of the phallus and was dark and curled. The& T3 c/ k: e) ^4 \
testicular volume was prepubertal at 2 mL each.
# o; ` b. [2 s0 lThe skin was moist and smooth and somewhat2 z8 H% f: |# Y* L3 m7 h0 C
oily. No axillary hair was noted. There were no' R) F; W+ w6 K6 S3 m
abnormal skin pigmentations or café-au-lait spots.4 M! _2 f8 E I' H
Neurologic evaluation showed deep tendon reflex 2+
' p Y; L/ S P) t) ^0 O+ r' [bilateral and symmetrical. There was no suggestion# S) u! |% b- v C" B, h
of papilledema.( H/ S8 |2 q* W! a7 R
Laboratory Evaluation
% l: ~) J6 T9 ]% a4 |( A E* WThe bone age was consistent with 28 months by
' Q, |( U8 j6 e4 d( |using the standard of Greulich and Pyle at a chrono- N5 \. U. a0 Z) R- ]
logic age of 16 months (advanced).5 Chromosomal5 K; P, q! l, B" T# F
karyotype was 46XY. The thyroid function test w' c7 N4 k( ~- ?
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
- w4 J1 C5 P* O) @7 `lating hormone level was 1.3 µIU/mL (both normal).
/ J/ r) ]2 i6 e% |. t$ ^/ i: uThe concentrations of serum electrolytes, blood8 i7 s: H+ _+ [! e7 p
urea nitrogen, creatinine, and calcium all were" V" \( W6 l. P3 {8 J) a
within normal range for his age. The concentration' m9 Z8 m" h5 q) a) R
of serum 17-hydroxyprogesterone was 16 ng/dL
. g) J$ G' w) \(normal, 3 to 90 ng/dL), androstenedione was 20
# z- z7 t6 M7 s6 s' }ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
N0 _% a/ A' }; Aterone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 Z1 t$ ^, J% zdesoxycorticosterone was 4.3 ng/dL (normal, 7 to6 w2 U3 Z6 J' k, n5 \- l
49ng/dL), 11-desoxycortisol (specific compound S)
3 q. W8 x* B4 q% U6 owas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
' \0 _+ S3 D* N2 Z, ]" H# e; p+ M" Rtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 Z- F [3 v+ s) {6 m- ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
5 L9 z1 m5 h% m; q, k/ oand β-human chorionic gonadotropin was less than/ ~ z$ S3 s! |, X
5 mIU/mL (normal <5 mIU/mL). Serum follicular' D: ]( I5 K ~
stimulating hormone and leuteinizing hormone
+ Y c3 o. Y, `- N3 Q9 econcentrations were less than 0.05 mIU/mL
+ M% V7 Y2 z1 D0 a& u4 z, J(prepubertal).
$ Y9 h4 V; g3 c: u# m2 M3 l& GThe parents were notified about the laboratory
0 y7 K2 O ^: @1 Tresults and were informed that all of the tests were
( Y- g5 O' U" T& knormal except the testosterone level was high. The
4 K) M0 f, u7 R Z. Wfollow-up visit was arranged within a few weeks to
6 b9 G# ~" v6 }( K/ gobtain testicular and abdominal sonograms; how-
* \1 F \# @, |+ R4 y6 S0 c% I+ Rever, the family did not return for 4 months.
; J/ t" H8 n* C( q$ k9 ?) n. s% @Physical examination at this time revealed that the& L; S6 X7 c& V, e2 ]0 [; {$ r
child had grown 2.5 cm in 4 months and had gained
8 h$ g6 K0 J% I5 @( e# H4 Z4 ^2 |; v2 kg of weight. Physical examination remained
$ n: P" |" Z$ c) C; W d. o6 f; m8 G4 dunchanged. Surprisingly, the pubic hair almost com-
, s! G7 X: g# O* _0 R( A3 v* r% qpletely disappeared except for a few vellous hairs at
0 d: y6 O: S8 w* I- k* f3 S. |the base of the phallus. Testicular volume was still 21 G5 M5 j: M2 J: Y& d1 n6 o
mL, and the size of the penis remained unchanged.2 g1 j4 {; ?! Y$ g
The mother also said that the boy was no longer hav-
p$ q# B1 s! [* @0 Ring frequent erections.) G" W' x% d8 Y/ x1 q" L2 ^
Both parents were again questioned about use of* t6 |7 h- I) y$ @) z
any ointment/creams that they may have applied to
6 T0 O: |" z7 W1 Nthe child’s skin. This time the father admitted the& A! p" H# [' ]& p& r* p: j
Topical Testosterone Exposure / Bhowmick et al 541
6 t. ~- B& a. b0 `2 q) f$ N" ~; Buse of testosterone gel twice daily that he was apply-
5 N* F+ K2 b0 cing over his own shoulders, chest, and back area for
8 }8 ]# K! A* va year. The father also revealed he was embarrassed) j& ]% b$ f$ m8 d" p
to disclose that he was using a testosterone gel pre-
. q6 t1 U; s" v- g- p. I% g/ d3 \scribed by his family physician for decreased libido* X# d2 R% L7 U7 ~( L9 M- t
secondary to depression.
1 C4 O# K. H8 s7 C/ r& [* `9 C1 KThe child slept in the same bed with parents.3 M" V* R# Q4 m% Q" E# w
The father would hug the baby and hold him on his3 q& ?3 \9 Q4 r! G0 C
chest for a considerable period of time, causing sig-
. F0 t1 \' b% x; {* Q0 `& Rnificant bare skin contact between baby and father.3 Q! E* t: o' y# k) x
The father also admitted that after the phone call,
! K B1 B# E8 E5 X7 w( kwhen he learned the testosterone level in the baby
) P9 x) b j! I2 c# }8 Lwas high, he then read the product information
5 m; ? H4 H- k( V: l" K( j% fpacket and concluded that it was most likely the rea-
* C3 x" L3 s, y( B% N! T' qson for the child’s virilization. At that time, they
! [& F& w( R1 [: p) v* l% Gdecided to put the baby in a separate bed, and the5 { F c+ U4 v- m2 t" Y" [( _
father was not hugging him with bare skin and had
7 y' F q5 |) L M# A) ?% t qbeen using protective clothing. A repeat testosterone- g' H9 s( y6 l! c! U* |9 D3 k5 `
test was ordered, but the family did not go to the, p# c0 T. z# K2 h
laboratory to obtain the test.3 W7 J/ Z' o8 y {- z r# W6 o
Discussion. h: }2 S/ l+ l: p$ H- `
Precocious puberty in boys is defined as secondary
- s+ L' k6 q0 j0 v' E& c4 e; ^sexual development before 9 years of age.1,46 R7 a) L0 m s! f+ d1 r( [
Precocious puberty is termed as central (true) when
7 J+ E+ P( f3 b+ z6 V& Ait is caused by the premature activation of hypo-2 ^# k6 ~5 l. a$ l
thalamic pituitary gonadal axis. CPP is more com-
5 ~ j! S4 a) P7 ^1 z9 Dmon in girls than in boys.1,3 Most boys with CPP( J; @: h1 T. p7 L* ]. M6 {
may have a central nervous system lesion that is
5 V6 z+ m; ~/ F; o' Jresponsible for the early activation of the hypothal-
- d' A! R/ M+ }3 tamic pituitary gonadal axis.1-3 Thus, greater empha-( q( e8 \8 M9 G1 w: C0 ^# y1 F. e! H
sis has been given to neuroradiologic imaging in
: c& m/ x4 F/ Y0 \boys with precocious puberty. In addition to viril-: f; t7 Z7 n+ Q6 f4 m+ C# f6 y* f8 Y
ization, the clinical hallmark of CPP is the symmet-
5 c0 b, s" n, `1 `+ frical testicular growth secondary to stimulation by4 y& L" c$ z5 w* s, g0 s
gonadotropins.1,3$ _2 r8 c8 x2 J6 a6 C
Gonadotropin-independent peripheral preco-. a% @$ }6 ]5 k5 t/ E
cious puberty in boys also results from inappropriate; H, h3 g5 i! O! I L
androgenic stimulation from either endogenous or
0 |8 z& Z, R! f. O0 B' ?exogenous sources, nonpituitary gonadotropin stim-
$ l. m% Q. ]3 bulation, and rare activating mutations.3 Virilizing5 ?; l6 K: g3 Y3 v
congenital adrenal hyperplasia producing excessive/ S$ T! A4 y3 H; s A
adrenal androgens is a common cause of precocious- N' m+ D: l' w* e9 Q$ s- s
puberty in boys.3,4( \( R; v/ Z$ e( u0 }9 s0 Q# a: C
The most common form of congenital adrenal' M& j, b" K! N
hyperplasia is the 21-hydroxylase enzyme deficiency.* N3 |8 M! ], C
The 11-β hydroxylase deficiency may also result in
$ A0 o) `% u [9 {excessive adrenal androgen production, and rarely,
6 C: }* [8 u& t& N6 Ban adrenal tumor may also cause adrenal androgen s; ^7 B, E1 h' e- Z2 \4 L+ [
excess.1,3( c* [9 }" d1 q6 S0 }& a7 r) @' |+ ?. h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ F8 [% ~3 }8 u$ ^, r8 E' l! J542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 v+ W' t- T) f& T7 ]1 ~7 ZA unique entity of male-limited gonadotropin-) h' l+ w+ {9 c
independent precocious puberty, which is also known
: W1 b8 ?# z& ~2 e. u, ~as testotoxicosis, may cause precocious puberty at a0 U! B2 g( n+ V& e. K
very young age. The physical findings in these boys
1 d% X. [1 X' ^! J% k0 y! wwith this disorder are full pubertal development,% H. K, U! c) j; Z( x$ @
including bilateral testicular growth, similar to boys
. E. W' X# z8 N3 Ywith CPP. The gonadotropin levels in this disorder' S. n" @: w! T& j y
are suppressed to prepubertal levels and do not show
7 I- z2 w; T. hpubertal response of gonadotropin after gonadotropin-
/ T4 N6 F7 g8 s3 jreleasing hormone stimulation. This is a sex-linked
3 i6 V0 e5 |5 V' v2 K6 g/ J4 uautosomal dominant disorder that affects only+ M6 J+ i2 \6 c0 y
males; therefore, other male members of the family7 U: |" j, R& J( l- |% S# R
may have similar precocious puberty.3
/ q& s. ]1 P) M0 AIn our patient, physical examination was incon-' b# ?: J# T( E z" n) [3 v1 D
sistent with true precocious puberty since his testi-9 a+ s* A o1 i, m- g0 v
cles were prepubertal in size. However, testotoxicosis
0 L6 v1 B; x0 s n0 m) }/ Ewas in the differential diagnosis because his father' x, ?+ B) C; Y. F" \
started puberty somewhat early, and occasionally,+ q, d$ F6 R4 Q2 j
testicular enlargement is not that evident in the! u0 Y0 K: l' _2 O# g e1 p, m) w
beginning of this process.1 In the absence of a neg-( o' ?0 W, P- Z5 V
ative initial history of androgen exposure, our3 r3 Z& e' A }1 d
biggest concern was virilizing adrenal hyperplasia,. r4 @: D" V1 @8 K& }0 @. s
either 21-hydroxylase deficiency or 11-β hydroxylase
* }$ J$ ]; f7 K% s3 K1 B& @% jdeficiency. Those diagnoses were excluded by find-
; G. F* V' |: A& K! Iing the normal level of adrenal steroids.
) `+ d8 O) e5 r/ g2 qThe diagnosis of exogenous androgens was strongly1 v7 s" u! Q: S2 v. l5 a9 R
suspected in a follow-up visit after 4 months because0 i. {7 ?) T# O' d$ v" x
the physical examination revealed the complete disap-
9 t' L$ U$ s! o9 v& f0 h' i1 |; Apearance of pubic hair, normal growth velocity, and) M) E" M2 A9 ^$ I& {& {" n
decreased erections. The father admitted using a testos-; W5 L) C0 H+ I% n: x7 q
terone gel, which he concealed at first visit. He was
+ a @3 f# v" e7 X' ousing it rather frequently, twice a day. The Physicians’8 L8 }7 l" u& R2 I7 x* O
Desk Reference, or package insert of this product, gel or
& D7 k F; Q1 m7 x9 Kcream, cautions about dermal testosterone transfer to
/ y% C3 F! D0 G$ }. j4 \& m' nunprotected females through direct skin exposure.
( H6 D- `; k# U, TSerum testosterone level was found to be 2 times the
5 b+ Z$ |* v1 X8 \/ A, hbaseline value in those females who were exposed to
. u' B4 _! p% \! @4 v* Meven 15 minutes of direct skin contact with their male
2 E( u5 ^* [) B2 d; ?partners.6 However, when a shirt covered the applica-1 e5 @3 [1 W+ B5 J! c1 z1 [
tion site, this testosterone transfer was prevented.
$ l9 J+ `5 r$ y6 O( Y3 M% \Our patient’s testosterone level was 60 ng/mL,
! u, B" z* G1 X. z9 n9 ewhich was clearly high. Some studies suggest that0 M) C5 K# ?3 G
dermal conversion of testosterone to dihydrotestos-
$ q7 F) C5 z) c6 Q, {terone, which is a more potent metabolite, is more
: H- w1 f- C2 z, L9 C: W+ m) N- z. Wactive in young children exposed to testosterone2 c: ]0 i0 V2 w
exogenously7; however, we did not measure a dihy-2 F- K& C: E7 F/ F
drotestosterone level in our patient. In addition to1 L# ^. t; G, Z& L5 {
virilization, exposure to exogenous testosterone in0 L5 N& ^8 _) X# P6 X
children results in an increase in growth velocity and. k! @! ]* {5 f# r9 T5 N
advanced bone age, as seen in our patient.
; P. b2 }2 Z Z2 ~& k% XThe long-term effect of androgen exposure during
- Z! B) s' ~8 I! o" X; r3 E3 Pearly childhood on pubertal development and final
1 S! }. }% }- Yadult height are not fully known and always remain+ h1 P7 T$ a- F; E4 R5 F. ?
a concern. Children treated with short-term testos-
9 e1 v$ k, Y0 y5 E% Aterone injection or topical androgen may exhibit some
" M5 L( V8 n8 R: w# b. r3 w+ Lacceleration of the skeletal maturation; however, after* e m, I# S* U6 w) |
cessation of treatment, the rate of bone maturation9 p8 l' R, x) C8 `
decelerates and gradually returns to normal.8,9. _5 F- U* o2 Z% q8 k% }5 X, @, X" t
There are conflicting reports and controversy* f2 |, Y; j _
over the effect of early androgen exposure on adult
$ \/ _+ C3 w/ Tpenile length.10,11 Some reports suggest subnormal% g# {) u }& C5 B: y4 I- ~( A
adult penile length, apparently because of downreg-
, G' F" Y6 v/ O. x6 ~& T* pulation of androgen receptor number.10,12 However,
, |. h! a7 `9 a1 r: o6 v! OSutherland et al13 did not find a correlation between, T. ~, q# U( N2 p
childhood testosterone exposure and reduced adult
1 ~$ A" {3 A# T0 w4 o; T* l" r2 Jpenile length in clinical studies.
) r) C2 U8 t) e1 Y+ yNonetheless, we do not believe our patient is9 |7 ~8 j% F/ i e/ l" C) V* ~+ x) v
going to experience any of the untoward effects from
- j( D3 I* C1 w& U3 Xtestosterone exposure as mentioned earlier because
' W% X5 Y* S, W$ qthe exposure was not for a prolonged period of time.! n3 W6 Y2 E X( T) G) m6 D
Although the bone age was advanced at the time of7 G: [: ~* U, J3 D1 D" P
diagnosis, the child had a normal growth velocity at X# S* J# p- r' K# ?
the follow-up visit. It is hoped that his final adult
/ y4 f1 W7 ]$ kheight will not be affected.+ R& W8 ?. j- w
Although rarely reported, the widespread avail-
& @0 T' \, N( I" L, W5 xability of androgen products in our society may
" |, W9 C. Z& i( s$ p& ?7 eindeed cause more virilization in male or female
5 e7 g- L; K9 z0 xchildren than one would realize. Exposure to andro-
5 U* V/ T/ @4 c( K8 M! dgen products must be considered and specific ques-- u% J6 \9 Y% h9 l% N
tioning about the use of a testosterone product or# S( \' R7 @8 u& p" y4 B- x8 |' h
gel should be asked of the family members during
! `( O1 l7 [9 @the evaluation of any children who present with vir-
$ r6 |- k. E5 T4 O5 ?1 rilization or peripheral precocious puberty. The diag-0 Q+ U8 c/ }' T* {3 c5 s
nosis can be established by just a few tests and by
# a% j: l% D- v: Jappropriate history. The inability to obtain such a
% O2 `5 x" K$ s9 w+ u C) P5 ghistory, or failure to ask the specific questions, may9 K# @, E, F0 v0 I- ^
result in extensive, unnecessary, and expensive) V4 d6 {7 z' [+ U- d
investigation. The primary care physician should be$ i4 t% Z( k7 L! n* A' {) h) t
aware of this fact, because most of these children
$ C7 b1 \, m- qmay initially present in their practice. The Physicians’
8 w1 Z2 p4 s) \ {Desk Reference and package insert should also put a
8 z+ ?4 Y4 Z+ J6 R# E0 jwarning about the virilizing effect on a male or
j& V$ ]: |) m- X, s1 }; a2 N, q: A( Cfemale child who might come in contact with some-
3 F% C/ V) h# P' |* bone using any of these products.
. E( ]. V( X! b( j* KReferences* m, G$ P! J: k5 D s
1. Styne DM. The testes: disorder of sexual differentiation7 y3 }7 a. h R, R+ u
and puberty in the male. In: Sperling MA, ed. Pediatric! ~3 H( Y) L2 ^
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 _; |' [8 x$ h- ]9 E' C
2002: 565-628.; t- \# B, T& ^/ A' K$ J
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 f4 Q2 h8 a# w7 S$ V* i) }* f& Epuberty in children with tumours of the suprasellar pineal |
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