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Sexual Precocity in a 16-Month-Old
4 ?. s1 e( N: u+ M2 G2 i+ hBoy Induced by Indirect Topical/ J+ }* o$ o( K- S! x
Exposure to Testosterone+ w) x- E: M+ h$ o8 a% _8 o
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( ^' }" D& F. h" `8 r' \
and Kenneth R. Rettig, MD1
9 i, t( j% V5 {Clinical Pediatrics; |0 B! Z) O" c% {4 X0 d- I/ p
Volume 46 Number 6
- N3 j. d* Y/ G9 B( o I! H7 PJuly 2007 540-543
' h6 e$ z! |0 e1 ?, w: n© 2007 Sage Publications
8 _8 V( [+ b3 [7 U1 s10.1177/0009922806296651' F4 u2 @9 Z* J* A
http://clp.sagepub.com! }) o& d2 I- L% c1 e
hosted at- G, P+ h E# T2 o. `; h
http://online.sagepub.com
7 S$ \: o$ {) E6 IPrecocious puberty in boys, central or peripheral,8 E# n2 I6 h( I# X$ w0 T: y
is a significant concern for physicians. Central; r# S F7 O* I m- k2 @
precocious puberty (CPP), which is mediated |, a' ], T! h8 R H9 v/ H2 \
through the hypothalamic pituitary gonadal axis, has
3 A1 j4 [ t" z M5 w3 na higher incidence of organic central nervous system. u' ?3 L# \1 P+ ~) R) O: t
lesions in boys.1,2 Virilization in boys, as manifested
7 u+ |+ a) ~ Q5 O# S7 iby enlargement of the penis, development of pubic
; z, U9 p! F% r$ t0 T' Y, `4 M xhair, and facial acne without enlargement of testi-0 g+ k' x1 H7 u( ~# m
cles, suggests peripheral or pseudopuberty.1-3 We
) `* \# h X- K4 ^3 e3 {6 t, B& a2 @report a 16-month-old boy who presented with the
" x. a6 R, y& {) D7 N& Lenlargement of the phallus and pubic hair develop-# e& e; v r+ H
ment without testicular enlargement, which was due
J8 ]% c3 e; F$ s U8 m! zto the unintentional exposure to androgen gel used by8 k, L" v5 Q5 {7 @: y7 j% S9 v
the father. The family initially concealed this infor-
" t7 x. ?# O+ _9 m) b7 Zmation, resulting in an extensive work-up for this
( r( o1 R4 \9 a+ T6 nchild. Given the widespread and easy availability of
" A. L9 A! Y9 [2 wtestosterone gel and cream, we believe this is proba-
8 w- A. l* O t- p$ N7 g$ S% ~! T+ Tbly more common than the rare case report in the
' z l' F; W/ G. Q9 t6 z6 d: uliterature.4
# l3 r, p. X* j5 t" l# M& ]& |/ r; ePatient Report7 s6 G" C8 u5 ~
A 16-month-old white child was referred to the
: T1 `; f& r* Z- h" Vendocrine clinic by his pediatrician with the concern2 w8 C- r, x, ~: |$ b
of early sexual development. His mother noticed
1 o5 L# X" O% Y$ P0 x8 V1 Y$ _0 D$ ilight colored pubic hair development when he was/ d. B6 k0 H& T; \: D7 n5 z
From the 1Division of Pediatric Endocrinology, 2University of# o/ v0 Z7 K4 {/ O' b$ Z
South Alabama Medical Center, Mobile, Alabama.
6 e( d6 ~' }; b4 g5 z H7 z( mAddress correspondence to: Samar K. Bhowmick, MD, FACE,' l! H! e8 U; b- o; Q3 P
Professor of Pediatrics, University of South Alabama, College of
3 j) d7 f* n; \9 q& L* T+ YMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' c$ k+ N0 Q& t
e-mail: [email protected].7 A N j! ]8 ^- b% g% }* C
about 6 to 7 months old, which progressively became0 b+ K. Z# x: X' d; i2 `
darker. She was also concerned about the enlarge-+ Y# S3 p. [+ O3 t: V k( F! |
ment of his penis and frequent erections. The child& x4 d8 S8 ?- t& z, Y+ m) q9 c
was the product of a full-term normal delivery, with7 K3 V; A# Z/ E( G* U
a birth weight of 7 lb 14 oz, and birth length of- Y4 N9 \7 Y# r; E% j- a+ \, A8 C
20 inches. He was breast-fed throughout the first year# p3 v) U& k, O$ X7 r
of life and was still receiving breast milk along with6 a8 A- J8 |* v, _8 T- j
solid food. He had no hospitalizations or surgery,
- P4 ]+ v L7 r0 Cand his psychosocial and psychomotor development9 V2 _. N+ A0 m
was age appropriate.
/ m) ^9 U1 |* pThe family history was remarkable for the father,
! A* h8 z+ t6 n7 |who was diagnosed with hypothyroidism at age 16,
9 e1 C8 p6 {/ b0 h4 gwhich was treated with thyroxine. The father’s4 N8 d c! c8 q. H! E: v
height was 6 feet, and he went through a somewhat2 H) H! \5 \. `0 }! V3 G: ]
early puberty and had stopped growing by age 14.7 Z( U3 ^6 H- j% E4 [ Y
The father denied taking any other medication. The
6 n& i0 \ Z) ]) M! C% Gchild’s mother was in good health. Her menarche! {4 t0 [( `/ p" V0 y3 |% c0 x/ x
was at 11 years of age, and her height was at 5 feet
" F+ M* M6 e, W8 q3 t5 inches. There was no other family history of pre-; d9 W" A3 J& s) E9 a( |
cocious sexual development in the first-degree rela-; S9 } j# `, h
tives. There were no siblings.
8 i% c/ G8 ~; w& X; l. tPhysical Examination
3 @" |, \( |# ?7 CThe physical examination revealed a very active,
. z( D$ S6 n9 B$ Oplayful, and healthy boy. The vital signs documented4 Z$ o8 e4 M- U2 N4 k0 f# z- q
a blood pressure of 85/50 mm Hg, his length was- U( _9 d- \3 ]% i/ V7 Q; G8 A* {
90 cm (>97th percentile), and his weight was 14.4 kg
% P" H! S8 c/ K) \/ u) T9 p(also >97th percentile). The observed yearly growth/ Z* r7 o& X' W$ P) _$ Z% c; ~
velocity was 30 cm (12 inches). The examination of+ W' A4 _/ M4 K c8 p( C) I
the neck revealed no thyroid enlargement.
2 h& X# g9 y( ]- {$ VThe genitourinary examination was remarkable for
$ d8 k/ C. _7 ?9 w* B4 `$ lenlargement of the penis, with a stretched length of8 k/ R' `7 ?1 i, {. s9 Q" E, T( m7 r
8 cm and a width of 2 cm. The glans penis was very well
8 P* J" T1 n. G+ v, Zdeveloped. The pubic hair was Tanner II, mostly around" y* e% W" `; X
540
& S- P! R! y- n9 U4 V! l* W7 }- {at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ U+ W4 J/ N9 z$ X! R
the base of the phallus and was dark and curled. The C" W1 r+ d7 p# C& S L
testicular volume was prepubertal at 2 mL each. f4 ]. f1 n0 _
The skin was moist and smooth and somewhat; b' H2 `6 N" o( g* a" O* W
oily. No axillary hair was noted. There were no
# ]8 G) {: q4 s" _; x9 U1 rabnormal skin pigmentations or café-au-lait spots.
" F# \4 O, n( A8 JNeurologic evaluation showed deep tendon reflex 2+. Y* _+ u& s5 S, t
bilateral and symmetrical. There was no suggestion* f! p% f8 s r0 _+ i
of papilledema.7 T( w W+ I" u* j8 t+ x: b
Laboratory Evaluation. _4 l8 \( D* \' O" Z: y: P
The bone age was consistent with 28 months by7 P. }, H2 K3 Q4 j5 ^3 h/ U
using the standard of Greulich and Pyle at a chrono-
$ W7 H0 S( j2 @7 E6 w1 l$ ylogic age of 16 months (advanced).5 Chromosomal& f3 f7 M+ r- ]
karyotype was 46XY. The thyroid function test3 G, g0 _) N0 e, g$ |
showed a free T4 of 1.69 ng/dL, and thyroid stimu-! K2 K% F' L9 s# Z5 J. |2 ^% x4 W
lating hormone level was 1.3 µIU/mL (both normal).
8 k! @9 W4 H9 t" oThe concentrations of serum electrolytes, blood
) A# G1 D5 J7 Surea nitrogen, creatinine, and calcium all were
( R4 L) K1 k% Hwithin normal range for his age. The concentration
; U9 \7 t6 f! M4 C7 T; Vof serum 17-hydroxyprogesterone was 16 ng/dL3 E3 _$ S4 D- U/ G$ L1 ?* D/ Y2 b! w9 Y
(normal, 3 to 90 ng/dL), androstenedione was 205 w) F. Z }/ z6 q4 D4 U; Z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' G# w3 o, y4 p/ v- R, Yterone was 38 ng/dL (normal, 50 to 760 ng/dL),; k$ C% F* A+ \* L: Y( M
desoxycorticosterone was 4.3 ng/dL (normal, 7 to' H% o! f% D' @( e9 O
49ng/dL), 11-desoxycortisol (specific compound S)
7 U# O- D% R. q. {& Twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-3 G' e) Y/ S- w4 [8 z6 C
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 h9 M* A, \" l j+ Z" M' o4 f
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ U( M& Y7 w8 {and β-human chorionic gonadotropin was less than5 t8 M' b* A/ O9 l* b+ x( f
5 mIU/mL (normal <5 mIU/mL). Serum follicular
* l- p$ j& t! Y$ o! dstimulating hormone and leuteinizing hormone
4 L \. ^: G! e$ |% \concentrations were less than 0.05 mIU/mL
* W5 L# m. d/ @* U7 c0 D# s(prepubertal).9 {' t& W5 U7 `* |: }6 P4 g; P9 X6 a
The parents were notified about the laboratory! n6 C' X- U! ~
results and were informed that all of the tests were0 ~2 c" L+ u+ ~" x1 v6 n: d/ g
normal except the testosterone level was high. The+ @ [$ Q* b! n4 r, v4 _
follow-up visit was arranged within a few weeks to
# w. I1 f$ Q) t+ P' Q4 A# `# Z, |obtain testicular and abdominal sonograms; how-
/ |9 r7 n. G0 kever, the family did not return for 4 months.' x$ G1 R$ R5 _" R P
Physical examination at this time revealed that the
% b3 J# P& q# s* \5 Z! lchild had grown 2.5 cm in 4 months and had gained* e+ a `+ A" Y+ V' p$ H0 u. W
2 kg of weight. Physical examination remained: s# l& `2 k# I( E
unchanged. Surprisingly, the pubic hair almost com-
" r% E5 G" T' C4 Ppletely disappeared except for a few vellous hairs at
- m* { H$ M/ {9 Dthe base of the phallus. Testicular volume was still 2
1 [$ U. F w. F( m1 Y6 ]" `* BmL, and the size of the penis remained unchanged.
& j# y8 [# i! t& _7 ?The mother also said that the boy was no longer hav-
' J) u' }: I( V; B# ^( [5 O! k! ring frequent erections.
X& d! k, M- x5 z; CBoth parents were again questioned about use of* x9 Y7 k ?1 J& p# d" d
any ointment/creams that they may have applied to
! I. K3 q/ j6 v( }% S$ D- _the child’s skin. This time the father admitted the
# w% r6 U& ` r0 K! L. |4 hTopical Testosterone Exposure / Bhowmick et al 5411 D; \! u0 s% Z$ s5 {6 ]
use of testosterone gel twice daily that he was apply-
9 i2 U1 V% g2 v7 xing over his own shoulders, chest, and back area for4 N# `) I9 n' I, [
a year. The father also revealed he was embarrassed4 V g4 N% F! k) h: a
to disclose that he was using a testosterone gel pre-- g& L6 U, F( T G) y" t
scribed by his family physician for decreased libido6 E1 y1 G4 s! x: `. H* f& k
secondary to depression., ?* b) }6 }. B
The child slept in the same bed with parents.
3 N( W2 U$ x$ Q( XThe father would hug the baby and hold him on his2 P. B8 p6 c/ z1 |1 E, g6 {+ J) O7 R
chest for a considerable period of time, causing sig-. ]/ h, C' O* Z b4 p
nificant bare skin contact between baby and father.
6 ]. W1 Q' U% _. y- X# YThe father also admitted that after the phone call,
' l$ ^+ c; g1 e# C: M- Swhen he learned the testosterone level in the baby# o; W3 l0 Y% N6 M: W' J* M2 |. F" X
was high, he then read the product information; I! v( d! d: z, ]" k% Z
packet and concluded that it was most likely the rea-
- n. c; m! w% yson for the child’s virilization. At that time, they
% e: ]1 a! c4 s; @9 c. {" Zdecided to put the baby in a separate bed, and the
6 }! ^$ ~# l" ~; a- i* u3 Ffather was not hugging him with bare skin and had
2 p/ |4 o% |7 `' J3 bbeen using protective clothing. A repeat testosterone- W+ K% K" K6 w5 b; i% Y, r+ M+ V
test was ordered, but the family did not go to the
$ E) w. M+ h: M1 ~! B7 xlaboratory to obtain the test.
2 V G" U" W: n$ E0 |Discussion+ L5 T+ g# V ^* P. Q# j
Precocious puberty in boys is defined as secondary
' [7 W9 \ N8 Usexual development before 9 years of age.1,4
: q5 p8 q+ A3 |- |0 I6 J0 A3 F4 DPrecocious puberty is termed as central (true) when
$ W3 l" U) C0 Iit is caused by the premature activation of hypo-
+ f+ }! j# z2 \% ~2 J# Vthalamic pituitary gonadal axis. CPP is more com-
) i3 m2 ]- s2 O; p& v9 L, D0 {mon in girls than in boys.1,3 Most boys with CPP
, D$ E1 @" K6 J( I; Ymay have a central nervous system lesion that is1 @5 D. F( z( D& D; j* q
responsible for the early activation of the hypothal-
9 t- h% k; ~8 Camic pituitary gonadal axis.1-3 Thus, greater empha-- W- C9 o& x- s( z6 t/ F- ]8 X
sis has been given to neuroradiologic imaging in
! P, ~( t2 O9 a. O6 {/ R6 uboys with precocious puberty. In addition to viril-' R# F+ p1 Y4 j# L7 `8 F9 ?0 m- a
ization, the clinical hallmark of CPP is the symmet-4 u4 a2 @" s5 [" U! O1 _
rical testicular growth secondary to stimulation by I5 c2 D3 o4 h, [% S, B. I
gonadotropins.1,3
/ h6 P) c: C) U d- jGonadotropin-independent peripheral preco-# a% H6 D: o9 P% ?$ [" M% a
cious puberty in boys also results from inappropriate' C% F8 O: @) A. e0 E
androgenic stimulation from either endogenous or
+ d2 A+ ?1 S0 o5 o$ Qexogenous sources, nonpituitary gonadotropin stim-
1 X& ]8 ]1 f1 V A: V7 Z5 o' Zulation, and rare activating mutations.3 Virilizing
& s! s+ u, x- Qcongenital adrenal hyperplasia producing excessive$ ~$ ?0 ~6 L/ E1 [( w: `
adrenal androgens is a common cause of precocious
1 R) q% k& G9 t( k+ }- ? p2 rpuberty in boys.3,4 R6 x+ Z7 n( X9 \' _: _3 w) _
The most common form of congenital adrenal
9 n6 p6 E( M7 u d- ~, Qhyperplasia is the 21-hydroxylase enzyme deficiency.
$ s$ p3 y+ i8 I6 k3 @6 b4 U/ cThe 11-β hydroxylase deficiency may also result in
2 T j/ _1 ]' `excessive adrenal androgen production, and rarely,# `" W: B5 {! T) o" S! X" m* t1 ?
an adrenal tumor may also cause adrenal androgen: Z) ^! B }$ p
excess.1,31 _. u; V v- Q' h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 H3 I% T! e: G7 `# B: h: [. [) T542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: ?$ w6 D; P9 W( T$ RA unique entity of male-limited gonadotropin-: W( ^; D K" a: G
independent precocious puberty, which is also known
3 J, L8 H/ Z5 Q8 Y3 Uas testotoxicosis, may cause precocious puberty at a$ p$ y" }4 z2 r; F( ]
very young age. The physical findings in these boys3 D+ N4 M+ d% u2 z" k
with this disorder are full pubertal development,4 j* c2 ]2 N$ | {' S% R
including bilateral testicular growth, similar to boys
- ^) P' g$ V# f" |' ~' Uwith CPP. The gonadotropin levels in this disorder! W6 u$ p* B* ?) A
are suppressed to prepubertal levels and do not show
- x: q0 ? U* S7 k: j2 C3 gpubertal response of gonadotropin after gonadotropin-
( B4 @! H8 z: W$ C* U1 o7 mreleasing hormone stimulation. This is a sex-linked
: r: R9 a5 @( U" z; ]. K `5 |autosomal dominant disorder that affects only* F7 F& p8 p; O, s
males; therefore, other male members of the family
# _, D% _0 L amay have similar precocious puberty.3
) }& L& `$ }6 J/ kIn our patient, physical examination was incon-- n5 S$ T8 `$ D
sistent with true precocious puberty since his testi-
0 m: E: c, T3 ^" F/ n- C& H& C) @cles were prepubertal in size. However, testotoxicosis+ g6 A( H B" i! U8 x
was in the differential diagnosis because his father
+ R3 z9 y6 O+ h: T$ Cstarted puberty somewhat early, and occasionally,$ ]! P: d' a7 W2 F+ `
testicular enlargement is not that evident in the
3 i, s3 F. B- I6 rbeginning of this process.1 In the absence of a neg-4 X0 o8 ^# n: r, M! N; @* ~
ative initial history of androgen exposure, our. H1 U4 S. g0 u+ ~ X, u* R" S
biggest concern was virilizing adrenal hyperplasia,; J( F( U6 n+ t6 G1 i" W
either 21-hydroxylase deficiency or 11-β hydroxylase
. z" L1 F% q1 ?0 b3 Rdeficiency. Those diagnoses were excluded by find-8 {. }7 T5 k0 F: E
ing the normal level of adrenal steroids.7 D9 d! L& r3 z4 [: D" t5 Y
The diagnosis of exogenous androgens was strongly
; s; e; F. N& m; esuspected in a follow-up visit after 4 months because
3 N# W# b" |* I2 U2 Y3 u$ W4 {the physical examination revealed the complete disap-
, f% H) a" o/ z, w( Spearance of pubic hair, normal growth velocity, and
! [1 x, t2 U, z) m9 ~decreased erections. The father admitted using a testos-: g/ P: m, x4 h1 p; [, |4 X
terone gel, which he concealed at first visit. He was# U$ k$ I! t5 H& h. o
using it rather frequently, twice a day. The Physicians’1 Y* e* y$ E7 |
Desk Reference, or package insert of this product, gel or
9 _( G& V7 P! q- |$ k6 ycream, cautions about dermal testosterone transfer to
% r, e. X7 ~9 Lunprotected females through direct skin exposure.2 t+ l0 s2 d+ |. A" m8 Q+ F Q
Serum testosterone level was found to be 2 times the I/ H0 `6 G$ g6 t
baseline value in those females who were exposed to2 s9 _0 u/ a. L) y q" v9 G
even 15 minutes of direct skin contact with their male
) a, k8 \, B7 k Apartners.6 However, when a shirt covered the applica-
( d) p: ~/ _# V; J- qtion site, this testosterone transfer was prevented.: I7 [) Z7 l( j, g3 i0 O: b& }/ R
Our patient’s testosterone level was 60 ng/mL,% a3 ]# f( X, b, b3 c
which was clearly high. Some studies suggest that
! Y" e z( Z: q0 h( Pdermal conversion of testosterone to dihydrotestos-; T: W7 i7 D+ U1 E, K$ H) C
terone, which is a more potent metabolite, is more
/ c4 K, [' S0 \% j" O/ p% ?& g8 b0 I5 Nactive in young children exposed to testosterone: z- N& ^, b( a- {9 ~
exogenously7; however, we did not measure a dihy-1 ^/ B0 _5 x4 v7 D' e" c
drotestosterone level in our patient. In addition to; x: N' ]0 X6 H5 R* n6 f
virilization, exposure to exogenous testosterone in
3 G7 q# z7 t) ]" R- Vchildren results in an increase in growth velocity and
+ s0 m; D# [3 }7 n( Padvanced bone age, as seen in our patient.
( }- [4 }$ ^- ^. ~5 JThe long-term effect of androgen exposure during7 u$ k% G' B! a) Y( |* G, I
early childhood on pubertal development and final
2 R- T! W2 y# Z; e+ C: Jadult height are not fully known and always remain' v% U$ U" \( k1 e1 V0 ?4 P- l4 f
a concern. Children treated with short-term testos- c: J% X9 q+ z9 q B/ w; D
terone injection or topical androgen may exhibit some, I4 G. s4 e d, d8 V6 _" D
acceleration of the skeletal maturation; however, after$ Z& A' t+ i0 N, B$ [$ |$ C
cessation of treatment, the rate of bone maturation
$ }! ]$ I0 ?8 S$ ldecelerates and gradually returns to normal.8,94 I3 m7 X+ \4 P7 S6 _6 j$ u
There are conflicting reports and controversy
0 F1 h6 _& l' {$ K- v5 n, M& Z5 xover the effect of early androgen exposure on adult0 K8 l( A, H# C5 d6 G
penile length.10,11 Some reports suggest subnormal% V: @' p+ t9 Z' d# X
adult penile length, apparently because of downreg-
& t9 U# f1 P5 K' H6 C) qulation of androgen receptor number.10,12 However,: [% ]: l1 P% l
Sutherland et al13 did not find a correlation between
8 n1 I0 B# B: w$ t; ?1 ]) t4 ^ zchildhood testosterone exposure and reduced adult
7 m. _; n3 D/ J; Qpenile length in clinical studies.
( U2 o2 u' L kNonetheless, we do not believe our patient is
. c# v& ]( l- U; s M( v& G4 v1 Sgoing to experience any of the untoward effects from
( i' R% h# P4 K: G' |testosterone exposure as mentioned earlier because; C3 W; T) b% i" E7 t W2 _( Z% b
the exposure was not for a prolonged period of time.
) S S$ \9 w p% fAlthough the bone age was advanced at the time of$ B) J( X/ H8 k# W
diagnosis, the child had a normal growth velocity at
. _* k6 c% U' athe follow-up visit. It is hoped that his final adult
* ?* a7 Z" l7 b. i% i! Q7 Theight will not be affected.
" k8 i) x4 A8 E: o5 s4 NAlthough rarely reported, the widespread avail-1 H1 H; K) _0 r5 b
ability of androgen products in our society may4 R! B1 e' }: r% A5 q
indeed cause more virilization in male or female( K$ B8 {+ T* c# W2 t
children than one would realize. Exposure to andro-9 x+ ^! o/ E) m5 I& g5 n" x/ ^
gen products must be considered and specific ques-
$ W# w0 I! i' ationing about the use of a testosterone product or, Y2 a5 R; K# H J+ m1 N7 y: I
gel should be asked of the family members during
# e+ O D. T0 E! Y Y: e2 j1 ^. R6 Ythe evaluation of any children who present with vir-/ q9 s2 M. z! O# K/ s$ T4 P% c' M
ilization or peripheral precocious puberty. The diag-5 F/ K" o6 m: @/ n) O
nosis can be established by just a few tests and by
+ |" \( W4 F% X6 z8 y1 } t* A) T! xappropriate history. The inability to obtain such a8 l2 P5 _7 L1 E! C3 i. N1 q
history, or failure to ask the specific questions, may
9 L! }+ N! n4 K4 t( @6 Xresult in extensive, unnecessary, and expensive1 y! n" T' j+ p; V! J* g
investigation. The primary care physician should be6 P' r) R) k" u) e$ i
aware of this fact, because most of these children
- p- m* V) a: |may initially present in their practice. The Physicians’0 F# W) c8 T, r ~, Y! l0 h
Desk Reference and package insert should also put a& E, k$ v- N/ S! P" B2 N, W }1 }
warning about the virilizing effect on a male or; T3 j# B1 M' k# X3 P" G$ \* L9 {8 g
female child who might come in contact with some-$ P1 |( a* o: L# y5 K
one using any of these products.
9 P( `! ]! |7 ZReferences0 l7 S- C2 ^- w, A
1. Styne DM. The testes: disorder of sexual differentiation
- ]: c {1 ^/ h) p7 b; W! c0 t3 land puberty in the male. In: Sperling MA, ed. Pediatric
4 `. t( k) K' l& x( I- aEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 T# _9 \7 B5 Y9 I o2002: 565-628.
5 E+ K0 v& Q+ `2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 h& M# ~% Y$ x1 ]0 Q
puberty in children with tumours of the suprasellar pineal |
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