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Sexual Precocity in a 16-Month-Old! A3 T0 X6 J. K, u# f
Boy Induced by Indirect Topical9 x& S8 j$ u O0 Q
Exposure to Testosterone& h( J% K- {/ w* D6 U
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
. s1 G. h3 w% f& L5 S Aand Kenneth R. Rettig, MD1
6 q+ N1 [! } ]7 ~Clinical Pediatrics, ^' L% d2 h2 y! |3 ]
Volume 46 Number 6. S) {" f6 ?; X' N! F. }; j& X/ ]
July 2007 540-5433 s; o9 c+ L F6 }, [- N. }+ L3 ]
© 2007 Sage Publications7 V! B3 ]* Q, D: p" D9 c1 v* E: Q
10.1177/0009922806296651' ?1 e) v' p) m
http://clp.sagepub.com$ V% u1 g4 g! Y9 V3 N( Z% k h! m
hosted at
6 @+ d2 K) [* khttp://online.sagepub.com
( r/ F( K9 g# e9 T5 `9 [/ N hPrecocious puberty in boys, central or peripheral,2 q( x6 H' Q% E
is a significant concern for physicians. Central4 ] ]: K# ?9 z& F
precocious puberty (CPP), which is mediated9 L" R# |( A' d
through the hypothalamic pituitary gonadal axis, has6 a7 o0 d; ^1 }' ^; `3 I
a higher incidence of organic central nervous system
3 h" W3 l+ f+ Y3 X8 B3 F9 mlesions in boys.1,2 Virilization in boys, as manifested4 q/ ^& K6 _$ T5 A
by enlargement of the penis, development of pubic# M; y" z/ M$ f9 K: u v( U7 u3 J, @
hair, and facial acne without enlargement of testi-) \0 J& q E0 }# l6 ~% ?
cles, suggests peripheral or pseudopuberty.1-3 We
+ u, \; Q# g8 X& R0 v4 N# {, J, ^report a 16-month-old boy who presented with the6 b- Y4 d! b _9 v# R3 u
enlargement of the phallus and pubic hair develop-2 Q3 p* y( Q$ C5 T- f
ment without testicular enlargement, which was due3 ?" e% P n" e; ]5 ~
to the unintentional exposure to androgen gel used by2 ~ f3 I/ o: `- S7 y
the father. The family initially concealed this infor-
/ n8 [+ g* \. U# q- }mation, resulting in an extensive work-up for this
! N/ y: W R9 T% c9 echild. Given the widespread and easy availability of' I8 m0 A! }2 t h9 T
testosterone gel and cream, we believe this is proba-
- ~) t0 _* X+ h5 f, u5 f! }; n/ Pbly more common than the rare case report in the
# x- R- w" T' ]( m$ f" E1 }. `literature.4
" _" _# u! K1 C! ]+ dPatient Report
# t' b2 O! E) tA 16-month-old white child was referred to the, | X$ ?# s" W8 i6 Y
endocrine clinic by his pediatrician with the concern/ w7 N# V2 L' v0 F; ~
of early sexual development. His mother noticed: v. w1 ]* S6 D: A/ X9 T
light colored pubic hair development when he was
" m" x, O. t+ L% F; K/ e, K. b: xFrom the 1Division of Pediatric Endocrinology, 2University of
( k7 u# _$ H& l/ Q" }! u6 ?South Alabama Medical Center, Mobile, Alabama.1 n4 r8 y8 N9 f. a, O8 G
Address correspondence to: Samar K. Bhowmick, MD, FACE,
; b/ V0 e% g% ZProfessor of Pediatrics, University of South Alabama, College of% U3 j0 L7 q3 l B
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 ?8 O# ]5 V% t5 h$ f' {2 \3 l8 C
e-mail: [email protected].4 N. ^; ~. l3 D# @; z
about 6 to 7 months old, which progressively became0 Z9 }! e3 q' G3 a1 }% w9 r
darker. She was also concerned about the enlarge-
1 L9 i0 A) G; ]ment of his penis and frequent erections. The child
, F- e6 @/ R! d. Qwas the product of a full-term normal delivery, with/ R, W3 K: m( S& K
a birth weight of 7 lb 14 oz, and birth length of- K$ O- F+ F/ ?( @) \) Y2 Y" l' P
20 inches. He was breast-fed throughout the first year7 }/ x* V+ p; d1 a- B: k$ T. F4 q5 i
of life and was still receiving breast milk along with
5 t. m' \2 P/ usolid food. He had no hospitalizations or surgery,7 g7 O* A- {$ _2 X& m3 C
and his psychosocial and psychomotor development$ j; J/ B/ ?$ a3 A$ Y' Z8 D8 {
was age appropriate.
! | u6 G6 @ SThe family history was remarkable for the father,
8 S- U) Z1 i1 _: y7 Fwho was diagnosed with hypothyroidism at age 16,& u+ N' j. o" `
which was treated with thyroxine. The father’s
R7 `( L5 x: |height was 6 feet, and he went through a somewhat
! b9 x8 @3 K2 _5 K+ i' Qearly puberty and had stopped growing by age 14.+ }2 u. m# \! c) Q
The father denied taking any other medication. The) B: ~+ p' Y ^' A# C Z6 V
child’s mother was in good health. Her menarche8 `7 ~2 G* f7 q9 u# D
was at 11 years of age, and her height was at 5 feet2 j) m7 i( h5 ]6 g. e. x- V
5 inches. There was no other family history of pre-
( a: R3 y5 q2 A% icocious sexual development in the first-degree rela-. G1 H5 H/ L5 N
tives. There were no siblings.9 r& }7 T! A: Q% }2 `+ `6 l
Physical Examination
5 W" U! x5 z* `- f) J4 ^The physical examination revealed a very active,! p! [& P; s. h3 G" E$ p
playful, and healthy boy. The vital signs documented
. R' }3 Q8 `( ?8 P1 R2 Q* D9 i% m( m& Oa blood pressure of 85/50 mm Hg, his length was9 `8 x( e+ O! `: P; |6 D9 y
90 cm (>97th percentile), and his weight was 14.4 kg N+ m0 k8 J3 p4 z' G1 `5 v; p
(also >97th percentile). The observed yearly growth! S/ h% E/ |0 T% N
velocity was 30 cm (12 inches). The examination of7 p/ p) ~. X2 n# Q' O7 Y% g
the neck revealed no thyroid enlargement.
m! x7 v3 m' K. b9 k- sThe genitourinary examination was remarkable for
/ K. s5 A: f) J$ I5 e7 Z" y! venlargement of the penis, with a stretched length of% r8 k" V8 P: G9 v
8 cm and a width of 2 cm. The glans penis was very well1 [. d1 V2 `6 i
developed. The pubic hair was Tanner II, mostly around
' Q1 D5 ] E0 R+ q: m! x" I540 w& e2 k) T% x5 F1 I4 W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! ^% y& [: D, M" dthe base of the phallus and was dark and curled. The
! ^7 q& r B, vtesticular volume was prepubertal at 2 mL each.5 O7 S/ Z! r# K1 D
The skin was moist and smooth and somewhat' n: L: s- q. E2 g6 y$ k
oily. No axillary hair was noted. There were no% N* h, @1 _9 D- N1 G
abnormal skin pigmentations or café-au-lait spots.
" Z6 p2 g: |# y. Y; VNeurologic evaluation showed deep tendon reflex 2+6 y7 [0 d1 ]/ g& ^
bilateral and symmetrical. There was no suggestion; T* M2 n: U; w: D% M) a3 h: ^
of papilledema.( G9 g5 e- Y: b) N( G
Laboratory Evaluation
7 {: c8 K& G' q9 V' x/ ]5 |4 y8 W8 YThe bone age was consistent with 28 months by
]4 g9 t7 C- M. X: L. pusing the standard of Greulich and Pyle at a chrono- {: b- L( t2 e5 a! g. R" [
logic age of 16 months (advanced).5 Chromosomal3 U u3 y2 N5 [; J( u7 J+ |
karyotype was 46XY. The thyroid function test* l" W: u8 k- G% ]- r7 W9 i
showed a free T4 of 1.69 ng/dL, and thyroid stimu-! p! c. H( @6 l x) h) j% m( Q
lating hormone level was 1.3 µIU/mL (both normal).3 G$ V; L5 \& h/ [
The concentrations of serum electrolytes, blood
, i, f6 ^; q3 L7 D( Jurea nitrogen, creatinine, and calcium all were
6 Y3 z/ v. e8 G& }within normal range for his age. The concentration0 _# ^, M) a! Y2 j% {! S: Y0 v
of serum 17-hydroxyprogesterone was 16 ng/dL2 ~5 E6 j6 C" c9 q; ~
(normal, 3 to 90 ng/dL), androstenedione was 20( ~3 J. @- f' G2 }" V+ u) f
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-- A/ |7 {* S" }- {- Q' E) {8 J
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" S7 h% ]% l, S, g' O8 `% a3 Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 n$ Z" n( o% j+ C49ng/dL), 11-desoxycortisol (specific compound S)1 D& J" ?6 s* e+ P% g0 U5 L+ ~
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-# Y0 |" }$ `8 \1 N* n
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% g8 z, T( |. d4 s, q/ L; k6 c' wtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 H8 d( A* x4 j2 G
and β-human chorionic gonadotropin was less than3 F9 L& T$ W* c5 @9 C
5 mIU/mL (normal <5 mIU/mL). Serum follicular
% L6 J8 Y, D1 Z; G- Lstimulating hormone and leuteinizing hormone
+ b$ f) N2 |! r+ f) Yconcentrations were less than 0.05 mIU/mL0 ^% F- F. y* W
(prepubertal).2 T) H5 X H: f% g
The parents were notified about the laboratory
: \" g" u% R9 R" a% n# `results and were informed that all of the tests were% j" a [6 N* _
normal except the testosterone level was high. The
+ v. w8 C! I. }: t, ~' F$ K( qfollow-up visit was arranged within a few weeks to; n9 [5 |# k% A- D! Y0 ?& W
obtain testicular and abdominal sonograms; how-0 q w1 y, z5 S( r$ ]
ever, the family did not return for 4 months.
; e6 H+ ^! ^' y0 NPhysical examination at this time revealed that the
+ H0 |6 `; F" D& p! }child had grown 2.5 cm in 4 months and had gained
G/ |/ P% S8 O: o5 j4 U+ ^5 [. K+ G2 kg of weight. Physical examination remained
+ C# ~* T5 J9 B( ?- o1 j8 t$ eunchanged. Surprisingly, the pubic hair almost com-- ] e Y/ J, @
pletely disappeared except for a few vellous hairs at
o! \/ \- J6 ]) r/ u) U' lthe base of the phallus. Testicular volume was still 2" h, V% ] R" Y. m+ q4 V
mL, and the size of the penis remained unchanged.
0 M/ V9 a0 v7 fThe mother also said that the boy was no longer hav-
" r& u; x( t) B; Ping frequent erections.
& Q( J. q" |3 D3 f6 A1 A* `/ DBoth parents were again questioned about use of
& A% Y; ]8 |' i2 Many ointment/creams that they may have applied to$ m: [$ W# f" p* W; U8 U9 A
the child’s skin. This time the father admitted the
; W( m" N# s$ Q) _: XTopical Testosterone Exposure / Bhowmick et al 541
& n I6 q I j) r; O0 Suse of testosterone gel twice daily that he was apply-4 c7 Z. P+ J" Q8 _/ O: M$ `
ing over his own shoulders, chest, and back area for; Y* U& N8 P5 ~ l% |
a year. The father also revealed he was embarrassed. G7 u8 F0 g+ X% Z) n1 V
to disclose that he was using a testosterone gel pre-
A+ b1 S0 |( @, xscribed by his family physician for decreased libido" r% A/ ^& V7 W, M& q
secondary to depression./ g, G) H7 d8 @# W7 o+ c
The child slept in the same bed with parents.7 A0 ]4 `0 X v1 Z" x6 ^7 S* }& S
The father would hug the baby and hold him on his
+ g; H/ @9 \1 i( k1 ychest for a considerable period of time, causing sig-, ?2 y% X. A8 l+ ~4 C3 d# t
nificant bare skin contact between baby and father.1 s; n# f; X% k, h' H2 B
The father also admitted that after the phone call,
H3 J- _8 `; W8 \- twhen he learned the testosterone level in the baby
0 B) Z& v% s! x. n& B8 N& j2 L# _was high, he then read the product information: ? O5 @( b8 K! P' {1 X# l
packet and concluded that it was most likely the rea-) b7 u @/ |8 p% \6 X+ J& F
son for the child’s virilization. At that time, they
' x$ j" F; y7 P; B2 j9 K# V* Mdecided to put the baby in a separate bed, and the3 ?% P$ `; N& s1 Z) u
father was not hugging him with bare skin and had
1 B5 r' N) Z$ ?( t5 N1 dbeen using protective clothing. A repeat testosterone0 h: L$ I' G- W' j7 |4 ]/ m, D2 I/ w
test was ordered, but the family did not go to the
% K0 J1 _- t+ i y0 n3 Wlaboratory to obtain the test.# \% \7 J( i) E- _
Discussion" S% W1 U/ i% n2 J! k4 q
Precocious puberty in boys is defined as secondary: q: j3 L! u0 `- X1 o: L1 E
sexual development before 9 years of age.1,4$ h% E* m& J1 m4 {8 y( `( ]' _! c
Precocious puberty is termed as central (true) when
7 o7 B" Z4 c3 Z/ w+ G5 }8 Tit is caused by the premature activation of hypo-
1 \7 d+ ~. T* X# Qthalamic pituitary gonadal axis. CPP is more com-. r% s0 `) E2 O* A D
mon in girls than in boys.1,3 Most boys with CPP
/ @2 _/ G4 Q: s4 s& {4 gmay have a central nervous system lesion that is7 \" c- e+ p5 W1 q7 C0 C
responsible for the early activation of the hypothal-
6 a9 q- F/ z# @, Z8 I, u: W3 `amic pituitary gonadal axis.1-3 Thus, greater empha-' K. ]3 G0 }7 g5 |( l
sis has been given to neuroradiologic imaging in! {1 v0 b3 O- w
boys with precocious puberty. In addition to viril-: k/ V0 J8 k# I8 f( J
ization, the clinical hallmark of CPP is the symmet-
( m5 t' Z/ V- F7 z3 x' S- arical testicular growth secondary to stimulation by
* W# {: I- g2 x% U# \gonadotropins.1,3* K1 O( T9 O% H& s9 [& I& _( b
Gonadotropin-independent peripheral preco-
7 {- Z1 {3 `% q0 Bcious puberty in boys also results from inappropriate
1 s# t( s; Q* V8 Y: w; J2 I" Q0 @androgenic stimulation from either endogenous or0 e! h$ A4 M# ^& z1 U; r2 f
exogenous sources, nonpituitary gonadotropin stim-
" M8 t0 v4 k8 o/ r9 ~ulation, and rare activating mutations.3 Virilizing
" v m+ x) E# S) S2 ]( D0 {% Bcongenital adrenal hyperplasia producing excessive9 B1 I. X; R. K/ c3 j3 d+ F% I9 K
adrenal androgens is a common cause of precocious
; d( G- L5 F* Z9 F; Bpuberty in boys.3,4& \& c7 b: r! q" }/ j( G" o2 Z! G
The most common form of congenital adrenal% ?! r4 S" I) N U) {
hyperplasia is the 21-hydroxylase enzyme deficiency.+ g3 ^% k. g) a1 M8 g, g/ u
The 11-β hydroxylase deficiency may also result in0 l* E7 z- w! S6 B: W% x
excessive adrenal androgen production, and rarely,/ ?& t$ s* D) s% Q6 ~
an adrenal tumor may also cause adrenal androgen
0 G& d4 {5 P9 z8 i# x. ]" Jexcess.1,33 `2 o) ~( K. C3 x' c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, ]3 l1 x4 A* y542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ [2 u: `- X1 k+ T2 Q- O6 x3 RA unique entity of male-limited gonadotropin-
$ X! c/ j" _* r) ~independent precocious puberty, which is also known* N- |3 t9 G& [; j1 H4 [0 u
as testotoxicosis, may cause precocious puberty at a
3 }- O6 P! C+ G7 kvery young age. The physical findings in these boys
) V# T" r2 y2 O* Jwith this disorder are full pubertal development,6 a9 N" }& }4 W2 x2 C0 N
including bilateral testicular growth, similar to boys: N; X1 T) Q' m# ~
with CPP. The gonadotropin levels in this disorder
; L8 i! Y$ B% v& N& Z- ^0 [; C- care suppressed to prepubertal levels and do not show
, G& r" Y! }/ d: Cpubertal response of gonadotropin after gonadotropin-5 n8 X2 p8 F1 G; L6 j
releasing hormone stimulation. This is a sex-linked
! k7 P+ C: g; T& y4 e) q9 B, `6 b% X7 Rautosomal dominant disorder that affects only
) q+ v; | Z+ }. T" |males; therefore, other male members of the family0 K* A3 v* `' F1 l: A9 J* P" v
may have similar precocious puberty.3! B% K2 J2 x7 F
In our patient, physical examination was incon-
, K" n5 u" V2 U, V0 X9 Dsistent with true precocious puberty since his testi-1 v0 E/ t5 _/ o$ T4 X
cles were prepubertal in size. However, testotoxicosis: m. S+ m( V7 U5 A. I- r6 e" }* {7 r
was in the differential diagnosis because his father: p0 V! n7 U6 q+ D
started puberty somewhat early, and occasionally,5 Z, C s y0 t. F
testicular enlargement is not that evident in the
; B9 _/ Z/ ]0 K7 T7 r. Fbeginning of this process.1 In the absence of a neg-. E; I: S; h6 H/ U, m% v$ e
ative initial history of androgen exposure, our1 U: P6 @; F' i. G$ B7 W
biggest concern was virilizing adrenal hyperplasia,- n' v; n& ]/ c
either 21-hydroxylase deficiency or 11-β hydroxylase
4 E+ r- V( w+ h4 J3 t& Gdeficiency. Those diagnoses were excluded by find-4 z6 k2 d: X$ t, @+ z$ w4 i
ing the normal level of adrenal steroids.
9 G' |/ d0 Q/ z7 u7 K- [4 m1 }, Z; ?The diagnosis of exogenous androgens was strongly
1 K8 u* V6 ?# Q- U( Z$ x- wsuspected in a follow-up visit after 4 months because4 A! k9 ^/ U- }
the physical examination revealed the complete disap-
1 F9 E, J! n! \5 {6 Rpearance of pubic hair, normal growth velocity, and. f" y. u P' g* ^, B0 D
decreased erections. The father admitted using a testos-
# ~" B0 H) |# w* T& o hterone gel, which he concealed at first visit. He was
6 X7 E+ S4 k& kusing it rather frequently, twice a day. The Physicians’
4 [! T/ t2 e" Q- U# i' ^0 o) s5 N5 f# ^Desk Reference, or package insert of this product, gel or" h( a/ [1 j7 v2 w
cream, cautions about dermal testosterone transfer to$ }' o I1 g6 B% H; I
unprotected females through direct skin exposure.
- L6 f* w* s, N# ^Serum testosterone level was found to be 2 times the, U! Y" ^. c0 D( |+ \! S. Z
baseline value in those females who were exposed to
1 ~( X' T# G1 L& Leven 15 minutes of direct skin contact with their male8 e& R2 Q0 Q/ I$ T
partners.6 However, when a shirt covered the applica-
2 ?4 Q$ m" j0 M/ b" u7 ztion site, this testosterone transfer was prevented.$ [" Z* D: W: @4 L" I/ I, L. [
Our patient’s testosterone level was 60 ng/mL,$ W! T" f; \/ s# t( K/ E( d8 I S, i
which was clearly high. Some studies suggest that
0 J5 b3 V6 z1 S" p; Fdermal conversion of testosterone to dihydrotestos-4 d9 g8 s+ S( L9 z0 m
terone, which is a more potent metabolite, is more3 ^7 d; B1 D" `
active in young children exposed to testosterone
& O" w: a% H/ A3 B; d! [) Pexogenously7; however, we did not measure a dihy-
4 T- y1 {% ~0 s0 z8 z2 S' b) Ldrotestosterone level in our patient. In addition to
9 o+ i+ O! b0 G! d. V8 Z9 z5 ?virilization, exposure to exogenous testosterone in& o9 r6 m$ n$ `
children results in an increase in growth velocity and
1 E. a2 Y$ ]( x! Z7 D) [3 W! Wadvanced bone age, as seen in our patient.$ H$ J/ S2 E6 _1 n/ P3 [$ t
The long-term effect of androgen exposure during
' N d, b! d' t, U/ oearly childhood on pubertal development and final- |9 K x* O% M% S
adult height are not fully known and always remain3 G; b$ k4 j" E; S4 o
a concern. Children treated with short-term testos-) G \& F% b# p- |
terone injection or topical androgen may exhibit some0 _! p0 G1 s$ }, @/ _. ^4 o, H D' v+ o
acceleration of the skeletal maturation; however, after
i* C6 Z4 T1 T0 N% N8 Gcessation of treatment, the rate of bone maturation4 z7 R9 s! G* O- z/ p
decelerates and gradually returns to normal.8,9" s6 `; d O" N4 P& E, U
There are conflicting reports and controversy
6 |; u( }$ f' `4 ]1 x( g3 D% vover the effect of early androgen exposure on adult( X& O; w, M$ e
penile length.10,11 Some reports suggest subnormal
3 v+ D* Y# V+ y$ }; ?; Radult penile length, apparently because of downreg- o2 \' B" h- ?+ F2 X6 H0 Z3 G9 {
ulation of androgen receptor number.10,12 However,, f% h6 p* A# f0 H, k
Sutherland et al13 did not find a correlation between
& f' l4 I$ b, r9 Z6 X; X3 V0 fchildhood testosterone exposure and reduced adult
. P. O3 H& K/ T1 \7 B% k* m8 Apenile length in clinical studies.# p) G' j7 k! C0 w4 ]
Nonetheless, we do not believe our patient is
5 H6 c4 a0 A: |, x, F( @: X( P4 ]going to experience any of the untoward effects from" L8 N# r! s3 }4 U
testosterone exposure as mentioned earlier because; }: W: ]. v! [7 H! B8 K
the exposure was not for a prolonged period of time.2 \ y: g" O* @1 V) @' P( B9 T
Although the bone age was advanced at the time of. s. D7 {6 X; K& `
diagnosis, the child had a normal growth velocity at: i7 \- {7 w( m' x; m* u
the follow-up visit. It is hoped that his final adult
/ I# u0 R2 J2 [1 cheight will not be affected.
% K4 \; F) Z ^4 P, pAlthough rarely reported, the widespread avail-
" T) o5 v( N. N7 U& fability of androgen products in our society may
; ?3 q, r8 T3 J4 V4 e8 cindeed cause more virilization in male or female& K2 A/ K& t- V( y G0 ~( ^$ t
children than one would realize. Exposure to andro-0 K, k L+ A; j) q% i: N9 @
gen products must be considered and specific ques-
$ M7 L2 O; W- A: ltioning about the use of a testosterone product or2 D% H/ J9 y, T3 l, n& U- k
gel should be asked of the family members during$ X5 d- u- n( L4 }# q/ b8 W4 m
the evaluation of any children who present with vir-5 h$ y9 z- e5 B$ {( f8 Z& o4 A8 ]& |, B
ilization or peripheral precocious puberty. The diag-
: k3 _; E5 U- M) H9 znosis can be established by just a few tests and by
% g3 G4 C. Y- R | R1 Pappropriate history. The inability to obtain such a
" m( }! o, L0 @$ ]history, or failure to ask the specific questions, may
1 @8 w' \ Y; {, s6 x6 B4 Mresult in extensive, unnecessary, and expensive0 N& B( I, |; M6 [1 N7 s
investigation. The primary care physician should be
" f7 g( w8 a% F) t1 yaware of this fact, because most of these children
/ a/ _( [3 J7 @, a- C- mmay initially present in their practice. The Physicians’. b) |' r, O( }* x( h5 B. P: i0 U
Desk Reference and package insert should also put a' p& K, b' g+ b, g+ U, ~9 H8 q8 }
warning about the virilizing effect on a male or" k. N# G4 q* ^0 y4 g
female child who might come in contact with some-
, V: O3 e% R1 i( z' vone using any of these products.
- y! e( [/ i9 g- O; t" D* l# B0 ?( BReferences- k) E* b9 ?4 I
1. Styne DM. The testes: disorder of sexual differentiation' y* Y/ s' U' j' \1 z' O! {& w
and puberty in the male. In: Sperling MA, ed. Pediatric% h) s% y7 b" \' p3 Z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 X) j9 C N$ l/ O7 b2002: 565-628.
. M% v3 S6 T2 Z: h1 n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% b6 v& [) o9 C/ \" x: j5 X" y
puberty in children with tumours of the suprasellar pineal |
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