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Sexual Precocity in a 16-Month-Old
: Y4 z" A0 m8 }/ Y* q: oBoy Induced by Indirect Topical) c: S/ K& }, u9 R; ~) X
Exposure to Testosterone
) a6 O; J; z$ N( {* qSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. }- ], k1 Y" i! o) E0 d5 @* ]8 I
and Kenneth R. Rettig, MD1+ o( z; {0 @$ v6 }
Clinical Pediatrics3 F6 L1 d. D, i/ v% ^/ O3 T0 s8 }
Volume 46 Number 6
/ O$ F! c, }/ e) U$ lJuly 2007 540-5432 S) W# P. @3 g9 |0 `
© 2007 Sage Publications4 c& U/ x+ k! t- x
10.1177/0009922806296651
5 w( t7 ?: [9 j5 I" vhttp://clp.sagepub.com3 U0 o6 [) i* Q1 Y# ]
hosted at
3 U7 {. S( y, nhttp://online.sagepub.com
# T& S. A! ]$ ^! I$ wPrecocious puberty in boys, central or peripheral,
! S: X- H: f+ U2 L& |0 E+ Tis a significant concern for physicians. Central3 v# U1 t" U. {6 L! h3 b
precocious puberty (CPP), which is mediated
& `' X6 q7 \ G( Xthrough the hypothalamic pituitary gonadal axis, has. R1 {. \/ c8 Z- \2 n: X7 _
a higher incidence of organic central nervous system- W% ?8 X$ j4 i6 ~& [& R2 G% X
lesions in boys.1,2 Virilization in boys, as manifested
8 Z/ d. q+ Y: N- d$ Oby enlargement of the penis, development of pubic: V: M- v# e+ ?& E- e5 I+ u* |. O
hair, and facial acne without enlargement of testi-
5 I7 x7 W0 M7 W* ~5 i2 H3 a8 d7 |cles, suggests peripheral or pseudopuberty.1-3 We& F1 B1 T6 h. h; k# ?/ X
report a 16-month-old boy who presented with the2 r* H# @) a/ ]% @
enlargement of the phallus and pubic hair develop-
# {8 C& T- C1 A1 g1 d) L$ qment without testicular enlargement, which was due# Q A7 l5 p& N( u9 ~+ Y
to the unintentional exposure to androgen gel used by
% o. Y- m o8 I& i0 H! L+ \: Uthe father. The family initially concealed this infor-; G9 G, v" M0 C
mation, resulting in an extensive work-up for this
" Y( F" k0 i/ F S/ V; Bchild. Given the widespread and easy availability of
! D8 m" S1 N9 F) W/ G# ltestosterone gel and cream, we believe this is proba-6 [( e' w# E' \) m8 n; S
bly more common than the rare case report in the/ n9 }9 E; @+ d2 |, L9 Z& t
literature.45 R3 U- k* C4 F
Patient Report) v& i/ X3 Y0 t6 I* h
A 16-month-old white child was referred to the
) E u3 \/ B" b" oendocrine clinic by his pediatrician with the concern
/ i* H* y c) V. N Fof early sexual development. His mother noticed
& j$ \1 H( ~( t" olight colored pubic hair development when he was, r# {3 L0 o3 T2 I( y. C
From the 1Division of Pediatric Endocrinology, 2University of) R- F1 X/ t, n7 E2 o7 I q
South Alabama Medical Center, Mobile, Alabama.
3 j' n3 m. N2 _% O' H& lAddress correspondence to: Samar K. Bhowmick, MD, FACE,
; |$ @: \, F" I$ h0 i i8 G' a8 L$ KProfessor of Pediatrics, University of South Alabama, College of
- [. O1 z6 T4 e8 B( G% bMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 D/ y( U9 u `6 V: d8 k6 V
e-mail: [email protected].
! D% X! V/ S$ x) w* l- f6 D- T! ]about 6 to 7 months old, which progressively became
, j, y' ]6 B2 I) m5 Ndarker. She was also concerned about the enlarge-
8 [" ]% X6 G) n2 W zment of his penis and frequent erections. The child4 K: v" o& e6 Y8 T
was the product of a full-term normal delivery, with
) q: M0 G0 q( I X4 ?: l: q; @- [a birth weight of 7 lb 14 oz, and birth length of
7 c% b5 R* s6 R- {; ], E9 T* }2 P20 inches. He was breast-fed throughout the first year
- `3 `! w: K, W) @, R# w# C+ p- s5 oof life and was still receiving breast milk along with
# _% h1 Y5 i) f! A, v H' A) Vsolid food. He had no hospitalizations or surgery,
; c* K) \6 h# b8 A" j. r: j8 rand his psychosocial and psychomotor development2 q* H3 _" a. t3 I8 _5 P0 @: a
was age appropriate.
2 y3 s& g _' U( G3 d: [The family history was remarkable for the father,5 t( p/ b' S! t u( T2 R3 @1 E
who was diagnosed with hypothyroidism at age 16,9 r# q: P; w7 k- C1 ?; g F' a
which was treated with thyroxine. The father’s/ M/ j# N$ G3 @4 H: m U
height was 6 feet, and he went through a somewhat
, m1 b: {3 _. w! T+ Fearly puberty and had stopped growing by age 14.# R- m" i2 [' U
The father denied taking any other medication. The
# w1 r8 |2 C q$ Y5 ichild’s mother was in good health. Her menarche
5 }$ E M% ]2 x K- z" r& T0 K2 hwas at 11 years of age, and her height was at 5 feet9 \. D% p+ B9 Z q _
5 inches. There was no other family history of pre-
# u3 n: h! I) B3 u: l6 s x2 H# vcocious sexual development in the first-degree rela-( I6 \5 d% ~# Y4 K2 F8 [& r/ ?3 W
tives. There were no siblings.% D. s# w& x" F+ m% F( _4 {) G
Physical Examination$ A ^( w- B" ^" | A4 r0 {+ ^& @
The physical examination revealed a very active,1 U: c+ t. k8 t6 D9 ^5 _2 Z+ d
playful, and healthy boy. The vital signs documented
- W& o$ A/ Y B( W- Ka blood pressure of 85/50 mm Hg, his length was$ M0 [$ J! i" ^
90 cm (>97th percentile), and his weight was 14.4 kg
: ?4 u: Z8 _6 v6 }" |(also >97th percentile). The observed yearly growth. T# K2 A, c( u" |# r, v
velocity was 30 cm (12 inches). The examination of& }" B& R9 B' l
the neck revealed no thyroid enlargement.
7 ^, P; _+ d5 r+ [( j0 YThe genitourinary examination was remarkable for, @8 k0 L7 V+ ~" o6 @
enlargement of the penis, with a stretched length of
+ Q7 |$ w I* M% H6 X$ }3 ~- u8 cm and a width of 2 cm. The glans penis was very well
/ A1 z+ y/ e7 C0 C/ z4 D9 Wdeveloped. The pubic hair was Tanner II, mostly around" `4 a& ~, e( T- B8 t3 ?
540
8 r# r7 V& v f$ A' a9 Yat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" e d' \& n9 a5 o0 ?the base of the phallus and was dark and curled. The
9 A6 h+ X* v5 K) o" w8 }' Stesticular volume was prepubertal at 2 mL each.& s2 |* u% j3 v. C* l3 a. \" Z( `
The skin was moist and smooth and somewhat
* c+ U9 W, ?, ^! T. u: Yoily. No axillary hair was noted. There were no, M) B2 C: Z; q* \ c
abnormal skin pigmentations or café-au-lait spots.' ?" W. [# ?3 y+ |. k! Z
Neurologic evaluation showed deep tendon reflex 2+* F! S6 E0 X6 O" l9 ]
bilateral and symmetrical. There was no suggestion
5 B$ g! @, `8 K: p) h5 jof papilledema.# _# u# a$ I0 t5 n1 O2 E8 y
Laboratory Evaluation8 D/ k. E1 f" F/ A$ T3 {
The bone age was consistent with 28 months by4 f$ r+ l# `5 J- x* \2 V
using the standard of Greulich and Pyle at a chrono-9 L! `* u: x1 E2 ]$ x0 e" u6 B5 X
logic age of 16 months (advanced).5 Chromosomal
' U* Y$ f# C1 S! F0 ]1 i, Ckaryotype was 46XY. The thyroid function test
+ B6 ^. K7 c8 T$ G# f+ k( Jshowed a free T4 of 1.69 ng/dL, and thyroid stimu-' y. f+ ~2 w. x5 N, F2 v9 K9 P f
lating hormone level was 1.3 µIU/mL (both normal).' y9 {, `9 l+ k
The concentrations of serum electrolytes, blood
/ ~/ ]. e* @8 }7 |/ durea nitrogen, creatinine, and calcium all were' l2 @; y3 f/ J
within normal range for his age. The concentration5 ]+ j/ M4 U7 ?# W* o( N0 {
of serum 17-hydroxyprogesterone was 16 ng/dL
. z' Q3 m; u) ?! e& I(normal, 3 to 90 ng/dL), androstenedione was 20
# z7 _, e4 O2 q% L5 ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 T- D. J$ m8 G! Gterone was 38 ng/dL (normal, 50 to 760 ng/dL),
% j, u |- [) @& T1 ^desoxycorticosterone was 4.3 ng/dL (normal, 7 to
" O' S# v$ V R$ P! V% U9 `& I49ng/dL), 11-desoxycortisol (specific compound S)) a, P, F1 J9 ~- c$ }/ k* ?
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
4 t) b- R& u7 y+ Qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: q+ t& ^. v7 N M) {$ vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
w' G+ S: I' gand β-human chorionic gonadotropin was less than( {+ E T: B& [
5 mIU/mL (normal <5 mIU/mL). Serum follicular
% d1 ]1 d2 x8 S4 k; bstimulating hormone and leuteinizing hormone
5 Z# r. ^: \: tconcentrations were less than 0.05 mIU/mL. D3 ]3 X& @! @, J; d1 ^9 `
(prepubertal).6 H) f$ ^4 S9 h* `; ~! K6 V1 a
The parents were notified about the laboratory
) G. D: |9 m9 ^- B1 eresults and were informed that all of the tests were; h( i7 E4 h3 s( X! G# [
normal except the testosterone level was high. The
: b5 z. {7 E* D" ifollow-up visit was arranged within a few weeks to
# q* q k, x3 S5 @6 M, Qobtain testicular and abdominal sonograms; how-4 n6 z. i6 g8 \9 Q: o, n1 a
ever, the family did not return for 4 months.+ p8 t2 q( @, e: J- i; O
Physical examination at this time revealed that the
c8 d1 ~5 K: y2 a J9 A1 Jchild had grown 2.5 cm in 4 months and had gained
3 S+ m# V4 [& M/ ?7 e2 kg of weight. Physical examination remained c; L# k- ]. A8 N: J* I
unchanged. Surprisingly, the pubic hair almost com-
. u. b; U7 v$ H2 bpletely disappeared except for a few vellous hairs at% D8 R( x$ p) L) X
the base of the phallus. Testicular volume was still 2
) [( o- f* g1 e5 T9 R3 |9 ~mL, and the size of the penis remained unchanged.! Z$ V. n. Q+ q( Q! }, ^* @
The mother also said that the boy was no longer hav-
- k8 Y& |" ]' r5 M- w+ oing frequent erections.6 l- H0 `: ?4 L/ B
Both parents were again questioned about use of, A" m; _/ P( f: f
any ointment/creams that they may have applied to6 g3 d" o* X) v4 O
the child’s skin. This time the father admitted the- E/ d6 l$ @2 y4 \: ~+ s H) F6 w
Topical Testosterone Exposure / Bhowmick et al 541
) h# J1 `3 r5 i2 _3 F* Kuse of testosterone gel twice daily that he was apply-/ |8 a' n! F) a# N* Z* p' d" W( C
ing over his own shoulders, chest, and back area for
% O' M5 s q/ L8 _2 W0 ^7 Wa year. The father also revealed he was embarrassed
3 M( X" r) \3 [8 @2 ~1 n0 Tto disclose that he was using a testosterone gel pre-
+ ?" j3 {/ G1 i bscribed by his family physician for decreased libido8 p) }3 |6 c2 Y! `; w0 t$ B w9 b
secondary to depression.
6 v0 A+ X. J$ O/ O. HThe child slept in the same bed with parents.
& Q0 n, K/ x" u& a! R/ u1 ]& t8 kThe father would hug the baby and hold him on his
# j! R% Z; r( y6 }chest for a considerable period of time, causing sig-
1 Y# X0 O( B. d, A1 F! D/ Hnificant bare skin contact between baby and father.' J, h: ^7 I2 h3 b7 n
The father also admitted that after the phone call,
* Y- [# I1 N, V, d4 p3 f% ]5 \/ gwhen he learned the testosterone level in the baby
. Z* O( M2 } |* Z2 wwas high, he then read the product information! k' Q7 |# b$ i9 y+ [9 Z
packet and concluded that it was most likely the rea-" S: O! _6 F8 X- G
son for the child’s virilization. At that time, they; o" g1 M( j7 J& K+ H
decided to put the baby in a separate bed, and the# h( D3 [+ A4 a# o
father was not hugging him with bare skin and had
: G2 Z. b: t( i3 ?) hbeen using protective clothing. A repeat testosterone
4 x* c7 Z8 o) a; b% s2 ]test was ordered, but the family did not go to the" X4 s% G. }% i0 U2 r& n* e1 ^
laboratory to obtain the test.2 t- H8 m' I+ r' X
Discussion
8 L: r$ \- \ q$ ^/ J7 yPrecocious puberty in boys is defined as secondary
& M, r% E; @+ Q) X! f+ H3 x* Xsexual development before 9 years of age.1,40 C- A* R. E* B* }# Q* _* {& g
Precocious puberty is termed as central (true) when
1 L" o7 |: n" }. V) w0 }4 Wit is caused by the premature activation of hypo-& V, ?7 r( E8 i$ E% z( j
thalamic pituitary gonadal axis. CPP is more com-. b$ o% p! i5 n. ]. m6 q
mon in girls than in boys.1,3 Most boys with CPP
" r# i2 K8 ^5 i6 ]may have a central nervous system lesion that is
! u ?( S' U0 ~8 z' F0 Y/ F% oresponsible for the early activation of the hypothal-
2 `0 f# c! V/ `- @0 y m# |amic pituitary gonadal axis.1-3 Thus, greater empha-, \( ]& ~, f ]: b( D& ]& e
sis has been given to neuroradiologic imaging in
) r; K7 U+ w1 f) pboys with precocious puberty. In addition to viril-
0 g0 Q- w3 r- s( kization, the clinical hallmark of CPP is the symmet-
% f( V$ Y- B& crical testicular growth secondary to stimulation by
4 @$ B6 \0 W1 m: }$ M+ p, Kgonadotropins.1,3) t" i& q* U; S [4 t
Gonadotropin-independent peripheral preco-
7 M/ G4 s% ^4 g! N* b5 t. Q: J, hcious puberty in boys also results from inappropriate
; o' y. t! o& V! Y5 q9 ?androgenic stimulation from either endogenous or' i+ Q ]4 ?/ S7 K/ C- K9 d
exogenous sources, nonpituitary gonadotropin stim-, ]; O8 y9 Y7 o) Q
ulation, and rare activating mutations.3 Virilizing
3 W' M1 n: g: h3 @; y: K xcongenital adrenal hyperplasia producing excessive
3 v4 `9 U( }. d7 {; s& j' Oadrenal androgens is a common cause of precocious
5 C9 y. X! J5 q: O- n( l! i0 mpuberty in boys.3,49 Q$ E% z) K* r7 Q1 ?: B0 o0 h
The most common form of congenital adrenal
0 _- L; R% m! X+ rhyperplasia is the 21-hydroxylase enzyme deficiency.
% _" ?$ ?, u% u, ~8 n& CThe 11-β hydroxylase deficiency may also result in! t [' i2 L7 g0 C: ~# Q
excessive adrenal androgen production, and rarely,
1 E- w1 e0 h4 l/ jan adrenal tumor may also cause adrenal androgen
7 ^8 ^! h0 L: n# D" [# L7 C( m& Yexcess.1,31 Q( T+ w# W# v: `( n$ e3 v) Q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) y! L* T: t( R" a; i9 U+ f
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% d! \% `3 k/ _' s4 sA unique entity of male-limited gonadotropin-9 S' B5 ^6 n M
independent precocious puberty, which is also known/ |: ]# ^9 c: v u4 |1 e/ e
as testotoxicosis, may cause precocious puberty at a' P& \0 V6 I+ W. ]# y% C9 f
very young age. The physical findings in these boys
5 d$ S0 p# ^4 Q$ cwith this disorder are full pubertal development,. Q9 K( }' D. u# V) u9 P, x
including bilateral testicular growth, similar to boys
0 r9 g: ]+ G) ?/ pwith CPP. The gonadotropin levels in this disorder
2 r l- y& K2 X0 S, s1 y, V6 X5 Fare suppressed to prepubertal levels and do not show" G3 i( ]1 [2 x: B. l+ w }
pubertal response of gonadotropin after gonadotropin-" d7 w* Q+ C3 p9 s, l
releasing hormone stimulation. This is a sex-linked( v2 ?5 P$ }0 n: {
autosomal dominant disorder that affects only7 n) o4 a' P. T- l' n; ] E! `
males; therefore, other male members of the family
$ O3 l9 o$ C8 \/ @! lmay have similar precocious puberty.3
/ D# Y8 M' B/ w# ^In our patient, physical examination was incon-) J8 G" _3 w) F2 v
sistent with true precocious puberty since his testi-# x4 C1 G2 o1 C
cles were prepubertal in size. However, testotoxicosis
' {. \. M! M0 B9 bwas in the differential diagnosis because his father
/ M7 D, R& U" o# Y3 kstarted puberty somewhat early, and occasionally,% G4 I$ _. Y: d5 @
testicular enlargement is not that evident in the) b U' r5 [6 D$ C2 \/ D
beginning of this process.1 In the absence of a neg-; ?2 D4 ?0 {2 {1 M( Q9 x3 \4 _
ative initial history of androgen exposure, our0 Z9 Z6 Y9 }3 Z4 I" X1 a" ^* e
biggest concern was virilizing adrenal hyperplasia,5 W, ~4 A" n, s
either 21-hydroxylase deficiency or 11-β hydroxylase
+ R- A' A+ H' ]2 _- G" ]" }deficiency. Those diagnoses were excluded by find-# V& u7 r* q2 |! ^" J1 F
ing the normal level of adrenal steroids.
6 O. ~6 c1 g1 x8 j' l+ LThe diagnosis of exogenous androgens was strongly
3 g. r( T3 J/ @( [suspected in a follow-up visit after 4 months because) t7 N' {% J( Y0 ~; i8 N
the physical examination revealed the complete disap- p$ r' B/ W2 M y( M/ [/ p9 s6 r
pearance of pubic hair, normal growth velocity, and. y, U+ D, k5 t0 K$ c
decreased erections. The father admitted using a testos-& K6 T) [! _) Y/ G7 S
terone gel, which he concealed at first visit. He was% r) \' e; Q3 J3 H9 a; U' D! N
using it rather frequently, twice a day. The Physicians’
+ T. U; x7 M# s9 _ ]" K% @Desk Reference, or package insert of this product, gel or
+ Y8 t& \# X" F% G) ?cream, cautions about dermal testosterone transfer to' o9 H$ F2 q2 b' @1 f9 {0 z
unprotected females through direct skin exposure.
6 v% C5 x ]; m8 J xSerum testosterone level was found to be 2 times the
# r, q4 ^; \% j( y! Rbaseline value in those females who were exposed to' N4 V3 D5 j1 r7 Y* ?# T+ D
even 15 minutes of direct skin contact with their male
( f2 B/ F& h7 Opartners.6 However, when a shirt covered the applica-" I* R2 m% O% M! Y/ |' x5 {! p
tion site, this testosterone transfer was prevented.
# d5 _# W* }- C9 FOur patient’s testosterone level was 60 ng/mL,
) W& S5 t8 Q8 n1 l: Q& J% Vwhich was clearly high. Some studies suggest that
1 N5 N. m0 h: W, x) g& Zdermal conversion of testosterone to dihydrotestos-
. T7 n: v. \- R- {' W) C# Hterone, which is a more potent metabolite, is more
/ G* M8 O% o6 H5 b. \active in young children exposed to testosterone
6 p4 t( y3 {5 |exogenously7; however, we did not measure a dihy-
) ^! i2 F5 Y) O: g# Ydrotestosterone level in our patient. In addition to
; q1 \7 @/ w/ k( x" X( h, z3 ]6 }virilization, exposure to exogenous testosterone in8 A5 z/ o- ?6 S, {
children results in an increase in growth velocity and
' N, p+ y8 [! c4 v2 Q# u8 G+ |* ^: Dadvanced bone age, as seen in our patient.& L. S; p8 ]5 \6 E+ ?+ P1 |9 L
The long-term effect of androgen exposure during0 J+ d6 \% T4 V& |
early childhood on pubertal development and final e- ?* x3 e+ z) g# ]% d
adult height are not fully known and always remain
. D; _3 b5 P# @2 W8 aa concern. Children treated with short-term testos- D# V& Y% [4 f& K
terone injection or topical androgen may exhibit some9 A; k1 L; C) M
acceleration of the skeletal maturation; however, after) L4 B4 `0 w/ U. t& {9 y5 d7 |# C9 z
cessation of treatment, the rate of bone maturation
- I2 A+ S/ X% G5 H. J( Jdecelerates and gradually returns to normal.8,9
7 |8 L- u. s8 p4 _) P# WThere are conflicting reports and controversy
- M. T N1 W2 |% t" U" C0 ?; yover the effect of early androgen exposure on adult- \; e# c* j U4 \# e* g$ w$ a
penile length.10,11 Some reports suggest subnormal0 X" G, ~2 d' w- u6 U+ L$ t
adult penile length, apparently because of downreg-
1 g7 i* j8 h/ r b6 \ulation of androgen receptor number.10,12 However,3 t/ \# I3 C- Z- v% ]
Sutherland et al13 did not find a correlation between
' h4 x: V5 j9 h( ]/ Ychildhood testosterone exposure and reduced adult' K9 O# d9 A5 j1 N
penile length in clinical studies.2 I3 e9 x- |# f+ v7 ?+ F
Nonetheless, we do not believe our patient is' Q$ q1 ^$ Y2 f
going to experience any of the untoward effects from3 i/ K: s7 q8 t3 Y; ^
testosterone exposure as mentioned earlier because
3 J+ T9 z; S5 Q* s, sthe exposure was not for a prolonged period of time.
9 I0 [: p, z5 H8 W# AAlthough the bone age was advanced at the time of3 }1 D6 s7 N" W4 |
diagnosis, the child had a normal growth velocity at& |" h: G* b2 [9 a8 k
the follow-up visit. It is hoped that his final adult
8 _' z/ o7 j/ `2 C E+ d1 t" ^height will not be affected.
( m; Q' p4 ~; I; u8 i HAlthough rarely reported, the widespread avail-, V; [8 y$ @) D+ H; A' j+ z
ability of androgen products in our society may
( V7 R. f1 S6 k9 T, Z7 y3 U9 Eindeed cause more virilization in male or female9 T# E" L9 D5 h3 x( }+ I/ ^
children than one would realize. Exposure to andro-
, {& I8 R$ H2 J6 Vgen products must be considered and specific ques-, p4 E$ ~! L: r. S% G
tioning about the use of a testosterone product or
& Z' ]& m9 h7 [gel should be asked of the family members during
1 C/ s( w& O% m, J* O0 Tthe evaluation of any children who present with vir-8 i5 X1 `0 k- f/ Q) z9 N
ilization or peripheral precocious puberty. The diag-
7 w! _$ O6 `( |) Qnosis can be established by just a few tests and by
1 G: y6 V: u( D: W' tappropriate history. The inability to obtain such a( w- Z4 g+ R9 w( q$ Y, K; Z
history, or failure to ask the specific questions, may
+ O7 w. R; ^2 |% o% J4 h9 U- j9 R; Xresult in extensive, unnecessary, and expensive# D4 K) G( w6 C+ d
investigation. The primary care physician should be, _1 o; M' ~5 s! {# [. m/ ]5 f
aware of this fact, because most of these children" f0 B) H$ p( U6 y
may initially present in their practice. The Physicians’% w2 G* f0 A7 O2 \9 M4 E
Desk Reference and package insert should also put a
4 J l7 t( \/ e6 j+ h+ k2 Bwarning about the virilizing effect on a male or) x' a0 h h6 p9 z0 K3 y1 N
female child who might come in contact with some-; z2 ?" M6 x. W' Y
one using any of these products.
! N d0 Y0 @0 Y3 Y( kReferences
2 I0 v F. `6 Y p6 g5 M3 {; S7 B) N1. Styne DM. The testes: disorder of sexual differentiation
' Y' W7 F, o0 s L" |& p) ^; U+ M( b& zand puberty in the male. In: Sperling MA, ed. Pediatric! U8 A: _% G2 b# ?: `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;) ]; @: a2 S" L" s5 ?5 v, N
2002: 565-628.
! N+ x- Y a$ D2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 s/ A4 N* `6 Z( L0 O
puberty in children with tumours of the suprasellar pineal |
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