- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:25:35
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old
4 {# S+ F6 \/ NBoy Induced by Indirect Topical! C2 Z" \ ]9 D" W! X/ S5 r
Exposure to Testosterone( [. @7 C# t# U
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- i1 @+ Y2 g* h
and Kenneth R. Rettig, MD1
+ D1 X: F1 p8 }6 l( CClinical Pediatrics3 ~+ c& F6 X: f. e
Volume 46 Number 6) e: U$ K) F/ ]. d2 h
July 2007 540-543- ^+ J1 t8 e/ W& m8 Q
© 2007 Sage Publications4 ?3 @3 S1 J) q g. u: j4 F
10.1177/0009922806296651
8 } Z# O9 U% b+ j3 Mhttp://clp.sagepub.com: B' F: {5 o9 y9 Q5 X( [5 c( \* c
hosted at( [8 W: V, T: A/ {5 {) S
http://online.sagepub.com: i4 e& c6 Z5 w$ v9 N
Precocious puberty in boys, central or peripheral,5 n, l) Z9 @3 R0 d# `! X
is a significant concern for physicians. Central
. t5 [, e' r- N3 }; wprecocious puberty (CPP), which is mediated
* i9 A% [+ k# ethrough the hypothalamic pituitary gonadal axis, has0 ]7 }. j2 O8 |/ r# c) p" C, I# ?
a higher incidence of organic central nervous system
8 x: a+ ?* ]# u+ u, W9 zlesions in boys.1,2 Virilization in boys, as manifested' i3 [5 k8 l% b$ M) I2 j: c6 i3 W4 j
by enlargement of the penis, development of pubic
' ^5 a5 _8 e3 a8 Mhair, and facial acne without enlargement of testi-
- r% f5 V" |+ Z4 kcles, suggests peripheral or pseudopuberty.1-3 We
+ Q, y/ z7 k% K7 u% Ereport a 16-month-old boy who presented with the
9 S- E K$ x6 O, q+ venlargement of the phallus and pubic hair develop-( a; t$ g* N" H4 ?6 O# l# B& j: k
ment without testicular enlargement, which was due; b l; F( Q; j: H6 Q* |
to the unintentional exposure to androgen gel used by/ N& \$ J0 ^1 Q9 Q% V1 o
the father. The family initially concealed this infor-6 f$ ?2 l8 \" \: T! N& M7 t
mation, resulting in an extensive work-up for this# ]% C! Z @# _( P
child. Given the widespread and easy availability of* G0 z5 m* f H! F M- c1 M
testosterone gel and cream, we believe this is proba-: F6 |; V5 @; V9 o5 H1 ] j
bly more common than the rare case report in the J6 W9 X! o- }. F% o* y6 P
literature.4
" K' Q+ e( \3 e) a! b/ OPatient Report
8 F( s& N$ `4 D: v# X) [A 16-month-old white child was referred to the
/ l, ^1 ^/ ~% F; _7 C5 W2 \- pendocrine clinic by his pediatrician with the concern) n' j& N2 W- g# b1 N0 d0 L
of early sexual development. His mother noticed6 G" u$ Y! `& [5 c. h1 g9 s' p6 g
light colored pubic hair development when he was$ }+ C! s% ]3 n7 Y0 q" v9 u
From the 1Division of Pediatric Endocrinology, 2University of
; k5 H) O) h( s! K" h% m4 mSouth Alabama Medical Center, Mobile, Alabama.3 U1 Z( k/ O' ?
Address correspondence to: Samar K. Bhowmick, MD, FACE,! ~; q/ t6 S5 F( o/ O- p
Professor of Pediatrics, University of South Alabama, College of0 Y6 f5 Q* ]& c. e6 S
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 B& O+ K6 x7 \
e-mail: [email protected]., h' a9 h2 |* y2 J9 \! V/ m
about 6 to 7 months old, which progressively became
& k2 e( b% z( b8 sdarker. She was also concerned about the enlarge-2 {4 G: l1 \( ~, I1 X
ment of his penis and frequent erections. The child
6 c+ l' \3 d: I$ ?was the product of a full-term normal delivery, with; R0 [. [4 w! v, H9 t* S
a birth weight of 7 lb 14 oz, and birth length of
' S$ T$ \2 ?6 m# l; u20 inches. He was breast-fed throughout the first year$ b! R; i& o* g1 o) s
of life and was still receiving breast milk along with
1 E1 E. E6 A8 Nsolid food. He had no hospitalizations or surgery,
7 ~: @0 r- i) z8 }! ^% m' @5 Iand his psychosocial and psychomotor development
: ]! E- h0 z, ]8 N& nwas age appropriate.9 L1 S. i c5 ^2 L9 k
The family history was remarkable for the father,8 L% B I0 Q8 F: c
who was diagnosed with hypothyroidism at age 16,6 U0 J5 t# D2 k# B- x8 Q9 z, o
which was treated with thyroxine. The father’s6 ` J8 q) y `2 y5 x7 ^% M1 ^
height was 6 feet, and he went through a somewhat# a; d, M' x! y4 D" \% k: M
early puberty and had stopped growing by age 14.8 I* v7 K ^: A7 @: {) K9 [
The father denied taking any other medication. The
$ g& O& P( h) K$ v& @4 wchild’s mother was in good health. Her menarche- @0 q& A5 O4 f- W
was at 11 years of age, and her height was at 5 feet5 }9 A- j; ^; d7 S/ t
5 inches. There was no other family history of pre-
3 X* q% Y( H4 }% e* g0 U$ H, ]3 J7 qcocious sexual development in the first-degree rela-# p- f0 U! _) O6 O; C2 b: _
tives. There were no siblings.' r, S6 h" Y3 p& l2 b$ a: A
Physical Examination! X. e) p$ Q0 v: G7 G! W
The physical examination revealed a very active,# i( s" e! @; H# ]9 H1 X& |
playful, and healthy boy. The vital signs documented: U1 a5 C$ \; @
a blood pressure of 85/50 mm Hg, his length was R" b% Y" }0 f' h- n; B) r
90 cm (>97th percentile), and his weight was 14.4 kg4 T. Z* e! e* K* _
(also >97th percentile). The observed yearly growth) C* s5 M+ p, `" w
velocity was 30 cm (12 inches). The examination of
/ }4 ]) A( j2 ^6 @6 o+ X! b, Pthe neck revealed no thyroid enlargement.
0 o- I3 C' a1 z$ S0 w/ Y( k6 ?: UThe genitourinary examination was remarkable for* G4 z/ d" d* y. i! e$ J3 d
enlargement of the penis, with a stretched length of" C; i) H$ ?" i- Z6 e3 p7 H {, g
8 cm and a width of 2 cm. The glans penis was very well
9 w4 J4 u! H; K, a& rdeveloped. The pubic hair was Tanner II, mostly around5 |- V, V$ H1 b, G, E
540
* [: }& T" a* `' I2 g) nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 T2 a; L. P+ c6 Z
the base of the phallus and was dark and curled. The* f) j* d* p' _7 K6 r* [# v, t
testicular volume was prepubertal at 2 mL each., @' J. i; h/ Y9 N( H
The skin was moist and smooth and somewhat
& x8 @6 w7 m4 K+ f9 G4 T* woily. No axillary hair was noted. There were no
' B6 R$ T3 r- W( r1 ]& ?* Qabnormal skin pigmentations or café-au-lait spots.
+ Q$ _9 o0 q( H- x- D4 h! M, M% RNeurologic evaluation showed deep tendon reflex 2+
{3 X/ S/ P) w* S6 Hbilateral and symmetrical. There was no suggestion
# V" C# U5 b+ x- F, A% M' ^$ J$ _. Iof papilledema.
* W0 d! Y* @/ P# I9 a; c1 iLaboratory Evaluation# }! v- I# z( {+ H" b# I
The bone age was consistent with 28 months by
$ }, p5 W6 G2 H1 O5 i+ j! Xusing the standard of Greulich and Pyle at a chrono-" O6 N, s2 Q! I# i
logic age of 16 months (advanced).5 Chromosomal' V+ _/ P' _- G: |* w3 K% }
karyotype was 46XY. The thyroid function test
( h: _' e4 O& r& N9 [showed a free T4 of 1.69 ng/dL, and thyroid stimu-3 i+ t- ^* P; a7 @, h9 t
lating hormone level was 1.3 µIU/mL (both normal).4 l8 x! `. m! y1 w: P7 N/ j
The concentrations of serum electrolytes, blood
4 T* W, N/ ]9 @, n! R+ K- gurea nitrogen, creatinine, and calcium all were
- ~, K8 c4 Z4 r" e9 h, f2 cwithin normal range for his age. The concentration; o0 U9 p" H) W; R/ g# ]' x
of serum 17-hydroxyprogesterone was 16 ng/dL4 g6 j. O$ F9 w# @
(normal, 3 to 90 ng/dL), androstenedione was 20
5 K' s0 n# D4 ]6 ^* Yng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& S% E( D& @# ?3 H, N) _terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 P4 _) t4 p! A; cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to- @; l! {. I4 s! B$ L
49ng/dL), 11-desoxycortisol (specific compound S); X- D7 G( D9 l
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 }7 U7 ~! c: L% R/ [tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total u8 m. |) d2 _- t$ \
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 z+ s% A8 [5 ]" E* V& Gand β-human chorionic gonadotropin was less than, `9 C5 D/ J% @8 p
5 mIU/mL (normal <5 mIU/mL). Serum follicular
; B$ @# L. w) a8 M& o. lstimulating hormone and leuteinizing hormone
8 M5 z! K, q# fconcentrations were less than 0.05 mIU/mL% y/ ]' T% {& C8 N9 S, o! i
(prepubertal).; X5 z" C4 B5 E$ h
The parents were notified about the laboratory
0 [8 r& \, v6 Rresults and were informed that all of the tests were0 x: }- I4 M. M" v/ v. U5 M
normal except the testosterone level was high. The
& t- e5 {) m/ k1 O8 \& T0 T; Q# Qfollow-up visit was arranged within a few weeks to
! F. ^ ]5 [9 f3 Nobtain testicular and abdominal sonograms; how-
, k4 ]9 k" {7 Tever, the family did not return for 4 months.
- d4 u5 j/ J& A+ {- e* ZPhysical examination at this time revealed that the
6 l+ N, e& h. s* uchild had grown 2.5 cm in 4 months and had gained1 Z" I2 t. [( ~+ D1 l$ C8 l- o
2 kg of weight. Physical examination remained0 h/ C) W8 I7 j& y2 {$ u
unchanged. Surprisingly, the pubic hair almost com-$ w1 X1 i' D9 H4 F/ ?" w" J# I
pletely disappeared except for a few vellous hairs at5 R6 m8 p9 w* K* K7 t1 E/ ~3 z2 ]
the base of the phallus. Testicular volume was still 2, R4 L6 a4 B; \/ i# d( ]/ W
mL, and the size of the penis remained unchanged." j/ S$ l' r t- {7 X
The mother also said that the boy was no longer hav-9 J& ^3 w/ k$ u. T
ing frequent erections.
" K: t, Y/ T' K \, _+ T' uBoth parents were again questioned about use of
+ m+ |: {$ H% {( M: J& M, R5 sany ointment/creams that they may have applied to$ S4 {5 |( @! Z' N. b
the child’s skin. This time the father admitted the$ i: V6 p6 w$ G; p7 q
Topical Testosterone Exposure / Bhowmick et al 541- E$ _# v% n' Y% k
use of testosterone gel twice daily that he was apply-
6 L7 s/ S0 L6 K! ^- ~/ ~( `ing over his own shoulders, chest, and back area for
1 D/ d; Q/ v" F" }a year. The father also revealed he was embarrassed# D( o/ F. R: Q- k1 b& f
to disclose that he was using a testosterone gel pre-8 U4 `0 _. d$ _6 C- I9 k
scribed by his family physician for decreased libido, M7 m" r, o% d
secondary to depression.9 @: f( t1 S7 x r4 Q2 [/ Z
The child slept in the same bed with parents.
9 N4 o# e2 w) B/ s, lThe father would hug the baby and hold him on his
% i/ r" ?$ Q4 U. A: ichest for a considerable period of time, causing sig-
( E4 G2 \8 V' s. v3 p2 }nificant bare skin contact between baby and father.
, N6 d7 V. O3 q' l- _" QThe father also admitted that after the phone call,- d9 w( E8 l/ b$ c1 b D; @
when he learned the testosterone level in the baby& s* l! ^8 _3 W1 p( _' j+ R5 ], B
was high, he then read the product information
0 v1 r" W( y7 H; U' w1 W5 ppacket and concluded that it was most likely the rea-9 F/ K! b8 H9 ]; N6 f& i% n
son for the child’s virilization. At that time, they( H# [; H8 k: A+ B
decided to put the baby in a separate bed, and the6 B7 m6 N! a% _5 Z- h. W1 p9 w
father was not hugging him with bare skin and had
2 j# _% w" o6 }been using protective clothing. A repeat testosterone
! i( I, k) m0 E4 E1 B. v# mtest was ordered, but the family did not go to the
: ]+ R) R1 y- Vlaboratory to obtain the test.% x# i! z' c! i2 K) g! x+ y
Discussion* e) f$ z l% n8 v6 ]. w
Precocious puberty in boys is defined as secondary
' Q8 z3 ]( N2 V9 y ~sexual development before 9 years of age.1,4
) X5 X$ t' _+ l) ZPrecocious puberty is termed as central (true) when
) C$ Y" d. G! I7 oit is caused by the premature activation of hypo-
$ R9 N8 D$ t! o2 Z3 j5 K+ [thalamic pituitary gonadal axis. CPP is more com-& ~( J+ E/ G! S# @3 r
mon in girls than in boys.1,3 Most boys with CPP
i+ d% @9 q0 s1 P( f- ~5 S& |0 Hmay have a central nervous system lesion that is
' j2 [. J4 ^5 _8 @responsible for the early activation of the hypothal-
% R! T' ~( u6 A8 `# Iamic pituitary gonadal axis.1-3 Thus, greater empha-7 S- Q, F9 r0 p0 I* W, s S3 T
sis has been given to neuroradiologic imaging in
8 e; X$ q u; j* Pboys with precocious puberty. In addition to viril-
/ p! m- j1 Q. p" C+ C, vization, the clinical hallmark of CPP is the symmet-
( G' G4 X9 c8 T- Wrical testicular growth secondary to stimulation by: t: J4 h( [1 x S
gonadotropins.1,3) j6 t2 z b: ]1 i' ?. s7 `; q
Gonadotropin-independent peripheral preco-
3 n* r$ h! ^8 H; N8 ~8 Mcious puberty in boys also results from inappropriate" L, T/ E( n7 |5 A+ _
androgenic stimulation from either endogenous or
. J! K1 {. m; e% Oexogenous sources, nonpituitary gonadotropin stim-
3 X8 p& n4 m3 h2 wulation, and rare activating mutations.3 Virilizing
; R8 o7 }) E$ w5 O/ M7 Ycongenital adrenal hyperplasia producing excessive8 @) F, J& R! z. ?' c2 K4 v
adrenal androgens is a common cause of precocious
. D8 v7 @! f* d8 wpuberty in boys.3,4# y0 K) b' F% c% I
The most common form of congenital adrenal, l, R0 r, L! m' n$ K' w/ ~
hyperplasia is the 21-hydroxylase enzyme deficiency.
) c# f1 F+ }. A/ YThe 11-β hydroxylase deficiency may also result in
* N* i( f# |/ V, Y/ q6 c& gexcessive adrenal androgen production, and rarely,% |* G: Q+ b( M. Y9 {1 }" S$ K8 V
an adrenal tumor may also cause adrenal androgen
4 x) _- t. v1 h: N+ I( h2 Fexcess.1,3+ U' n5 ]1 O+ R1 n5 M+ s. v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" k4 q8 z% z6 n$ M* i3 m8 T542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ p9 ~/ u2 d6 M) @A unique entity of male-limited gonadotropin-( B5 ?# e/ V6 y! C; P7 R! x
independent precocious puberty, which is also known
, i8 a. d) j& s0 Oas testotoxicosis, may cause precocious puberty at a
" _; ]0 V$ C) Wvery young age. The physical findings in these boys5 n8 I f; i* ?2 a4 h8 c q. q
with this disorder are full pubertal development,9 y2 m- x& i2 z% [: i& y
including bilateral testicular growth, similar to boys2 ?3 s5 x+ q8 l$ r
with CPP. The gonadotropin levels in this disorder
. V" F0 k) x+ J$ p0 S6 ]are suppressed to prepubertal levels and do not show
& N. f4 {( Y( R. [1 P7 gpubertal response of gonadotropin after gonadotropin-
4 O' M- x8 I% z+ R: @releasing hormone stimulation. This is a sex-linked
4 j& Q, @ J2 F1 ^autosomal dominant disorder that affects only
; [, F4 M( u8 t+ Tmales; therefore, other male members of the family
0 t; ~/ s" h+ |! ]6 r9 omay have similar precocious puberty.3
C' ?; z% S6 }* Q& ? }In our patient, physical examination was incon-2 @" y* i1 j2 q0 l" l
sistent with true precocious puberty since his testi-6 e& t; ^+ r* D
cles were prepubertal in size. However, testotoxicosis4 d7 K2 c) o5 y0 k& X0 v9 h' e5 }
was in the differential diagnosis because his father3 t, j) L. R" X6 s
started puberty somewhat early, and occasionally,, p. v/ Q f0 R
testicular enlargement is not that evident in the! K5 T8 j8 v% ]5 d9 g A% ~2 q
beginning of this process.1 In the absence of a neg-4 q, M' \9 V4 l) c
ative initial history of androgen exposure, our
0 ~0 R7 b1 Q4 Abiggest concern was virilizing adrenal hyperplasia,
2 o( W9 |$ z; u) C. F$ keither 21-hydroxylase deficiency or 11-β hydroxylase5 ]1 R/ R) j8 _4 j9 E
deficiency. Those diagnoses were excluded by find-- g5 t& Z O! z e z6 p
ing the normal level of adrenal steroids.
' D! S* E* n7 Z$ D2 HThe diagnosis of exogenous androgens was strongly) d5 B G1 J2 R# b2 E& {8 Y
suspected in a follow-up visit after 4 months because* P7 [( i/ ^+ s* Z0 [
the physical examination revealed the complete disap-
/ S4 m5 T8 H* k% J: Ipearance of pubic hair, normal growth velocity, and
% t0 o; ~( `1 gdecreased erections. The father admitted using a testos-2 i- J1 L. e* n; O) y
terone gel, which he concealed at first visit. He was
3 ?; Z- E( k; susing it rather frequently, twice a day. The Physicians’
- o! q' H+ t# o9 ?! w( WDesk Reference, or package insert of this product, gel or* j; K3 C/ e2 |" }/ w+ i! a7 l% j
cream, cautions about dermal testosterone transfer to4 D+ B+ g" e% A3 n4 [) S" v: h
unprotected females through direct skin exposure.
5 G' j! _5 s' T- U% j0 gSerum testosterone level was found to be 2 times the
5 c' H1 T( w: p$ Ibaseline value in those females who were exposed to; y+ U, J+ x9 K2 b/ _
even 15 minutes of direct skin contact with their male+ Z" o3 s D% V1 l% Q% a" }" F- R0 i
partners.6 However, when a shirt covered the applica-
) v( m% Z1 u3 Mtion site, this testosterone transfer was prevented.. k3 e2 M8 S! R) f
Our patient’s testosterone level was 60 ng/mL,; I1 b) Q2 w$ S; ^ r; A9 E9 u% ], A
which was clearly high. Some studies suggest that
5 P! f! i- \0 E6 a7 mdermal conversion of testosterone to dihydrotestos-+ d* }/ k" d% }8 i
terone, which is a more potent metabolite, is more K# A q- F( `' _
active in young children exposed to testosterone! g; o- `4 B1 ?. y
exogenously7; however, we did not measure a dihy-
1 s6 M) _' Z; G, t$ _. Kdrotestosterone level in our patient. In addition to; V$ a4 a6 g/ V9 F8 |
virilization, exposure to exogenous testosterone in7 r, \; B" O+ ?) o3 C
children results in an increase in growth velocity and% U3 X+ @0 O% J' M
advanced bone age, as seen in our patient. z& ^/ T# e; [; g1 \# X/ F
The long-term effect of androgen exposure during
3 D! a7 w5 E) \. N# Searly childhood on pubertal development and final7 v% _& H- D9 b6 }* z
adult height are not fully known and always remain
" o8 L! u. J# a: o6 Ja concern. Children treated with short-term testos-- [( x- X7 d( v+ j
terone injection or topical androgen may exhibit some
# Z& U4 e* ~; A) [6 Pacceleration of the skeletal maturation; however, after
- o7 r2 `# C Z4 Y# R0 w; Kcessation of treatment, the rate of bone maturation7 J2 v( Z( [% P2 ?
decelerates and gradually returns to normal.8,9
! x; g- U' f# k' k8 a( dThere are conflicting reports and controversy2 D2 {/ r; s+ x. u$ M# v& E
over the effect of early androgen exposure on adult9 W& z2 X. b9 ]& r
penile length.10,11 Some reports suggest subnormal3 \0 z( t7 w# ]9 I3 J
adult penile length, apparently because of downreg-
k; M4 R( j* a6 culation of androgen receptor number.10,12 However,
) [8 L7 C; \6 J L7 N0 B& f# dSutherland et al13 did not find a correlation between8 m% z3 |* O5 G6 ~% d% @
childhood testosterone exposure and reduced adult/ G' n! z; G7 |. \
penile length in clinical studies.
: i% G$ J3 W( l4 T4 J$ U1 {Nonetheless, we do not believe our patient is
$ {! }$ a7 B1 u& Vgoing to experience any of the untoward effects from- W3 ~) Y& j% _( e0 S3 `) d3 C
testosterone exposure as mentioned earlier because
0 o7 H0 N ]; J! r% Nthe exposure was not for a prolonged period of time.
+ g4 l1 v& D! ~3 ?5 x! n4 K3 t6 ZAlthough the bone age was advanced at the time of
- T5 }/ O9 p$ m; z. B. Adiagnosis, the child had a normal growth velocity at
# i. a8 l. l5 E% r, c8 cthe follow-up visit. It is hoped that his final adult# t3 f; S" V7 {; Z! J: X
height will not be affected. U) e' J: [& `4 ~4 {
Although rarely reported, the widespread avail-; a3 B, |8 F( G7 ?! ^" @
ability of androgen products in our society may
* @! x8 p, ^. C$ v) hindeed cause more virilization in male or female$ [* @2 h) Q# y" c! }* N
children than one would realize. Exposure to andro-7 S( r1 H- w) I& ^, F
gen products must be considered and specific ques-6 a1 I$ |+ f% r1 D0 Q$ x3 Y
tioning about the use of a testosterone product or
6 v/ `/ L6 f) u, e" T; n( Y$ |gel should be asked of the family members during- {' Y" V/ [5 z2 k- }5 ]) ^3 }. o
the evaluation of any children who present with vir-# i, k* V7 K4 a* Z
ilization or peripheral precocious puberty. The diag-
% E B$ V& M+ |6 Onosis can be established by just a few tests and by. |2 ~& q! y! b" }* |7 H& w, [
appropriate history. The inability to obtain such a' h* N% y3 T; C/ P4 m9 {
history, or failure to ask the specific questions, may
, |4 a8 l0 {1 v2 aresult in extensive, unnecessary, and expensive6 ?# @9 K9 b) w6 |; r* {) {6 ]
investigation. The primary care physician should be. m" s% y7 A5 \0 W) `! N
aware of this fact, because most of these children
$ M. {. e% U$ u; J' f! k+ bmay initially present in their practice. The Physicians’& p' [' y% l/ U) T0 X4 Z. p! z
Desk Reference and package insert should also put a
6 u9 ~9 q0 A7 {# j6 n4 ywarning about the virilizing effect on a male or8 L* q; f( _, I. M6 d5 K5 ^/ G' F
female child who might come in contact with some-
. T/ f' ? ~! p+ b" d, Fone using any of these products." T, ~+ ^! b3 A
References
1 L1 A7 U( a4 d: V7 q1. Styne DM. The testes: disorder of sexual differentiation
0 Z! r! f) T; a C9 E9 o' Eand puberty in the male. In: Sperling MA, ed. Pediatric
, S5 } F; C: ^2 {0 C( wEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 s+ _% i( Y6 ~+ m& i5 h2002: 565-628.
3 K, ?2 B* ^! I# E ]7 r2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious$ `2 i- W$ d% f {; P9 h7 l
puberty in children with tumours of the suprasellar pineal |
|