Pediatric emergency medicine trisk 105

avoid skin creams or talcum powders. The majority of patients are treated
successfully as outpatients with a follow-up appointment in 2 to 3 days to ensure
the infection is improving. Ill patients or those failing outpatient antibiotic
therapy, require hospital admission for intravenous antibiotics. Ultrasound
confirms the presence of a breast abscess. Breast abscesses should be drained via
needle aspiration by a surgical specialist; incision and drainage are rarely
necessary. In the well-appearing older child or adolescent with breast abscess,
ultrasound-guided needle aspiration has proven equivalent to surgical incision
and drainage while minimizing breast damage. Therefore, aspiration in
combination with antibiotics has become the treatment of choice. ED point-ofcare ultrasound (POCUS) with guided needle aspiration of breast abscesses is a
promising treatment strategy but requires further evaluation.


TABLE 16.1
BREAST ENLARGEMENT/MASSES
I. Inflammatory conditions
A. Cellulitis and mastitis
B. Breast abscess
II. Noninflammatory conditions
A. Infancy
1. Physiologic hypertrophy
2. Tumor (rare)
B. Childhood
1. Premature thelarche
2. Precocious puberty
3. Prepubertal gynecomastia (male)
4. Malignancy (rare)
C. Adolescence
1. Male
a. Postpubertal (physiologic) gynecomastia
b. Exogenous hormonal stimulation

c. Drug exposure
i. Phenothiazines
ii. Opiates
iii. Cannabis (tetrahydrocannabinol)
iv. Anabolic steroids
v. Antiretroviral therapy
vi. Tricyclic antidepressants
vii. Calcium channel blockers or digoxin
d. Endocrinopathy
e. Nipple cyst
f. Malignancy (rare)
2. Female
a. Isolated, benign cyst
b. Fibroadenoma
c. Fibrocystic disease
d. Juvenile hypertrophy
e. Hematoma/fat necrosis (posttraumatic)
f. Papillomatosis
g. Cystosarcoma phyllodes and other cancers (rare)


TABLE 16.2
COMMON BREAST LESIONS
Newborn
Physiologic hypertrophy
Mastitis (mastitis neonatorum)
Prepubertal Child
Premature thelarche (female)
Pubertal/Postpubertal Male
Pubertal gynecomastia

Pubertal/Postpubertal Female
Enlargement/galactorrhea secondary to pregnancy
Mastitis and breast abscess
Fibroadenoma
Fibrocystic disease
Benign, isolated cysts
TABLE 16.3
LIFE-THREATENING BREAST LESIONS
Newborn
Mastitis (mastitis neonatorum)
Prepubertal Child
Breast enlargement with precocious puberty (secondary to hormonal secretion
by a tumor)
Postpubertal Male
Breast enlargement with abnormal sexual development (secondary to hormonal
secretion by a tumor)
Postpubertal Female
Neoplastic mass
Galactorrhea secondary to prolactin-secreting tumor

Benign Cysts and Masses


Enlargement of breast tissue may occur at any age. Hypertrophied breast tissue
occurs in the first few weeks of life secondary to maternal estrogen stimulation in
male and female infants. This is a normal physiologic response that abates over
time, parental reassurance is the treatment. Isolated unilateral or bilateral
thelarche may occur in preschool-aged girls. In the absence of development of
secondary sexual characteristics, this is consistent with isolated benign premature
thelarche. Enlargement usually resolves spontaneously within 2 years, though

continued follow-up with a primary care physician is prudent. Breast enlargement
in the setting of secondary sexual characteristics, such as pubic hair (precocious
puberty) in girls, or any breast enlargement in young boys (prepubertal
gynecomastia), is abnormal and additional evaluation indicated. History and
examination focused on the presence of adrenal, ovarian, or hypothalamic
pathology, including hormone-secreting tumors and intracranial tumors, is
indicated. Review recent medication usage as several medications can cause
gynecomastia ( Table 16.1 ). Unless an intracranial mass is suspected, most
children can be referred for outpatient workup with an experienced physician or
endocrinologist.
Fibroadenomas are the most common benign breast lesion (>75%) in the
adolescents. These masses are most often discovered by self-examination. They
are solitary, well-circumscribed, mobile, rubbery, masses located in the upper
outer breast quadrant that are typically <2 to 3 cm in size. Patients often have
intermittent tenderness that is associated with the menstrual cycle. Ultrasound can
be considered to document this diagnosis and help exclude other pathology.
Fibroadenomas can be observed over time; associated malignancy is rare.
Treatment is required for giant fibroadenomas (>5 cm) which may destroy normal
breast tissue; referral to a pediatric or breast surgeon for excisional or core biopsy
is recommended.
Fibrocystic disease is a benign, progressive process generally seen in women
during the reproductive years, but may also present in adolescence. Fibrotic tissue
is most prominent in the upper outer quadrants of the breast and unilateral or
bilateral. Frequently, presentation is that of cyclically painful nodules that change
in size during the course of the menstrual cycle, with the maximal symptoms
during the premenstrual phase. Serosanguinous nipple discharge is rarely present.
Importantly, in the adolescent population, these lesions are not precancerous.
Breast ultrasonography can be used to confirm the diagnosis although neither
needle aspiration nor breast biopsy is required. Treatment is largely symptomatic
with breast support, nonsteroidal analgesics, and avoidance of caffeine. Oral

contraceptive agents can reduce symptoms in severe cases, but are not typically