Pediatric emergency medicine trisk 106

prescribed only for fibrocystic disease in adolescence. Follow-up and subsequent
evaluation by a primary care physician is recommended; referral to a surgeon for
needle aspiration or core biopsy is indicated for painful, large, solitary lesions.
Nipple masses represent another group of generally benign breast lesions.
Benign intraductal papillomatosis is the most common etiology and can be seen
in prepubertal or pubertal boys and girls, often coming to attention because of
bleeding from the nipple. Occasionally, the lesion may obstruct the nipple and
causing pain and possibly infection. In extremely rare instances, a nipple mass
can represent an intraductal carcinoma. In these cases, cytologic examination of
the bloody nipple discharge can be of diagnostic value. Therefore, expedient
referral to a breast surgeon or pediatric surgeon is indicated after detection of
nipple mass with bloody discharge. In cases of benign nipple masses, careful
observation for several weeks by an experienced primary care physician or
surgical specialist is indicated. If the nipple mass or bleeding persists, excision is
the treatment of choice.
Trauma to the breast can lead to hematomas and fat necrosis, both of which are
palpated as firm, lumpy, well-circumscribed breast masses. Initially, these lesions
may be tender. If left untreated, they may develop into areas of scar tissue that are
affixed to the skin. Fat necrosis is relatively common, but the differentiation from
other more serious lesions may be difficult, requiring consultation with a surgeon
or use of serial ultrasounds in cases of uncertainty.

Malignant Masses
Primary cancers of the breast have been reported in children, but are exceedingly
rare, with an incidence of 1 in 1,000,000 females less than age 20 years. In
children, breast tumors accounting for less than 1% of all malignancies and less
than 0.1% of all breast cancers occur in the pediatric age group. Metastatic
disease is far more common than primary breast tumors, and may be secondary to
Hodgkin and non-Hodgkin lymphoma, neuroblastoma, and leukemia, and
rhabdomyosarcoma. Adolescent or childhood breast tumors are often classified as
secretory carcinomas that behave more benignly than breast cancers in adults.

Other histologic classifications of breast malignancies reported in children and
adolescents include carcinomas, sarcomas, and cystosarcoma phyllodes, which
can have both benign and malignant features. Physical examination
characteristics suggestive of malignancy include a hard, nontender, solitary mass
with ambiguous margins. The mass may be fixed to surrounding tissues, and
overlying skin changes such as edema, warmth, skin dimpling, and/or nipple
retraction may be present. Other signs include bleeding from the nipple and local
lymphadenopathy may be present. The appropriate treatment for suspected


malignant lesions is the same as that for a benign mass—prompt referral to a
pediatric or breast surgeon for definitive workup, usually consisting of core
biopsy. Among the strongest risk factors for malignant breast masses in the
pediatric population include chest irradiation, particularly when incurred during
high-dose treatment for Hodgkin disease or with radioiodine treatment for thyroid
cancer. Radiation exposure between ages 10 and 16 years is most harmful. In girls
treated for Hodgkin lymphoma, there is a higher incidence of breast cancer within
20 years of treatment. Children with a strong familial history of breast
malignances, such as those who are offspring of women with inherited cancer
syndromes, are also more susceptible to developing breast malignancy. Selfexamination is important for detection of potential malignant breast masses, and
adolescents should be encouraged to routinely perform them, especially if at
increased risk of developing breast cancer. For children at particularly high risk,
routine screening with magnetic resonance imaging should be considered.

Abnormal Secretions (Nipple Discharge)
There are multiple etiologies of abnormal nipple secretions in children and
adolescents. These can be divided according to their potential for surgical
management. Nonsurgical causes typically present as nonspontaneous discharges.
The most common example is discharge fluid expressed during breast selfexamination. The fluid may be milky, multicolored, and sticky and is a normal,
physiologic discharge of little concern. When breast infection (mastitis or

abscess) is present, a purulent discharge may be expressed or occur
spontaneously.
Galactorrhea is the most common spontaneous nipple discharge and usually
occurs bilaterally. Pregnancy and lactation are typical causes of galactorrhea;
however, in the absence of these conditions, increased prolactin states should be
suspected. Structural lesions of the hypothalamus and pituitary (e.g., adenomas)
and exogenous medications can cause increased prolactin levels. Drugs
implicated include oral contraceptives, tricyclic antidepressants, phenothiazines,
metoclopramide, α-methyldopa, anabolic steroids, and cannabis. As mentioned
earlier, in utero estrogen exposure can lead to breast bud hypertrophy in neonates;
in addition, this hypertrophy can be accompanied by a colostrum-like material
that has been referred to as “witch’s milk.” This discharge occurs temporarily,
until maternal estrogen levels decline, and is not considered pathologic.
Other nonsurgical spontaneous nipple discharges have been described as
multicolored, grossly bloody, serous, or clear and watery. Nonbloody discharges
are rarely indicative of malignancy. Mammary duct ectasia, traumatic nipple
erosions (e.g., “jogger’s nipple”), and eczema are among the more common


causes of nonbloody discharges. These disorders can be treated with nipple
hygiene, warm compresses, and topical antibiotics, if necessary. When nipple
discharge is described as serosanguinous or frankly bloody, or when it tests
positive for occult blood, the potential for surgical pathology increases,
particularly when a mass is palpable below the nipple. However, surgical
etiologies remain rare, with malignancy present in only 6% of bloody nipple
discharges. Any pediatric patient with spontaneous nipple discharge not explained
by an obvious cause (e.g., jogger’s nipples) should be referred to a breast or
surgical specialist for close follow-up and further diagnostic and therapeutic
evaluation.

Lesions Associated With Pregnancy and Lactation
Significant changes occur in the female breast as a result of pregnancy, most
prominently an increase in breast size and weight. Although pregnant patients
may have any of the breast lesions seen in nonpregnant patients, they are prone to
develop some unique conditions. The most frequent of these is puerperal
(lactational) mastitis, which develops in up to one-third of lactating women,
usually within the first few weeks postpartum. Lactational mastitis is likely to
result from infection with S. aureus, with an increasing incidence of CA-MRSA.
Streptococcus species, gram-negative organisms, mycobacteria, Candida, and
Cryptococcus have also been implicated as causative organisms of lactational
mastitis. Breast abscess may also arise, and frequently requires drainage of
purulent material. Treatment of lactational mastitis consists of warm compresses,
antistaphylococcal antibiotic therapy, and frequent evacuation of breast milk.
Breast engorgement may exacerbate the symptoms of breast infection; therefore,
continued feeding or pumping is recommended. The risk of mother-to-infant
transmission of infection is rare and breastfeeding can typically continue. In cases
where there is substantial pain, or the infant does not like the taste of infected
milk, feeding can proceed in the opposite breast. Mastitis within the first 2 weeks
postpartum is often a result of cracked nipples, infant attachment difficulties, and
anatomic abnormalities (e.g., cleft lip or palate); later onset is usually a result of
poor hygiene or inadequate emptying of the breast with subsequent milk stasis,
engorgement, and colonization of bacteria within the milk.
Pregnant patients may also have simple milk-filled cysts called galactoceles,
which are often tender and located on the periphery of the breast. Ice packs,
breast support, and aspiration may be needed to relieve the obstruction of the
milk-filled ducts.
Nonlactating pregnant patients may develop bloody discharge from the nipple
during the second or third trimester, representing a benign condition from

epithelial cell proliferation. If the discharge persists after delivery, a more
thorough investigation for alternate etiologies is recommended. Fibroadenomas
often increase in size during pregnancy and may result in significant pain.
Excision is often advised for any solitary mass and the patient should be
expediently referred to a breast surgeon. The number of cases of breast
malignancy diagnosed during pregnancy is very low.

Miscellaneous Breast Lesions
Congenital Lesions
Supernumerary breasts (polymastia) and supernumerary nipples (polythelia) are
congenital conditions that are unlikely to present as chief complaints in the ED,
but that may be discovered incidentally on examination. Polymastia results from
failure of the embryonic mammary ridges to regress and is present at birth, often
resembling skin tags or nevi, and may not be noticed until the tissue is
hormonally influenced. Supernumerary breasts are most commonly found in the
axillae but have been reported to occur in several locations. This ectopic tissue
may become tender with menses and has been reported to develop the same range
of pathology as normal breast tissue, necessitating excision under certain
circumstances.
Polythelia may be sporadic or familial, and is most commonly found on the
left, inferior to the normal nipple. In newborns, polythelia may appear as small,
wrinkled lesions with or without pigmentation. Polythelia is typically of little
significance, though there is a possible association with unsuspected urologic
anomalies. For this reason, patients with polythelia should be referred for at least
a primary screening of underlying urologic disease. Otherwise, this disorder
requires no treatment unless the diagnosis is uncertain (e.g., the lesion looks like a
possible melanoma) or is perceived as a cosmetic problem.
Premature Thelarche
Premature thelarche refers to isolated breast development without other signs of
puberty. Minimum acceptable age for thelarche is 8 years; appearance of breast

tissue prior to this age should prompt consultation with an endocrinologist.
Typically appearing within the first 2 years of life in its most common form,
premature thelarche is a benign, transient condition of unknown etiology. Cases
of premature thelarche usually present to the ED secondary to concern raised by
parents of prepubertal girls, and reassurance is usually all that is required.
However, premature thelarche may be the first sign of true precocious puberty or