Pediatric emergency medicine trisk 107

pseudopuberty, or exposure to exogenous estrogens, and careful follow-up with
the primary physician is required.
Juvenile Breast Hypertrophy
Juvenile breast hypertrophy is a rare disorder characterized by sudden, rapid,
massive breast enlargement at a time of intense endocrine stimulation, usually
between 8 and 16 years of age, after onset of menarche. It is believed to result
from end-organ hypersensitivity to estrogen. The hypertrophy is usually bilateral
and asymmetric and may progress at an alarming rate over 36 months. The
differential diagnosis of this lesion includes cystosarcoma phyllodes, juvenile
fibroadenoma, and precocious puberty; however, true endocrine or neoplastic
lesions are uncommon. In some cases, the hypertrophy regresses in 1 to 3 years,
but referral to a breast surgeon is always indicated; breast reduction or even total
ablation may become necessary. This disorder is often associated with extreme
emotional and psychosocial distress for patients and families.
Gynecomastia
Gynecomastia is a term commonly used to describe a broad spectrum of clinical
breast lesions in boys, including excess breast tissue, breast enlargement, and
masses of tissue below the nipple that are discrete and nonadherent to the chest
wall, and may occur unilaterally or bilaterally. Gynecomastia has been described
as the male equivalent of fibrocystic changes in the female breast, based on
histologic evidence. Typically, local breast tissue demonstrates evidence of mild
estrogen–testosterone hormone imbalance, resulting from physiologic changes
(neonatal, puberty, aging); exogenous medications; tumors of the testes, adrenal
glands, and lungs; metabolic conditions (cirrhosis, hyperthyroidism, renal
disease); or hypogonadism.
From a clinical perspective, gynecomastia occurs in about 50% of all boys
between the ages of 11 and 18 years and typically lasts about 2 years. It can be
associated with growth spurts and can also cause a significant degree of pain. The
glandular enlargement is about 4 cm and resembles the early stages of female
breast budding. More commonly, gynecomastia presents to the emergency
physician because of associated anxiety in adolescent boys. If the patient has

normal-sized genitalia and none of the predisposing conditions listed earlier,
reassurance is all that is required, though inquiry about both prescription and
illicit use of drugs should be sought. There is often particular concern about
gynecomastia in obese boys, since they may appear to have an overabundance of
fatty tissue in the breast region. Of note, the incidence of true gynecomastia is not


increased in boys who are obese, compared with those who are not obese. Rarely,
a few conditions can be mistaken for physiologic gynecomastia, such as
lipomastia, a round adipose tissue mass, or neoplasm. If there is any concern for
these entities or systemic diseases, then the patient should be urgently referred to
an endocrinologist. Overall, gynecomastia is best managed by referral to the
primary care physician for continued follow-up.
Physiologic Mastalgia
During the first trimester of pregnancy, some teenage girls may complain of
breast fullness, though nongravid patients may experience breast pain as well,
likely related to the hormonal milieu of the breast throughout the menstrual cycle.
Mastalgia is often described as a bilateral, poorly localized, dull, achy pain that
radiates to the axillae. The pain is often worse with activity and relieved with the
onset of menses. In general, there are no abnormal physical findings, except
tender, nodular breasts. Most patients will improve with reassurance, analgesics
such as nonsteroidal anti-inflammatory medications, warm compresses, and
breast support. If the pain is refractory to these measures, other suggested
therapies include caffeine avoidance, salt restriction, and diuretics. Danazol, a
synthetic androgen, is reserved for severe, debilitating pain.

EVALUATION AND DECISION
History and Physical Examination
Initial evaluation of a breast lesion begins with a careful history and physical
examination ( Table 16.4 ). The two most common categories of breast lesions

presenting in children are infections and structural or mass lesions. In the absence
of infection, evaluation of mass lesions requires a detailed menstrual history and a
chronology of the development of secondary sexual characteristics. Features of
intracranial masses, including headaches or visual changes, should be assessed.
Pregnant or lactating patients may also present to a pediatric ED. These patients
should be queried regarding breastfeeding or breastfeeding attempts, as well as
about general symptoms related to changes in the breast tissue. Medications may
have an effect on the growth of certain breast lesions and may also affect
hormonal pathways, leading to abnormal breast secretions ( Table 16.1 ). Few
breast disorders may have a familial pattern; however, a careful family history
can be helpful.
A comprehensive physical examination should be performed on any pediatric
patient who complains of a breast mass or lesion. Premature appearance of


secondary sexual characteristics, hirsutism, or abnormal skin coloring may
indicate the presence of an endocrinopathy. A detailed evaluation of the breasts
and adjacent structures is essential. The chest wall should be inspected for any
gross deformities, asymmetry, or skin changes. The physician should have the
patient lean forward with hands on hips and again observe for any asymmetry or
skin retraction. With the patient supine with arms above the head, the physician
should palpate each breast in a series of concentric circles radiating outward from
the nipple, looking and feeling for nodules, cysts, masses, or inconsistencies in
the breast tissue. Each areola should be gently compressed to assess for masses or
nipple discharge. If present, the color, character, and odor of any discharge should
be noted. The physician should feel for the presence of any masses or
lymphadenopathy in both axillae.


TABLE 16.4

IMPORTANT HISTORICAL AND PHYSICAL EXAMINATION
COMPONENTS IN THE EVALUATION OF A BREAST LESION
History
Onset and duration of lesion
Pain
Nipple discharge
Relationship of lesion with menses
Complete menstrual and sexual development history, including sexual activity
and previous pregnancies
Family history of breast disease
Diet
Medications and illicit drugs
Concomitant medical disorders
Systemic symptoms: fever, weight loss, sweating, headaches, visual changes
Physical Examination
Breasts: symmetry, skin appearance, temperature, areola, nipples, secretions,
masses, chest wall, axillae
Lymph nodes
Hair distribution
Genitalia

Diagnostic Testing
The majority of patients presenting to the ED will not require intensive laboratory
or radiologic testing. All postmenarchal girls should have a pregnancy test
performed; breast tenderness and swelling are among the earliest signs of
pregnancy. The most helpful test in the emergency setting is breast
ultrasonography, which is useful in distinguishing between masses and cystic
lesions as well as the presence of abscess with mastitis. Other imaging studies are
rarely helpful. Mammography is of little value in children and adolescents, owing
to the high proportion of fibroglandular tissue within the breast. Chest

radiography is rarely helpful, except when the examiner elicits signs and
symptoms from the lungs or chest wall that may be referred to the breast. If