Pediatric emergency medicine trisk 108

nipple discharge is present, Gram stain, culture, and rarely cytology can be of
value. Fine-needle aspiration is used in a limited fashion in children and adults,
since the majority of lesions are typically benign. Serum endocrinology testing
may be indicated for some breast lesions, although these generally take place
outside the ED.

FIGURE 16.1 Approach to breast complaints in the prepubertal child.

APPROACH
The approach to the patient with complaints related to the breast primarily
depends first on whether the patient is prepubertal or pubertal/postpubertal.
Among patients who are pubertal/postpubertal, the considerations vary greatly
between boys and girls. Finally, unique considerations pertain to the pregnant or
lactating girl, as discussed earlier in this chapter.

Prepubertal Child
Among prepubertal children ( Fig. 16.1 ), the most common breast disorders are
physiologic hypertrophy in the newborn period and premature thelarche in young
girls. When physiologic hypertrophy is noted in newborns, erythema or
tenderness should be assessed, and mastitis and potential serious bacterial


infection should be considered. Breast development in prepubertal girls, without
other signs of puberty, particularly in those younger than 2 years of age, is likely
due to the common and benign condition of premature thelarche. Since this may
be the first sign of precocious puberty, urgent follow-up with the primary care
physician and/or an endocrinologist for additional testing is recommended.
Among prepubertal children, isolated lesions underneath the nipple also may be
noted and are usually benign cysts.

Pubertal/Postpubertal Male

The adolescent male ( Fig. 16.2 ) may complain of breast pain without evidence
of clearly palpable breast enlargement. This sensation may be caused by minor
chest trauma in a boy with early pubertal gynecomastia or may represent
underlying chest pain (see Chapter 55 Pain: Chest ). Most often, adolescent males
will present for bilateral (sometimes asymmetric) enlargement diffusely
throughout the breast tissue, which usually represents (physiologic) pubertal
gynecomastia, in the setting of normal sexual development. Unilateral, discrete
masses or bilateral, diffuse enlargement with abnormal sexual development
require subspecialty referral and additional diagnostic evaluation.

Pubertal/Postpubertal Female
The initial step in evaluating the adolescent girl ( Fig. 16.3 ) is to obtain a
pregnancy test, which, when positive, points to a number of conditions that are
specific to the gravid state (see earlier discussion). Both pregnant and
nonpregnant girls may experience a myriad of disorders related to the breast. The
emergency physician’s primary goal is to distinguish underlying disorders that are
causing chest rather than breast pain (see Chapter 55 Pain: Chest ) and to assess
for a few relatively minor problems, including cellulitis, abscess, hematoma, and
traumatic erosions. In cases where there is concern for deeper infection or an
irregular or large breast mass, breast ultrasonography can be used to rule out
severe, life-threatening etiologies. Less severe causes of breast enlargement,
masses, and discharge require outpatient follow-up and evaluation by an
appropriate specialist.


FIGURE 16.2 Approach to breast complaints in the pubertal/postpubertal boy.


FIGURE 16.3 Approach to breast complaints in the pubertal/postpubertal girl.
refers to milky, as opposed to bloody, serous, or purulent discharge.

a

Galactorrhea

Suggested Readings and Key References
Al Ruwaili N, Scolnik D. Neonatal mastitis: controversies in management. J Clin
Neonatol 2012;1(4):207–210.
Arca MJ, Caniano DA. Breast disorders in the adolescent patient. Adolesc Med
Clin 2004;15:473–485.
Demoor-Goldschmidt C, Allodji RS, Jackson A, et al. Breast cancer, secondary
breast cancers in childhood cancer male survivors-characteristics and risks. Int
J Radiat Oncol Biol Phys 2018;102(3):578–583.
Gao Y, Saksena MA, Brachtel EF, et al. How to approach breast lesions in
children and adolescents. Eur J Radiol 2015;84(7):1350–1364.
Kennedy RD, Boughey JC. Management of pediatric and adolescent breast
masses. Semin Plas Surg 2013;27:19–22.
Lam E, Chan T, Wiseman SM. Breast abscess: evidence based management
recommendations. Expert Rev Anti Infect Ther 2014;12(7):753–762.
Lee EJ, Chang YW, Oh JH, et al. Breast lesions in children and adolescents:
diagnosis and management. Korean J Radiol 2018;19(5):978–991.