Pediatric emergency medicine trisk 0422 0422

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