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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