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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