Pediatric emergency medicine trisk 0430 0430

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.