Common Breast Abnormalities in Pediatrics
        
 
    1. Neonatal breast enlargement- secondary to increase endogenous steroids at the end of pregnancy. May express milk ("witches' milk"). Rarely becomes infected. Self-limited. Develops later in preterm infants. May persist for up to six months.

    NEONATAL BREAST ABSCESS
    We recently managed a 15-day-old newborn male with a right breast abscess with subcutaneous extension over the entire ipsilateral chest wall, flank and back. Two days before admission the mother noted bilateral breast enlargement, and 24 hours later the right breast was red, swollen and tender. There had been no manipulation of the breast. Just before admission the mother noticed fever and several pustules in the groin. For several days after admission to the intensive care unit, the infant required intubation and repeated surgical drainage of pus from the chest wall. Material from the pustule and the cell wall drainage grew methicillin-resistant Staphylococcus aureus (MRSA) that was clindamycin susceptible (D-test negative), the community-acquired MRSA that has been prevalent in Dallas since 2002. This is a unique case of neonatal breast abscess because of the extent of infection. In our experience, first published in 1975 (Am J Dis Child 1975;129:1031), most neonates with breast abscess have an uncomplicated course and are full-term. Abscesses are seen equally in males and females, except after 2 weeks of age when they occur principally in females. The most common cause is S. aureus, although Group B streptococci and occasionally Gram-negative organisms such as coliforms and Salmonella species have been encountered. Most patients lack systemic symptoms and are afebrile. Occasionally the blood culture is positive, but we do not recommend a lumbar puncture in those who otherwise appear well. Treatment usually consists of antibiotic therapy and drainage of the abscess, when necessary. The infant described above did well and was discharged after 3 weeks of therapy. (PIDJ Jan 06)


    2. Supernumerary breasts and nipples- very common and located along the "milk line" from the axilla to the symphis pubis. Most are just below and medial to the normal breast. May appear as only a pigmented lesion. Are usually asymptomatic and no treatment necessary. 
    3. Premature Thelarche- isolated breast development without signs and symptoms of other secondary sexual traits such as estrogen effects, osseous development, acne, etc. Common between the ages of 2-5 and usually not progressive. No further evaluation necessary other than observation and if secondary sexual traits develop, ultrasound and endocrine evaluation may be necessary.
    4. Gynecomastia- defined as the presence of mammary tissue in males. 
      a. Approximately 2/3 of males will have breast tissue development during puberty. Present with incidental finding of a subareloar nodule by the child that is often tender. Doesn't progress and no treatment necessary other than reassurance. This is often very alarming to families. Regresses after 1-2 years in most cases. 
      b. Progression of mammary tissue that resembles female tissue. Etiologies include:
        1. Familial
        2. Exogenous estrogens
        3. Exogenous steroids
        4. Klinefelter's syndrome
        5. Peutz Jegher Syndrome
        6. Pituitary tumors
        7. In adults associated with chronic liver disease, Marijuana use, other drugs
        8. INH, phenothiazines, Valium, Ketoconazole, street drugs
        9. Treatment- medical or surgical. Should observe for period of time to make sure that spontaneous regression does occur. May have surgery because of psychological problems.


    5. Nipple Discharge-

      a. Galactorrhea - must R/O prolactin producing pituitary lesion or hypothyroidism
      b. Bloody/brownish may have duct pathology such as an intraductal papilloma. They are usually unilateral and benign and should have surgical consult for removal


    6. Trauma - much more common now with the increased participation of females in sports
    7. Mastitis- often seen in neonates and infants. Most common organism is S.aureus. Older patients may develop abscesses most commonly caused by S. aureus. May be associated with overlying skin lesions and trauma. 
    8. Breast pain with menses- usually develops after ovulation is established. Treatment with NSAIDS and supportive bra.
    9. Breast Masses- Self examination of breasts should be initiated around the time of the adolescent's first internal examination. Breast cancer is rare in pediatrics and adolescents. Presence of breast masses usually produce anxiety in the patient and families.

       a. fibroadenomas(54%)- most common surgically excised breast lesion. Multiple, mobile, firm lesions. Follow through a few menstrual cycles because may spontaneously regress. Remove because of cosmetic deformity, family anxiety, and rare finding of cancer
      b. fibrocystic disease(24%). Diffuse bilateral breast thickening without discrete mass. Often premenstrual tenderness. Treatment with oral contraceptives ? effective.
      c. virginal hypertrophy(13%). Enlargement of all breast tissue. Usually perform cosmetic mammoplasty
      d. cystoadenoma phylloides (2%)- Firm discrete masses. Usually rapid growing and common in black teenagers. Surgical removal recommended. 
      e. Evaluation with a surgeon and radiologist are recommended before doing work-up.


    10. Asymmetry

      a. May be mild and reassurance all that is needed. If significant, surgery may be necessary
      b. Associated with chest wall anomalies and may require surgical and cosmetic repair.
        1. Poland Syndrome- pectoralis minor absent with hand deformities

References
    1. Dudgeon, David. Pediatric breast lesions: Take the conservative approach. Contemporary Pediatrics. January 1985.
    2. Santen R, Mansel R. Benign Breast Disorders.  NEJM Juy 21, 2005
    3. Kelly V. et al. Bloody Nipple Discharge in an Infant and a Proposed Diagnostic Approach.  Pediatrics April 2006
    4. Braunstein G.D. Gynecomastia. NEJM Sept 20 2007
    5. Diamanatopoulos S. and Bao Y.  Gynecomastia and Premature Thelarche.  Pediatrics in Review September 2007