avoid skin creams or talcum powders The majority of patients are treated successfully as outpatients with a follow-up appointment in to days to ensure the infection is improving Ill patients or those failing outpatient antibiotic therapy, require hospital admission for intravenous antibiotics Ultrasound confirms the presence of a breast abscess Breast abscesses should be drained via needle aspiration by a surgical specialist; incision and drainage are rarely necessary In the well-appearing older child or adolescent with breast abscess, ultrasound-guided needle aspiration has proven equivalent to surgical incision and drainage while minimizing breast damage Therefore, aspiration in combination with antibiotics has become the treatment of choice ED point-ofcare ultrasound (POCUS) with guided needle aspiration of breast abscesses is a promising treatment strategy but requires further evaluation TABLE 16.1 BREAST ENLARGEMENT/MASSES I Inflammatory conditions A Cellulitis and mastitis B Breast abscess II Noninflammatory conditions A Infancy Physiologic hypertrophy Tumor (rare) B Childhood Premature thelarche Precocious puberty Prepubertal gynecomastia (male) Malignancy (rare) C Adolescence Male a Postpubertal (physiologic) gynecomastia b Exogenous hormonal stimulation c Drug exposure i Phenothiazines ii Opiates iii Cannabis (tetrahydrocannabinol) iv Anabolic steroids v Antiretroviral therapy vi Tricyclic antidepressants vii Calcium channel blockers or digoxin d Endocrinopathy e Nipple cyst f Malignancy (rare) Female a Isolated, benign cyst b Fibroadenoma c Fibrocystic disease d Juvenile hypertrophy e Hematoma/fat necrosis (posttraumatic) f Papillomatosis g Cystosarcoma phyllodes and other cancers (rare) TABLE 16.2 COMMON BREAST LESIONS Newborn Physiologic hypertrophy Mastitis (mastitis neonatorum) Prepubertal Child Premature thelarche (female) Pubertal/Postpubertal Male Pubertal gynecomastia Pubertal/Postpubertal Female Enlargement/galactorrhea secondary to pregnancy Mastitis and breast abscess Fibroadenoma Fibrocystic disease Benign, isolated cysts TABLE 16.3 LIFE-THREATENING BREAST LESIONS Newborn Mastitis (mastitis neonatorum) Prepubertal Child Breast enlargement with precocious puberty (secondary to hormonal secretion by a tumor) Postpubertal Male Breast enlargement with abnormal sexual development (secondary to hormonal secretion by a tumor) Postpubertal Female Neoplastic mass Galactorrhea secondary to prolactin-secreting tumor Benign Cysts and Masses Enlargement of breast tissue may occur at any age Hypertrophied breast tissue occurs in the first few weeks of life secondary to maternal estrogen stimulation in male and female infants This is a normal physiologic response that abates over time, parental reassurance is the treatment Isolated unilateral or bilateral thelarche may occur in preschool-aged girls In the absence of development of secondary sexual characteristics, this is consistent with isolated benign premature thelarche Enlargement usually resolves spontaneously within years, though continued follow-up with a primary care physician is prudent Breast enlargement in the setting of secondary sexual characteristics, such as pubic hair (precocious puberty) in girls, or any breast enlargement in young boys (prepubertal gynecomastia), is abnormal and additional evaluation indicated History and examination focused on the presence of adrenal, ovarian, or hypothalamic pathology, including hormone-secreting tumors and intracranial tumors, is indicated Review recent medication usage as several medications can cause gynecomastia ( Table 16.1 ) Unless an intracranial mass is suspected, most children can be referred for outpatient workup with an experienced physician or endocrinologist Fibroadenomas are the most common benign breast lesion (>75%) in the adolescents These masses are most often discovered by self-examination They are solitary, well-circumscribed, mobile, rubbery, masses located in the upper outer breast quadrant that are typically 5 cm) which may destroy normal breast tissue; referral to a pediatric or breast surgeon for excisional or core biopsy is recommended Fibrocystic disease is a benign, progressive process generally seen in women during the reproductive years, but may also present in adolescence Fibrotic tissue is most prominent in the upper outer quadrants of the breast and unilateral or bilateral Frequently, presentation is that of cyclically painful nodules that change in size during the course of the menstrual cycle, with the maximal symptoms during the premenstrual phase Serosanguinous nipple discharge is rarely present Importantly, in the adolescent population, these lesions are not precancerous Breast ultrasonography can be used to confirm the diagnosis although neither needle aspiration nor breast biopsy is required Treatment is largely symptomatic with breast support, nonsteroidal analgesics, and avoidance of caffeine Oral contraceptive agents can reduce symptoms in severe cases, but are not typically ... required for giant fibroadenomas (>5 cm) which may destroy normal breast tissue; referral to a pediatric or breast surgeon for excisional or core biopsy is recommended Fibrocystic disease is