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prescribed only for fibrocystic disease in adolescence Follow-up and subsequent evaluation by a primary care physician is recommended; referral to a surgeon for needle aspiration or core biopsy is indicated for painful, large, solitary lesions Nipple masses represent another group of generally benign breast lesions Benign intraductal papillomatosis is the most common etiology and can be seen in prepubertal or pubertal boys and girls, often coming to attention because of bleeding from the nipple Occasionally, the lesion may obstruct the nipple and causing pain and possibly infection In extremely rare instances, a nipple mass can represent an intraductal carcinoma In these cases, cytologic examination of the bloody nipple discharge can be of diagnostic value Therefore, expedient referral to a breast surgeon or pediatric surgeon is indicated after detection of nipple mass with bloody discharge In cases of benign nipple masses, careful observation for several weeks by an experienced primary care physician or surgical specialist is indicated If the nipple mass or bleeding persists, excision is the treatment of choice Trauma to the breast can lead to hematomas and fat necrosis, both of which are palpated as firm, lumpy, well-circumscribed breast masses Initially, these lesions may be tender If left untreated, they may develop into areas of scar tissue that are affixed to the skin Fat necrosis is relatively common, but the differentiation from other more serious lesions may be difficult, requiring consultation with a surgeon or use of serial ultrasounds in cases of uncertainty Malignant Masses Primary cancers of the breast have been reported in children, but are exceedingly rare, with an incidence of in 1,000,000 females less than age 20 years In children, breast tumors accounting for less than 1% of all malignancies and less than 0.1% of all breast cancers occur in the pediatric age group Metastatic disease is far more common than primary breast tumors, and may be secondary to Hodgkin and non-Hodgkin lymphoma, neuroblastoma, and leukemia, and rhabdomyosarcoma Adolescent or childhood breast tumors are often classified as secretory carcinomas that behave more benignly than breast cancers in adults Other histologic classifications of breast malignancies reported in children and adolescents include carcinomas, sarcomas, and cystosarcoma phyllodes, which can have both benign and malignant features Physical examination characteristics suggestive of malignancy include a hard, nontender, solitary mass with ambiguous margins The mass may be fixed to surrounding tissues, and overlying skin changes such as edema, warmth, skin dimpling, and/or nipple retraction may be present Other signs include bleeding from the nipple and local lymphadenopathy may be present The appropriate treatment for suspected malignant lesions is the same as that for a benign mass—prompt referral to a pediatric or breast surgeon for definitive workup, usually consisting of core biopsy Among the strongest risk factors for malignant breast masses in the pediatric population include chest irradiation, particularly when incurred during high-dose treatment for Hodgkin disease or with radioiodine treatment for thyroid cancer Radiation exposure between ages 10 and 16 years is most harmful In girls treated for Hodgkin lymphoma, there is a higher incidence of breast cancer within 20 years of treatment Children with a strong familial history of breast malignances, such as those who are offspring of women with inherited cancer syndromes, are also more susceptible to developing breast malignancy Selfexamination is important for detection of potential malignant breast masses, and adolescents should be encouraged to routinely perform them, especially if at increased risk of developing breast cancer For children at particularly high risk, routine screening with magnetic resonance imaging should be considered Abnormal Secretions (Nipple Discharge) There are multiple etiologies of abnormal nipple secretions in children and adolescents These can be divided according to their potential for surgical management Nonsurgical causes typically present as nonspontaneous discharges The most common example is discharge fluid expressed during breast selfexamination The fluid may be milky, multicolored, and sticky and is a normal, physiologic discharge of little concern When breast infection (mastitis or abscess) is present, a purulent discharge may be expressed or occur spontaneously Galactorrhea is the most common spontaneous nipple discharge and usually occurs bilaterally Pregnancy and lactation are typical causes of galactorrhea; however, in the absence of these conditions, increased prolactin states should be suspected Structural lesions of the hypothalamus and pituitary (e.g., adenomas) and exogenous medications can cause increased prolactin levels Drugs implicated include oral contraceptives, tricyclic antidepressants, phenothiazines, metoclopramide, α-methyldopa, anabolic steroids, and cannabis As mentioned earlier, in utero estrogen exposure can lead to breast bud hypertrophy in neonates; in addition, this hypertrophy can be accompanied by a colostrum-like material that has been referred to as “witch’s milk.” This discharge occurs temporarily, until maternal estrogen levels decline, and is not considered pathologic Other nonsurgical spontaneous nipple discharges have been described as multicolored, grossly bloody, serous, or clear and watery Nonbloody discharges are rarely indicative of malignancy Mammary duct ectasia, traumatic nipple erosions (e.g., “jogger’s nipple”), and eczema are among the more common 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 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 epithelial cell proliferation If the discharge persists after delivery, a more thorough investigation for alternate etiologies is recommended Fibroadenomas often increase in size during pregnancy and may result in significant pain Excision is often advised for any solitary mass and the patient should be expediently referred to a breast surgeon The number of cases of breast malignancy diagnosed during pregnancy is very low Miscellaneous Breast Lesions Congenital Lesions Supernumerary breasts (polymastia) and supernumerary nipples (polythelia) are congenital conditions that are unlikely to present as chief complaints in the ED, but that may be discovered incidentally on examination Polymastia results from failure of the embryonic mammary ridges to regress and is present at birth, often resembling skin tags or nevi, and may not be noticed until the tissue is hormonally influenced Supernumerary breasts are most commonly found in the axillae but have been reported to occur in several locations This ectopic tissue may become tender with menses and has been reported to develop the same range of pathology as normal breast tissue, necessitating excision under certain circumstances Polythelia may be sporadic or familial, and is most commonly found on the left, inferior to the normal nipple In newborns, polythelia may appear as small, wrinkled lesions with or without pigmentation Polythelia is typically of little significance, though there is a possible association with unsuspected urologic anomalies For this reason, patients with polythelia should be referred for at least a primary screening of underlying urologic disease Otherwise, this disorder requires no treatment unless the diagnosis is uncertain (e.g., the lesion looks like a possible melanoma) or is perceived as a cosmetic problem Premature Thelarche Premature thelarche refers to isolated breast development without other signs of puberty Minimum acceptable age for thelarche is years; appearance of breast tissue prior to this age should prompt consultation with an endocrinologist Typically appearing within the first years of life in its most common form, premature thelarche is a benign, transient condition of unknown etiology Cases of premature thelarche usually present to the ED secondary to concern raised by parents of prepubertal girls, and reassurance is usually all that is required However, premature thelarche may be the first sign of true precocious puberty or ... mass—prompt referral to a pediatric or breast surgeon for definitive workup, usually consisting of core biopsy Among the strongest risk factors for malignant breast masses in the pediatric population... 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