Pediatric emergency medicine trisk 108

nipple discharge is present, Gram stain, culture, and rarely cytology can be of value Fine-needle aspiration is used in a limited fashion in children and adults, since the majority of lesions are typically benign Serum endocrinology testing may be indicated for some breast lesions, although these generally take place outside the ED FIGURE 16.1 Approach to breast complaints in the prepubertal child APPROACH The approach to the patient with complaints related to the breast primarily depends first on whether the patient is prepubertal or pubertal/postpubertal Among patients who are pubertal/postpubertal, the considerations vary greatly between boys and girls Finally, unique considerations pertain to the pregnant or lactating girl, as discussed earlier in this chapter Prepubertal Child Among prepubertal children ( Fig 16.1 ), the most common breast disorders are physiologic hypertrophy in the newborn period and premature thelarche in young girls When physiologic hypertrophy is noted in newborns, erythema or tenderness should be assessed, and mastitis and potential serious bacterial infection should be considered Breast development in prepubertal girls, without other signs of puberty, particularly in those younger than 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 FIGURE 16.2 Approach to breast complaints in the pubertal/postpubertal boy FIGURE 16.3 Approach to breast complaints in the pubertal/postpubertal girl refers to milky, as opposed to bloody, serous, or purulent discharge a Galactorrhea Suggested Readings and Key References Al Ruwaili N, Scolnik D Neonatal mastitis: controversies in management J Clin Neonatol 2012;1(4):207–210 Arca MJ, Caniano DA Breast disorders in the adolescent patient Adolesc Med Clin 2004;15:473–485 Demoor-Goldschmidt C, Allodji RS, Jackson A, et al Breast cancer, secondary breast cancers in childhood cancer male survivors-characteristics and risks Int J Radiat Oncol Biol Phys 2018;102(3):578–583 Gao Y, Saksena MA, Brachtel EF, et al How to approach breast lesions in children and adolescents Eur J Radiol 2015;84(7):1350–1364 Kennedy RD, Boughey JC Management of pediatric and adolescent breast masses Semin Plas Surg 2013;27:19–22 Lam E, Chan T, Wiseman SM Breast abscess: evidence based management recommendations Expert Rev Anti Infect Ther 2014;12(7):753–762 Lee EJ, Chang YW, Oh JH, et al Breast lesions in children and adolescents: diagnosis and management Korean J Radiol 2018;19(5):978–991  ... 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... children and adolescents Eur J Radiol 2015;84(7):1350–1364 Kennedy RD, Boughey JC Management of pediatric and adolescent breast masses Semin Plas Surg 2013;27:19–22 Lam E, Chan T, Wiseman SM Breast