Breast Problems
Pediatric breast problems can be categorized to those that arise in infancy and those later in childhood. They may manifest as nipple discharge, masses or lumps, with redness or swelling of the breast area. It is not uncommon for some children to have extra breast tissue or extra nipple tissue. This extra tissue rarely causes any physical symptoms but can be removed if it leads to emotional or psychological problems.
In the pediatric population breast cancer is extremely uncommon. Most breast problems are benign and many resolve without specific treatment. Operations on the breast of prepubertal girls should be carefully undertaken because of the risk of adverse effects upon future breast development.
Swelling or discharge in infants:
Many infants will have a normal fluid or discharge from one or both nipples which is usually clear or even milky. It has been referred to as “witch’s” milk and is seen both in males and females. Sometimes the breast bud underneath the nipple is enlarged and may stay enlarged for several months after birth as if the baby was developing early small breasts. This is normal and does not indicate anything wrong with the baby. It is not caused by abnormal care or feeding of the child.
Nipple discharge is a result of hormonal stimulation of the infant breast tissue by hormones that a mother normally makes during the last trimester of pregnancy. Some of these will cross into the infants circulation across the placenta. From there they travel to the baby’s breast tissue and stimulate the breast tissue to increase in size. Once the stimulation is no longer present the breast tissue will stop making fluid and usually shrink back down to normal over several weeks although this may persist over a few months.
Some infants will have a palpable lump right beneath the nipple up to 2 or 3cm. across. This lump may be felt for weeks or even months and in some baby’s may be palpable throughout the childhood years. For most babies the breast bud is not palpable.
The presence of nipple discharge in the infant is not a reason to stop breast feeding. Occasionally stimulation of the nipple by manipulation or squeezing may prolong the production of fluid. Some babies will have redness and swelling around the nipples and most times this will resolve spontaneously. Occasionally the tissue becomes infected and requires antibiotics.
A child with fever, swelling or tenderness of one breast more than the other may have a breast infection called mastitis. Antibiotics usually clear up the infection although on occasion the infection progresses to an abscess that may require aspiration or surgical incision and drainage. Bloody discharge from the nipple is rare and is usually benign.
In the adult, where bloody discharge warrants immediate attention and can indicate abnormal growth in the breast, in a child it is usually the result of transient growth of ducts beneath the nipple. Usually the discharge resolves spontaneously. If the drainage lasts for months sometimes surgery is indicated to remove the abnormal duct. However, it is not always simple to isolate the duct and since most cases of bloody discharge are not cancerous, surgery is recommended only for those cases in which the drainage lasts for a prolonged time.
Occasionally an adolescent who has gone through or is undergoing puberty will have clear nipple discharge. This is rarely a cause for concern and is the result of drainage from the gland just beneath the nipple. This drainage usually stops spontaneously in three to five weeks.
Small glands beneath the nipple that help lubricate the nipple are called Montgomery glands. These are sebaceous or sweat type glands and are a normal part of a woman’s nipple. Sometimes a lump can be felt in the skin at the nipple. Thin nipple discharge in a healthy non-pregnant girl should resolve spontaneously and is usually not treated with medication. Surgery or biopsy should be avoided.
Occasionally a young girl or adolescent will suffer a traumatic blow or fall on her breast. She may then develop a bruise or a hematoma and injury to the underlying fatty tissue that may break down to necrosis or death of the tissue. This can develop into an abscess especially if the skin overlying the injury is cut or scraped. A red tender area that was injured but now appears to be fluid filled, may indicate an abscess that requires drainage.
Normal breast development first appears shortly after birth and then again at the beginning of puberty. Boys as well as girls will have a small breast bud that can be felt for a few weeks after they are born. Thelarche is the term for mature breast development and may begin in girls as early as eight or nine years of age. The timing of breast development varies greatly from one person to another and in some girls may not occur until well into the teenage years.
Premature breast development can be seen in young girls and the term premature thelarche is used. In this case a small non-tender swelling of 2 to 4 cm. can be felt just beneath the nipple. While this subsides spontaneously in up to 50 percent of cases, it may persist until the time of puberty. It does not preclude normal development later on. Early development it is not a cause for concern in the absence of other signs of early puberty such as that of pubic and axillary hair, menstruation or other effects of estrogen hormonal stimulation.
Many adolescent girls are focused on their body image and in this era of cosmetic surgery many would wish to augment their breasts. However, it is wise to delay any intervention until full/normal development is complete late in the teenage years as any intervention prior to this time may alter the normal process. Breast surgery or nipple piercing prior to this time may disrupt normal development and breast feeding at a later date. It is also normal for one breast to be slightly larger or smaller than its mate --- other than breast masses. Because of heightened awareness of breast cancer, any lump in the child often creates a great deal of anxiety for the child and the parent. Breast cancer is extremely rare before the age of 20 and accounts for less than one percent of all breast lumps or lesions in children. Less than one-tenth of one percent of all breast cancer occurs in children or adolescents.
Many girls, have lumpiness throughout their breasts. These represent areas of normal breast tissue evolving at different times. Persistence of sometimes painful breast tissue in young women after puberty is often labeled fibrocystic breast disease. This is actually not a disease and not abnormal, although the term has persisted. There is no increased risk of cancer in these patients.
In many young girls the tenderness can worsen with the menstrual cycle and may be under hormonal influence. In some cases, it can be relieved by regulating the menstrual cycle with oral contraceptives. If there is no dominant mass in the breast, aspiration or biopsy is not indicated.
A single, dominant breast lump within the breast of a young girl is often a cause for concern and should be monitored by a physician. If the mass continues to grow beyond two menstrual cycles it may require aspiration or biopsy.
Mammography should not be used in the teenage group as a screening test for breast cancer. Because of the density of the tissue in a young woman and the rarity of breast cancer a mammogram cannot reliably prove helpful to screen for breast cancer and subjects the patient to unnecessary radiation risk. Ultrasound examination is an imaging study which may be of benefit, although careful physical examination by a trained physician is usually just as rewarding.
The most common diagnosis for breast lump in an adolescent female is a benign fibroadenoma. This is a firm, rubbery lump within the breast tissue which is not attached to the skin or muscle. It may appear to move around when palpated or examined. It is a lump which displaces normal breast tissue and although many are only 1 or 2cm in size they can grow to a large size, as large or larger than the normal breast tissue on that side. A small percentage of these lumps will spontaneously regress or decrease in size. If the mass distorts the appearance of the breast or continues to grow in size after one or two menstrual cycles, it can be removed. Once the fibroadenoma is removed, adjustment by normal breast tissue that has been pushed aside will return the normal contour of the breast.
Breast Cancer in Children:
Breast Cancer is unusual in a young girl and most lumps or masses that are seen will be benign (non-cancerous). As mentioned earlier less than 0.1% of all breast cancer occurs in children.
Juvenile Secretory Carcinoma is a rare form of breast cancer in children. These are usually small, poorly defined masses that merge with the surrounding breast tissue. They are usually slow growing and less aggressive than adult cancers. Local excision with close follow-up is usually sufficient to remove the tumor.
Cystosarcoma Phylloides is a rare tumor of the breast that can occur in children. It is a rapidly growing tumor which stretches the breast and the overlying skin. About 25 percent of these tumors are cancerous so primary treatment is to resect the tumor mass.
There are other types of cancer that may spread to the breast tissue. This includes lymphoma, a disease of the lymphatic system since there is a significant number of lymph nodes within the breast and the area of the axilla (armpit).
Other tumors of childhood may occasionally spread to the breast area and are treated according to the primary mass. All girls should be taught breast self-examination once their breasts are developing and they are going through their menstrual cycles. This should be the beginning of a life long habit.
Gynecomastia or abnormal breast development in boys:
Gynecomastia refers to any breast development in a boy who is older than an infant. Many boys develop a small 1 to 2cm. disc like swelling below the nipple early in puberty. Although most boys do not recognize this lump it is quite common and happens in two-thirds of most teenage boys. It may develop in the first year or two after the onset of puberty and gradually disappears. This is simple pubertal gynecomastia.
Nipple discharge is usually not seen but many boys will complain of tenderness or pain which is frequently the increased sensation in an area richer in nerve endings than the surrounding skin.
Breast development may also be seen in those teenagers who are obese as they will have significant fatty deposits in the breast area. The appearance of breast is often distressing for the boy and may lead to surgical resection of the abnormal tissue.
Some medications have been shown to cause gynecomastia. The use of marijuana is linked to breast growth in boys and men. Other medications such as steroids, digitalis or anti-depressants and diuretics have also been shown to stimulate breast development in males.
In the absence of medications an endocrine evaluation to measure hormone levels, may be indicated in boys with significant gynecomastia. Boys undergoing puberty who develop gynecomastia should be simply reassured, however, since the small growth usually disappears. It may persist for a year or two, however.
Extra breasts or nipple tissue can accompany normal growth of breasts. Up to three percent of the population will have an extra nipple away from the normal site on the chest wall. The milk line, like that in other mammals, extends with an imaginary line from the armpit through the area of a normal breast down to the groin. An accessory nipple can be removed with a straight forward surgical procedure.
Breast Hypertrophy:
Occasionally breast development in a young girl will be so extensive that the breasts become massive and continue to grow out of proportion to the rest of the girl. This is called juvenile breast hypertrophy and may lead to chronic neck and back pain and may require breast reduction surgery. However the process may continue and surgery may need to be repeated.
Amastia is the term given for the absence of breast tissue. Treatment in the female does consist of breast reconstruction on the affected side, once growth of the opposite breast is complete.
Polands Syndrome is a condition involving abnormal development of the breast, the underlying muscles and the ribs. It may involve one or both sides of the chest and be associated with anomalies of the hand and upper extremities.
The extent of the deformity can be slight or severe ranging from the simple absence of breast tissue to absence of all or part of the chest muscle and underlying ribs. In males with Polands’ Syndrome reconstruction of the chest often is unnecessary if there is no underlying chest wall deformity. In females full breast reconstruction is performed at the time of full normal breast development and can be planned in conjunction with or following reconstruction of the chest wall.
Articles and graphics adapted from O'Neill: Principles of Pediatric Surgery. © 2003, Elsevier.