Breast disorders in children and adolescents

INTRODUCTION — Breast development during adolescence is an important marker of the transition to adulthood [1]. Most breast abnormalities in childhood and adolescence are benign, but they can be a source of concern for the child/adolescent and may result in poor self-esteem.

An overview of breast disorders in children and adolescents will be presented here. Breast masses in children and adolescents, gynecomastia in male children and adolescents, and disorders of the breast in adult women are discussed separately.

●(See "Breast masses in children and adolescents".)

●(See "Gynecomastia in children and adolescents".)

●(See "Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass".)

●(See "Overview of benign breast diseases".)

●(See "Breast pain".)

BREAST DEVELOPMENT — The breasts start forming in the fifth week of embryonic life. They originate from ectodermal elements termed mammary ridges. The mammary ridges extend from the embryonic axilla to the inguinal region, but only the area over the fourth intercostal space develops further, while the rest atrophies. Under the influence of steroid hormones during childhood growth and development, the breast buds enlarge, and glandular elements appear [2]. Adipose tissue and lactiferous ducts (lobes of the mammary gland at the tip of the nipple) grow in response to estrogens, while progesterone stimulation causes lobular growth and alveolar budding [1].

Thelarche typically begins between the ages of 8 and 13 years, with an average age of onset of 10.3 years [3,4]. While the breast bud is one of the first signs of puberty, the estimated mean time for full breast development is 4.2 years [5]. Adolescent breast development is described according to the stages developed by Tanner in 1969 (picture 1) [5]. (See "Breast development and morphology" and "Normal puberty".)

BREAST EXAMINATION

Clinical examination — A complete breast exam is not indicated at preventive visits unless there is a related health concern. However, the breasts should be visually assessed for sexual maturity rating between the ages of 11 and 21 years [6]. The American College of Obstetricians and Gynecologists suggests that clinical breast examination be offered every one to three years beginning at age 25 years [7]. Elements of a complete breast examination are listed below:

●Newborns – Examination of the newborn includes assessment of breast size, nipple position, presence of accessory nipples, and nipple discharge [8]. Asymmetric breast enlargement and/or a thin milky nipple discharge ("witch's milk") related to stimulation from maternal hormones can occur in both males and females and is a normal finding. (See 'Congenital abnormalities' below and "Breast masses in children and adolescents", section on 'Neonates and infants'.)

●Prepubertal children – Examination of the prepubertal child includes inspection and palpation of the chest wall for masses, pain, nipple discharge, and signs of premature thelarche in females or prepubertal gynecomastia in males. (See "The pediatric physical examination: Chest and abdomen", section on 'Breasts' and "Definition, etiology, and evaluation of precocious puberty".)

●Adolescents – Clinical examination of the adolescent breast includes observation for gross abnormalities (eg, asymmetry, dimpling, color changes, etc) while the female is in the upright position. Breast palpation is performed with the patient in the supine position; the arm ipsilateral to the breast that is being examined should be placed over the patient's head [1,8]. The breast tissue is examined with the flat finger pads using the vertical strip method, concentric circular method, or in a clockwise fashion like the spokes on a wheel [8]. The sexual maturity rating (also called the Tanner stages) should be noted (picture 1). A complete breast examination includes palpation for axillary, supraclavicular, and infraclavicular lymphadenopathy. In addition, the areola should be compressed to assess for nipple discharge. (See 'Nipple discharge' below.)

Breast self-awareness — We suggest that adolescent patients be counseled about breast self-awareness (ie, awareness of the normal appearance and feel of their breasts) and to notify their health care provider if they notice a change such as a mass or new onset of redness or nipple discharge [7]. We do not encourage adolescents to perform self-breast examination (ie, routine, repeated, systematic inspection and palpation of their breasts).

Although experts historically have recommended teaching adolescents self-breast examination for the purpose of screening for breast cancer, there is lack of evidence that breast self-examination impacts rates of breast cancer diagnosis, breast cancer death, or tumor stage or size at the time of diagnosis [7]. Screening for breast cancer is discussed separately. (See "Screening for breast cancer: Strategies and recommendations".)

The promotion of breast self-awareness is consistent with the recommendations of the American College of Obstetricians and Gynecologists and the United States Preventive Services Task Force, who suggest that women be counseled about breast self-awareness and to notify their health care provider if they notice a change [7,9]. (See "Screening for breast cancer: Strategies and recommendations", section on 'Role of breast self-examination'.)

CONGENITAL ABNORMALITIES

Accessory breast tissue — Accessory breast tissue is present at the time of birth in 1 percent of the population (both males and females) [10]. The terminology for accessory breast tissue depends upon the type of tissue that is present. Polymastia refers to the presence of any accessory breast tissue. Polythelia refers to supernumerary (or accessory) nipples. Although polythelia is present at birth, it may not be recognized until later in life.

In most cases, accessory breast tissue consists of a small areola and nipple. However, glandular tissue also may be present. Accessory nipples may occur at any point along the milk line from the axilla to the groin where appropriate regression during embryonic development did not occur (picture 2A-C and figure 1); the most common site is just inferior to the normal breast [11]. The most common site for polymastia is the lower axilla [12].

Some studies have suggested an association between polythelia and renal anomalies [13]; renal ultrasonography may be indicated to evaluate this possibility in children with supernumerary nipples, particularly if they have other congenital anomalies [8]. Although there are little high quality data to guide the decision, we generally suggest renal ultrasonography for patients with supernumerary nipples after a discussion of the risks and benefits. If a renal anomaly is found, ultrasonography of the uterus and ovaries may be warranted since the genitourinary systems develop together during embryogenesis, and concomitant genital tract abnormalities may be present.

Supernumerary nipples usually are asymptomatic [8]. Surgical removal may be indicated if the patient is concerned about their appearance. Surgical excision of polymastia also may be warranted to prevent painful swelling during pregnancy [1] and/or the rare development of fibroadenoma or tumor in accessory breast tissue [14-17]. (See "Breast masses in children and adolescents", section on 'Fibroadenoma'.)

Athelia and amastia — Athelia refers to the absence of a nipple. Amastia refers to the absence of breast tissue. This is a rare condition that is thought to occur from obliteration of the milk line during embryogenesis. When bilateral, it is often associated with other congenital anomalies.

Unilateral amastia is one of the manifestations of Poland syndrome (also called Poland sequence), which consists of unilateral absence or hypoplasia of the pectoralis muscle and a variable degree of ipsilateral hand and digit anomalies, including syndactyly, brachydactyly, and oligodactyly [18]. (See "Breast development and morphology", section on 'Abnormalities in breast development' and "Chest wall diseases and restrictive physiology", section on 'Poland syndrome'.)

Athelia and amastia may be treated with corrective surgery. (See 'Breast augmentation' below.)

ABNORMALITIES OF SIZE AND SYMMETRY

Neonatal breast hypertrophy — Benign neonatal breast hypertrophy is discussed separately. (See "Breast masses in children and adolescents", section on 'Neonates and infants'.)

Small breasts — Most adolescents with bilaterally small breasts (hypomastia, micromastia) and otherwise normal sexual development (eg, typical amount and distribution of sexual hair, regular menses) are normal and deserve reassurance [8]. Underlying conditions that should be considered in females with small breasts and abnormalities of pubertal development include hypothyroidism, ovarian failure, and androgen excess [19]. Significant hypomastia also can be associated with connective tissue disorders, mitral valve prolapse, or previous radiation to the chest wall [20]. (See "Evaluation and management of primary amenorrhea" and "Evaluation and management of secondary amenorrhea" and "Adrenal hyperandrogenism".)

Breast asymmetry — Concerns about breast asymmetry (picture 3) are common among adolescents. Most mature women have some degree of breast asymmetry. Asymmetry may be more pronounced between Tanner stage 2 and 4, when the breast is developing, but often improves by Tanner stage 5 (picture 1) [21]. Despite this improvement, 25 percent of adult women have some degree of breast asymmetry [22].

Breast asymmetry also may result from unilateral limitation of breast growth related to injury of the prepubertal breast (eg, trauma, infection, surgery) [10]. In addition, the appearance of breast asymmetry may be caused by an abnormality of the rib cage or scoliosis [10].

For patients with considerable asymmetry, after performing a complete breast examination to exclude mass, cyst, or abscess in the larger breast, the size of each breast should be measured and recorded annually through middle adolescence. The glandular tissue is measured with a tape measure in the horizontal and vertical dimensions; nipple measurements also should be recorded [23,24].

The early adolescent patient with breast asymmetry should be reassured that their breasts are still growing and that the final degree of asymmetry cannot be determined until the breasts have fully developed, which occurs around 18 years of age. Adolescents who are self-conscious about the asymmetry should be encouraged to wear a padded bra or a bra that is padded on the smaller side (available online or from stores that service mastectomy patients) to help mask the asymmetry [1]. A major difference in size can be treated with a prosthetic insert (also available from stores that service mastectomy patients).

If annual serial measurements of the breast demonstrate no further growth, and the patient is unhappy about the discrepancy in breast size, a referral to a breast or plastic surgeon for augmentation of the smaller breast and/or reduction of the larger breast may be warranted. (See 'Breast augmentation' below and 'Breast reduction' below.)

Breast flattening — Breast flattening, or breast ironing, is an underrecognized form of gender-based violence in which the breasts of young females are ironed, pounded down, or otherwise flattened to reduce their size or delay their development in an effort to protect them from unwanted sexual attention and/or delay sexual activity [25,26]. It is a traditional practice in some parts of Africa (eg, Cameroon, Guinea-Bissau, Chad, Togo, Benin) and has been described in immigrant communities [27]. Breast flattening is often performed in secret by female family members. Females who have undergone breast ironing may not report it due to embarrassment or fear of discrimination or repercussions for their relatives.

Although there is little published information about the short- or long-terms effects of breast flattening, reported sequelae include pain, bruising, cysts, scarring, asymmetry, and/or atrophy of the breasts; inverted nipples; and difficulty breastfeeding [25,26,28]. Victims may have low self-esteem and loss of feelings of femininity.

Increased clinician awareness may facilitate early recognition and prevention. The risk of breast flattening may be increased among children whose female relatives have undergone breast flattening and whose relatives consider breast flattening to be essential to their cultural identity [26,27]. The possibility of breast ironing should be considered in females of African heritage who are embarrassed about their bodies or are reluctant to undergo medical examination, particularly examination of the chest.

Additional information about breast ironing is available from the National Female Genital Mutilation Center.

Tuberous breast — Tuberous breast is a variant of breast development in which the base of the breast is limited and the nipple and areola are overdeveloped (picture 4). The etiology is unknown. If the breast examination is otherwise normal, the patient may be referred for cosmetic surgery. The available surgical options vary depending on the location of the hypoplastic breast tissue.

Breast atrophy — Atrophy of breast tissue may occur secondary to weight loss, including from chronic diseases or eating disorders. Breast size may be restored with weight gain. (See "Eating disorders: Overview of epidemiology, clinical features, and diagnosis".)

Breast atrophy also occurs in birth-assigned female transgender adolescents who are receiving gender-affirming testosterone therapy. (See "Management of transgender and gender-diverse children and adolescents", section on 'Gender-affirming hormone therapy'.)

Juvenile breast hypertrophy — Juvenile breast hypertrophy (also called macromastia) refers to spontaneous overgrowth of breast tissue. It is extremely uncommon. The etiology is unclear but may be related to an abnormal response to gonadal hormones [29].

The overgrowth may be unilateral or symmetric (more common) and begins around menarche. In adolescents with juvenile breast hypertrophy, each breast may weigh several pounds (picture 5) [30,31]. Patients often complain of receiving negative attention from others as well as having back pain and limited physical activity. During phases of rapid growth, skin changes, such as peau d'orange or necrosis, may occur. Resolution is rare [29].

The differential diagnosis for juvenile breast hypertrophy includes juvenile fibroadenoma, non-breast cancers, and phyllodes tumors [8,29,32]. (See "Breast masses in children and adolescents".)

Treatment is based upon the stage of the patient's growth. A proper fitting, supportive bra may provide some relief from back pain. After achievement of full breast development, surgery can be considered for cosmetic reasons and/or chronic back pain. Patients should be counseled that reduction mammoplasty in the appropriate adolescent with realistic expectations has a high satisfaction rate and that this surgery usually affords the ability to breast-feed in the future [33-35].

Surgical management

Breast augmentation — Teenagers may seek breast augmentation for reconstructive purposes related to congenital defects (eg, amastia, severe breast asymmetry, tuberous breast) or for purely aesthetic reasons [36].

The American Society of Plastic Surgeons has developed a briefing statement on plastic surgery for adolescents [37]. The key points of the statement include:

●Candidates for purely aesthetic breast augmentation should be at least 18 years of age (by which time the breasts should be fully developed)

●The adolescent should have realistic expectations about the surgery and its outcome (including the possible need for additional surgery)

●The adolescent must have the physical and emotional maturity to ensure the most positive outcome (ie, to be able to tolerate the discomfort and temporary disfigurement of the procedure)

●Adolescents undergoing breast augmentation should understand the risks of the procedure (infection, bleeding, breast pain, implant leakage, rupture, wrinkling of the skin, permanent scarring, development of scar tissue around the implant, changes in nipple and breast sensation, and possible alteration in breastfeeding ability) [38]

●Parental consent is required if breast augmentation is performed in a patient who is younger than 18 years of age

●Breast augmentation should be performed only by board-certified surgeons

The American College of Obstetricians and Gynecologists also provides guidance on breast surgery for adolescents.

Resources for teenagers seeking breast augmentation surgery for aesthetic purposes are available from the US Food and Drug Administration.

Implant based breast augmentation is discussed separately. (See "Implant-based breast reconstruction and augmentation".)

Breast reduction — Potential indications for breast reduction in adolescents include juvenile breast hypertrophy, breast asymmetry, or large breasts that are debilitating to the adolescent [31,36,39,40]. Surgical therapy for gynecomastia is discussed separately. (See "Management of gynecomastia", section on 'Surgery'.)

As with breast augmentation surgery, it is important that breast growth be complete, that the patient have a stable psychosocial history, and that the patient and their parents understand the risks and benefits of the procedure before surgery is undertaken [39,41,42]. Long-term satisfaction among adolescents who have undergone breast reduction surgery appears to be high [31,34,35,43].

The risks, benefits, and potential complications of breast reductions surgery are discussed separately. (See "Overview of breast reduction".)

BREAST PAIN — Breast pain (also called mastalgia or mastodynia) may occur in early pregnancy, during exercise, as a side effect of oral contraceptives or the contraceptive implant, or premenstrually in association with fibrocystic changes. It can also be idiopathic. Information from the history can help to identify factors contributing to breast pain so that appropriate management can be undertaken.

●Patients with poorly localized cyclic pain – In the absence of other findings, cyclic and poorly localized mastalgia may be considered to be the severe end of the spectrum of physiologic swelling. Treatment entails reassurance, a supportive bra, and analgesia [41]. Oral contraceptive pills have been shown to improve symptoms in a majority of females and can be used in adolescents [10]. In adult females, danazol and tamoxifen also have been effective, but these drugs have not been studied in adolescents. We suggest treatment with ibuprofen and/or oral contraceptive pills for adolescents [44].

●Patients with large breasts – Adolescents with large breasts who are physically active may have pain related to stretching of Cooper ligaments (fibrous bands between the skin and the pectoral fascia). They may obtain some relief by using a sports bra [22].

●Patients with focal pain – Focal tenderness may be suggestive of a tender cyst, rupture through the wall of an ectatic duct, or a particularly tender area of breast nodularity; focal tenderness also may be related to poorly fitting underwire bras; acute enlargement of cysts and periductal masses may cause severe localized pain with sudden onset [45].

●Patients who recently started oral contraceptives – Symptoms related to oral contraception typically improve within the first few months after initiation. If they do not, the practitioner and patient may have to reconsider the risks and benefits of continuing the medication. (See "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Common side effects' and "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Early side effects'.)

●Patients with a contraceptive implant – Breast tenderness is a common side effect of contraceptive implants. (See "Contraception: Etonogestrel implant", section on 'Counseling points'.)

●Patients taking medications or using illicit substances – Mastalgia has been associated with certain drugs (eg, phenothiazines, exogenous hormones, and marijuana) [10].

●Pain exacerbated by caffeine consumption – Limiting caffeine intake may provide relief for some patients [46], even though controlled studies have failed to demonstrate an association between caffeine and mastalgia [47-49].

Examination of the breasts and regional lymph nodes may reveal cysts, abscesses, or localized inflammation [44]. Palpation of the chest wall can help to identify extramammary causes of chest pain, such as inflammation of the costochondral junctions (Tietze syndrome) [44,45]. Other causes of extramammary chest pain include cervical root syndromes, lung disease, and gallstones [50]. (See "Major causes of musculoskeletal chest pain in adults", section on 'Tietze's syndrome'.)

Laboratory evaluation is usually not necessary. A pregnancy test should be performed if pregnancy is a possibility [44]. Ultrasonography to determine whether the mass is cystic or solid may be warranted if a mass is detected. (See "Breast masses in children and adolescents".)

Treatment is geared toward removing the underlying cause.

NIPPLE DISCHARGE — Nipple discharge is uncommon in children and adolescents, and most cases are associated with benign causes [8,12]. Nipple discharge in adult women is discussed separately. (See "Nipple discharge".)

When a pediatric patient presents complaining of nipple discharge, it is important to attempt to express the fluid from the breast and to culture it. The appearance of the fluid (milky, purulent, serous, etc) helps to determine the potential cause and subsequent evaluation [8,12]. In addition, nipple discharge should be differentiated from areolar secretions. (See 'Differential diagnosis' below.)

Clinical evaluation — The evaluation should determine whether the discharge is spontaneous or provoked by manipulation of the breast, whether the discharge is unilateral or bilateral, and whether the patient is taking any medications associated with nipple discharge (eg, some antipsychotics and antidepressants, among others) (table 1). A nipple discharge may occur during milk production (lactation) after childbirth, as a result of mechanical stimulation of the nipple by fondling or sucking, or due to irritation from clothing. Cancers generally present with spontaneous (rather than provoked) grossly bloody discharge arising from a single duct and are exceedingly rare in children and adolescents [45]. Children and adolescents with spontaneous nipple discharge without an obvious cause should be referred to an appropriate specialist (eg, pediatric endocrinologist, pediatric gynecologist) [50]. Bilateral nipple discharge is essentially always due to an endocrinologic or physiologic process.

A complete breast examination should be performed. The specific goals of the examination are to:

●Elicit discharge from the nipple; the application of a warm compress and massage from the periphery of the breast toward the nipple areolar complex may facilitate detection of mammary secretion; gentle, firm pressure should be applied at the base of the areola (not on the nipple). It is important to observe whether the discharge comes from one or more ducts on the nipple; flow from one duct is more worrisome than that from multiple ducts [45]. A good light and magnifying lens can help with this identification.

●Delineate and document breast masses. (See "Breast masses in children and adolescents".)

●Note the symmetry and contour of the breasts, position of the nipples, scars, vascular pattern, skin retraction, dimpling, edema or erythema, ulceration or crusting of the nipple, and changes in skin color.

●Identify localized areas of tenderness and relate them to areas of pain noted by the woman and to other physical findings.

●Detect enlarged axillary, infraclavicular, or supraclavicular lymph nodes.

Differential diagnosis — The appearance of the fluid (milky, purulent, serous, etc) helps to determine the potential cause and subsequent evaluation, as described below [8,12].

●Milky discharge – Milky discharge is characteristic of galactorrhea, which is typically bilateral and may be caused by pregnancy, postpartum or postabortion states, hypothyroidism, hypogonadism, overstimulation from manual manipulation, certain drugs (table 1), and prolactin-secreting tumors [8,12,51]. A prolactin level >250 ng/mL is highly suggestive of a pituitary tumor [52]. Antipsychotic medications are the most common cause of pharmacologic hyperprolactinemia [53]. (See "Causes of hyperprolactinemia".)

Depending upon additional findings from the history and examination, the evaluation for galactorrhea in an adolescent may include a pregnancy test, prolactin level, thyroid function studies, luteinizing hormone, and follicular-stimulating hormone [1,54]. If there is a question about whether the discharge is true galactorrhea, it can be sent for fat staining [1]. (See "Clinical manifestations and evaluation of hyperprolactinemia" and "Clinical manifestations of hypothyroidism".)

●Multicolored/sticky discharge – Multicolored, sticky nipple discharge associated with a cystic lesion may be associated with mammary duct ectasia, which is a benign condition characterized by distension of subareolar ducts with fibrosis and inflammation [10]. (See "Breast masses in children and adolescents", section on 'Mammary duct ectasia'.)

●Purulent discharge – Purulent nipple discharge suggests an infection of the breast (eg, cellulitis or abscess) and should be sent for culture with susceptibility testing [8]. (See "Mastitis and breast abscess in children and adolescents" and "Mastitis and breast abscess in infants younger than two months", section on 'Introduction'.)

●Serous or serosanguineous discharge – Serous drainage from the nipple or areola may occur in association with excretion from Montgomery tubercles (also called Morgagni tubercles, small soft papules located around the areola) (figure 2) [8,12]. In females (or males) with Montgomery tubercles, a small subareolar lump may be palpable [8]. The management of Montgomery tubercles is discussed separately. (See "Breast masses in children and adolescents", section on 'Cysts of Montgomery'.)

Serosanguineous nipple discharge also may be caused by intraductal papilloma (benign proliferative tumors of the mammary ducts), fibrocystic changes, or, rarely, cancer [8]. (See "Breast masses in children and adolescents", section on 'Fibrocystic change'.)

Other causes of serosanguineous drainage include traumatic nipple erosions ("jogger's nipple," which also can be grossly bloody) and eczema, both of which can be treated with nipple hygiene and warm compresses [50].

●Bloody discharge – Bloody nipple discharge is rare in infants and young children [55]. The most common cause is mammary duct ectasia. (See "Breast masses in children and adolescents", section on 'Mammary duct ectasia'.)

Grossly bloody nipple discharge in adolescents may be caused by intraductal papilloma, chronic nipple irritation (eg, jogger's nipple) or cold trauma (eg, cyclist's nipple), mammary duct ectasia, chronic cystic mastitis, and, rarely, breast cancer [1,50]. (See "Breast masses in children and adolescents" and "Mastitis and breast abscess in children and adolescents" and "Mastitis and breast abscess in infants younger than two months", section on 'Introduction'.)

●Apocrine chromhidrosis – Apocrine chromhidrosis, the secretion of colored sweat by the apocrine glands of the areola, may be confused with bloody nipple discharge [8]. Characteristically, the discharge occurs when the patient exercises or manually exerts pressure around the areola. Both cytologic examination and cultures are negative. No treatment is indicated for this condition [56].

BREAST INFECTION — Breast infections in neonates, children, adolescents, and lactating women are discussed separately. (See "Breast masses in children and adolescents" and "Common problems of breastfeeding and weaning" and "Lactational mastitis".)

BREAST MASSES — Breast masses in children and adolescents are discussed separately. (See "Breast masses in children and adolescents".)

SUMMARY

●Most breast abnormalities in children and adolescents are benign. (See 'Introduction' above.)

●Breast asymmetry (picture 3) is a common finding during breast development; it persists after sexual maturity in approximately 25 percent of patients. (See 'Breast asymmetry' above.)

●In appropriate patients with the desire for breast surgery, breast surgery should occur after full growth is attained. Surgery should be performed only by qualified surgeons. (See 'Surgical management' above.)

●Common causes of breast pain in adolescents include early pregnancy, fibrocystic changes, inadequate support of large breasts during exercise, certain drugs (exogenous, phenothiazines, marijuana), and breast masses. History and physical examination usually can distinguish between these etiologies. (See 'Breast pain' above.)

●Nipple discharge is uncommon in children and adolescents; most cases are associated with benign lesions. (See 'Nipple discharge' above.)