A wide variety of breast disorders occur in children – both girls and boys. Breast conditions include growth disturbances such as unusually large breasts in girls called macromastia, breast asymmetry when one breast is larger than the other and breast enlargement in boys called gynecomastia. Breast masses in children occur and are usually benign including collections of milk called galactoceles and in adolescents masses called fibroadenomas in girls. One of the most common breast abnormalities is extra nipples found in the armpits and on the abdomen in both boys and girls.
Normal Breast Development
Often the first sign of puberty in girls is breast development or “budding.” From this point, it may take as few as 18 months or as long as nine years for the breasts to fully mature.
Unusually Large Breasts in Girls (Macromastia)
Macromastia is characterized by breasts that are disproportionately large compared to the rest of the body. While breast size can be a matter of taste, young women with macromastia have problems with upper back and neck strain, trouble participating in sports because of interference by the breast tissue, tingling in the fingers and sometimes skin rashes between and beneath the breasts. With time, the weight of the breasts can cause the bra straps to notch the shoulder skin. Extremely large breasts are a very real source of anguish for adolescent women because of unwanted attention and harassment. Attempting to hide or mask their breasts with special clothing, including minimizing brassieres is not usually very helpful.
Macromastia that occurs over weeks or months at the very onset of puberty is called virginal hypertrophy. This condition is very rare and is treated by pediatric endocrinologists.
Abnormal Breast Development
Asymmetric breasts are the rule rather than the exception. When the asymmetry is significant, plastic surgeons may be able to help “balance the breasts.” Asymmetry can be present since birth as in Poland’s Syndrome or breasts may develop with differing shapes or amounts of breast tissue. An unusual source of breast asymmetry is a giant fibroadenoma, where a benign mass rather than breast tissue is the source of enlargement. Physical examination can usually identify the source of asymmetry. Asymmetry, once noted, rarely changes.
Surgeries can be planned with the patient to provide balance to the two breasts. Correction may involve making larger breasts smaller, making smaller breasts larger or combinations of the two. The surgeon and patient can develop a personalized approach to breast asymmetry that suits the unique circumstances of the patient. Timing of surgery is dependent of the amount of asymmetry and needs of the patient.
Breast masses in adolescent girls are infrequent and usually benign. The most common breast lump — in approximately 70% of cases — is a fibroadenoma. In fact as many as 15% of patients may have multiple fibroadenomas; these masses are smooth, mobile, and round; fortunately, they are usually benign. The masses may occasionally become larger just before the patient's menstrual period. Careful monitoring of these lumps, typically every one to three months, may be all the treatment needed. Ultrasonography is often used to help confirm the diagnosis. Rarely a biopsy may be performed if the patient and family request it.
Like fibroadenoma, fibrocystic lumps in the breast are very common in the adolescent girls. Physical findings may include a solitary breast lump or many small lumps throughout. Some girls notice breast tenderness and a feeling of “heaviness” especially before their menstrual periods. Avoiding caffeine is recommended; in addition, one tablespoon at bedtime of evening primrose oil may be helpful in reducing breast discomfort.
Congenital Anomalies of the Breast
Several rare conditions that occur during fetal development may be found in newborn infants — the absence of nipples (athelia) and the absence of breast tissue (amastia) — may occur on both sides of the body or only on one. Amastia in girls can be treated with implants, called augmentation mammoplasty.
In approximately 1% of the population, an extra breast (polymastia) or extra nipple (polythelia) occurs, a condition that may be inherited. The extra nipples are slightly more common in males than in females. If these conditions occur in girls, hormonal stimulation that happens during a menstrual cycle may cause discomfort.
Breast enlargement in boys is known as gynecomastia. All males have breast tissue behind the nipple and in 50–60 percent of boys during puberty this breast tissue will be enlarged and, even, tender. The condition is benign and typically goes away by itself. The findings in a physical examination may be a solitary, round, movable and usually tender lump located just underneath the nipple that may vary in size from just under ½ inch to slightly more than an inch in diameter. The enlargement may be widely spread out over the breast area to the point of developing raised areolas or a breast mound.
Gynecomastia can involve one or both sides. If the lump is not movable or discharge is present, further tests are necessary to rule out other endocrine and hormone imbalance conditions.
Like macromastia in girls, no one knows the cause for certain, but sensitivity to estrogens is thought to be the source. Gynecomastia can be associated with use of anabolic steroids and marijuana. Liver failure, chromosomal imbalance and pituitary and testicular tumors are very rare causes of gynecomastia.
Although the condition typically disappears with no treatment in 80% of young men, persistent breast enlargement might cause pain, discomfort or psychological trauma. Removing the extra breast tissue in a procedure called subcutaneous mastectomy may be done. A medication is currently being tested for use in shrinking breast tissue in adolescents with gynecomastia, but the treatment is only available in trial studies.
No one knows why some women have overgrowth of breast tissue, but it is thought to be an unusual sensitivity to estrogens.
Diagnosis & Treatment
Treatment often begins with weight loss if the patient is overweight and with physical therapy to improve posture and symptoms of neck and back strain. If symptoms persist, the breasts can be made smaller by surgery called a reduction mammoplasty. Surgery should be deferred until a young woman is close to her adult height and the breast is mature. Typically, this is two to three years after menses have begun and after shoe size stops changing.
Reduction mammoplasty surgeries are typically done as outpatients under general anesthesia. Activities are limited for four to six weeks, but usually patients are back at school by the next week. Surgery of this type may or may not be covered by medical insurance, depending on symptoms, duration, response to conservative therapy, body-mass index (BMI) and the amount of tissue that is removed to reduce the breast size.