It is important to consider the age of the patient and his or her stage of pubertal development when assessing the potential cause of breast enlargement, as it is common for an individual’s breasts to develop at different rates. Disorders involving breast swelling most often present during the pubertal years, although they may occur in infancy and early childhood. Many patients may be uncomfortable disclosing breast concerns during an initial patient history; therefore, related abnormalities may be only coincidentally identified during routine physical examination. A breast examination should be performed as part of every well child care visit.

Some of the most common breast concerns, such as breast asymmetry and gynecomastia, may not be true diseases but rather normal physiological variants. Breast enlargement and swelling may also be congenital, infectious, or hormonal in etiology. In male patients, the most common cause of breast tissue development is benign physiologic gynecomastia.

• Breast tissue development occurring in females less than 8 years of age is generally considered to be abnormal, although there may be racial or ethnic variations noted.

• Benign gynecomastia often begins as unilateral breast enlargement and involves the right side twice as often as the left.

• Breast tissue in gynecomastia tends to be tender and/or painful soon after the onset of breast enlargement.

• Development of gynecomastia either before puberty begins or after puberty is completed would not be consistent with benign physiologic gynecomastia.

• In a teenager with gynecomastia, the history should include a list of any medications or recreational drugs that the patient might be using, as drugs may be the cause of gynecomastia. Some drugs associated with gynecomastia include anabolic steroids, marijuana, heroin, isoniazid (INH), metronidazole, dilantin, ketoconazole, ranitidine, and omeprazole.

• Rapid, painful growth of breast tissue in females in early adolescence is seen with a diagnosis of juvenile breast hypertrophy.

• A history of significant chest wall trauma in the prepubertal female may predispose to underdevelopment of the breast on the side of the trauma and thus contribute to breast asymmetry.

• A history of breastfeeding, nipple piercing, or breast trauma often precedes the development of a breast infection.

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