The most important issues related to the examination of the breasts in older children involve assessment of normal maturational development. For years the established normal age range for onset of breast development was 8 to 13 years of age (average age of 11 years), with breast development occurring before 8 years being abnormal. Some recent studies suggest that the lower age cutoff should be 7 years for Caucasian females and 6 years for African-American (and probably Hispanic) females, though there remains some controversy about the exact age.
Physical changes in a young girl's breasts are one of the first signs of puberty. As in most developmental changes, there is a systematic progression of mat-urational changes. Generally, over a 4-year period, the breasts progress through five stages, called Tanner stages or Tanner sex maturity rating (SMR) stages, as shown on the next page. These progress from a preadolescent stage, to the appearance of breast buds, to subsequent enlargement and change in the contour of the breasts and areola. These stages are accompanied by the development of pubic hair and other secondary sexual characteristics as shown on p. 713. Menarche usually occurs when a girl is in breast stage 3 or 4, and by then she has passed her peak growth spurt (see the figure on p. 700). These sequential changes in breast development are important to understand in relation to overall pubertal changes, and are helpful in counseling girls about their physical maturation.
In about 10% of girls, the breasts develop at different rates and considerable asymmetry may result in either size or Tanner stage. This generally resolves, and reassurance to the patient is most helpful.
In older adolescent girls, a comprehensive breast examination should be accompanied by instructions for breast self-examination (p. 313).
In boys, the breasts consist of a small nipple and areola. During puberty, about one third of boys develop a firm button of breast tissue 2 cm or more in diameter, and these are often noted in one breast only. Obese boys can develop substantial breast tissue.
Supernumerary nipples occasionally are found on the thorax or the abdomen along a vertical line below the true nipple(s), as shown on p. 714. They appear as small, round, flat or slightly raised, pigmented lesions, and are not clinically significant.
Masses or nodules in the breasts of adolescent girls should be examined carefully. They are usually benign fibroadenomas or cysts; less likely etiologies include abscesses or lipomas. Breast carcinoma is extremely rare in adolescence, and nearly always occurs in families with a strong family history of the disease.
A substantial number of adolescent boys develop gynecomastia, or breast enlargement, on one or both sides. While usually slight, the enlargement can be substantial and quite embarrassing. It generally resolves within a few years.
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