Bloody Nipple Discharge in Infancy
A healthy 12-month-old girl presented for a routine well-child checkup. The mother had noted a bloody discharge on the infant’s shirt over the right nipple on several occasions but otherwise had no concerns. She denied any history of masses, redness, trauma, or bruising over the girl’s chest.
The girl had no history of easy bruising or bleeding. She had not had any recent illnesses, fevers, or rashes. Her only medication was a topical estrogen cream used intermittently over the past 3 weeks for labial adhesions. There was no other pertinent past medical history. Her growth and development were appropriate for her age, her diet was regular, and her immunizations were up to date. There was no family history of bleeding disorders or breast cancer or other cancers.
On physical examination, a small drop of blood was expressed from the right nipple. No breast enlargement, masses, lumps, nodules, or skin changes were found, and there was no axillary, supraclavicular, or groin lymphadenopathy. The genitourinary examination was positive for a moderate labial adhesion. The rest of the examination findings were unremarkable.
Ultrasonography of the right breast was ordered to check for masses or abnormal tissue, but the parents did not complete this test. Results of a complete blood count were normal. Laboratory tests showed normal thyroid-stimulating hormone and estradiol levels and a serum prolactin level of 55.1 µg/L (reference range, 4.8-23.3 µg/L). Culture of the expressed fluid revealed skin flora. At the recommendation of a pediatric endocrinologist, the tests were repeated; this time, the serum prolactin level was normal.
The parents were asked to monitor their daughter closely and to return if they observed any changes or worsening of the bleeding. At her routine well visit 3 months later, her nipple discharge had resolved completely.
Until 2005, 7 cases of infants with bloody nipple discharge (BND) had been reported,1 with the first in 1983.2 This number has increased to approximately 30 since then. BND continues to be a rare finding in the pediatric population.3,4
Historically, BND in children had been a cause of significant distress, mainly because it is a sign of carcinoma of the breast in adults.3,5,6 Because no practice guidelines existed for these cases, unnecessary invasive surgeries often were performed.1,7 Over time, it was found that most cases of BND were related to mammary duct ectasia, a benign breast condition that usually presents as bleeding but can be accompanied by a discrete mass or enlargement of the breast.8 The bleeding typically resolves spontaneously within 1 to 9 months.1 There have been no reports of breast cancer in children younger than 12 months with BND.9
Breast enlargement and BND can be adverse effects of topical estrogen use; however, the systemic estrogen level would need to be elevated to produce this effect.
Given the likelihood of a benign process, Kelly et al1 proposed a basic diagnostic approach to an infant presenting with BND. The initial workup should include culture tests, cytology tests with Gram staining of the discharge, and assessment of serum levels prolactin, thyroid-stimulating hormone, and estradiol levels.1
Ultrasonography of the breast is considered a good noninvasive imaging modality.1,9 Ultrasonography may show dilated ducts, ducts filled with debris, and cystic changes in cases of mammary duct ectasia.8,10 However, pediatric surgical consultation is recommended if additional abnormal findings are present.1,4 If mastitis is suspected, antibiotic therapy is recommended.1,3 Magnetic resonance imaging of the brain should be performed if the hormone levels are elevated.1,8
In rare cases in which the BND does not resolve spontaneously, or where the patient presents with other symptoms such as a breast lump, surgical intervention may be indicated.8
1. Kelly VM, Arif K, Ralston S, Greger N, Scott S. Bloody nipple discharge in an infant and a proposed diagnostic approach. Pediatrics. 2006;117(4):e814-e816.
2. Berkowitz CD, Inkelis SH. Bloody nipple discharge in infancy. J Pediatr. 1983;103(5):755-756.
3. Seo JY, Kim SJ, Lee SJ, Song ES, Woo YJ, Choi YY. Bloody nipple discharge in an infant. Korean J Pediatr. 2010;53(10):917-920.
4. Çorapçioğlu F, Akanse G, Sarper N, Taneri H, Yildiz K. Mammary ductal ectasia as cause of bloody nipple discharge in a 28-month-old boy. Turk J Pediatr. 2005;47(4):379-381.
5. Richards T, Hunt A, Courtney S, Umeh H. Nipple discharge: a sign of breast cancer? Ann R Coll Surg Engl. 2007;89(2):124-126.
6. De Praeter C, De Coen K, Vanneste K, Vanhaesebrouck P. Unilateral bloody nipple discharge in a two-month-old male. Eur J Pediatr. 2008;167(4):457-459.