Bloody Nipple Discharge in an Infant and a Proposed Diagnostic Approach

Victoria M. Kelly, Khuram Arif, Shawn Ralston, Nancy Greger and Susan Scott
Pediatrics 2006;117;e814
DOI: 10.1542/peds.2005-0794

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located on the World Wide Web at:
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2006 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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EXPERIENCE & REASON

Bloody Nipple Discharge in an Infant and a Proposed

Diagnostic Approach
Victoria M. Kellya, Khuram Arif, MDb, Shawn Ralston, MDc, Nancy Greger, MDb,d, Susan Scott, MDb,d
bDepartment of Pediatrics, Ambulatory Care Clinic, and Divisions of cPediatric Critical Care and dPediatric Endocrinology, aUniversity of New Mexico College of Medicine,
Albuquerque, New Mexico

The authors have indicated they have no nancial relationships relevant to this article to disclose.

ABSTRACT
Bloody nipple discharge is a rare finding in infants and is associated most often with benign mammary duct ectasia.
The rarity of this symptom in infants and its association with breast carcinoma in adults can lead to unnecessary
investigation and treatment. Here we describe a 4-month-old boy with bilateral bloody nipple discharge that resolved
spontaneously without treatment by 6 months of age. Furthermore, we propose a strategic method for the evaluation
of such infants.

NFANTILE BLOODY NIPPLE discharge, although rare, can

be very distressing to the childs parents and health

care providers. Although this finding can be associated
with breast carcinoma in adults, all of the reported cases
in infants have been found to be benign processes.110
The diagnostic workup in several of these infants involved invasive procedures, including mastectomy.5,6
Evaluation of bloody nipple discharge in infants on the
basis of its associated pathologies in adults can lead to
unnecessary and deforming procedures, worry, and cost.
Here we present a typical case of bilateral bloody nipple
discharge in a 4-month-old boy. After discussing this
case, we suggest an approach to evaluation of bloody
nipple discharge in infants.

CASE REPORT
A 4-month-old male presented with bilateral bloody
nipple discharge without associated breast hypertrophy.
The discharge was intermittent for 2 months, beginning initially as a thin, whitish fluid and then becoming
a thicker pinkish/red discharge over time. The parents
denied any manipulation or palpation of the breast tissue and did not notice any associated change in the size
of the breasts. The past medical history was unremarkable, including a term delivery without complications,
no surgical history, and no medications. The child was
breastfed. The physical examination revealed a small
amount of serosanguinous discharge from both nipples.
There was no palpable mass in either breast and no
evidence of enlarged breast tissue. The remainder of the
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KELLY, et al

physical examination was unremarkable, with normal

male genitalia and bilaterally descended testes.
Prolactin and estradiol levels were within the ageappropriate reference range at 17.05 ng/mL and 18 pg/
mL, respectively. Culture of the discharge was negative,
and no white blood cells were observed on microscopy.
Ultrasound was suggested, but the family did not follow
through. At the 6-month checkup, the discharge had
resolved completely and there was no palpable breast
tissue; the parents reported that the discharge ceased by
time the child was 5 months old. Breastfeeding was
discontinued at 4 months of age.

DISCUSSION
In the past 25 years, there have been 7 published cases of
bloody nipple discharge in infants and 3 cases in children
4 years of age. In 1983, Berkowitz and Inkelis3 reported the first 2 cases of bloody nipple discharge in a
male and a female infant, both 6 weeks old. Both patients presented with unilateral bloody nipple discharge
and ipsilateral breast hypertrophy without evidence of
infection. Neither imaging studies nor surgical intervenKey Words: blood, breast/pathology, breast/secretion, breast/surgery, breast
neoplasms, infant, mammary duct ectasia, mastectomy, nipples/secretion
www.pediatrics.org/cgi/doi/10.1542/peds.2005-0794
doi:10.1542/peds.2005-0794
Accepted for publication Oct 13, 2005
Address correspondence to Victoria M. Kelly, 4328 Altura Mesa Lane NE, Albuquerque, NM 87110.
E-mail: vmkelly@salud.unm.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2006 by the
American Academy of Pediatrics

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tion were performed, and after careful observation, the

girl had full resolution of all symptoms by 9 months of
age and the boy exhibited a decrease in breast size and
only a small amount of bloody discharge at the 1-month
follow-up. The bloody discharge was thought to be an
unusual response of neonatal breast tissue to maternal
hormones, similar in etiology to bloody nipple discharge
in pregnant women.
Stringel et al4 reported cases of bloody nipple discharge in a 3-year-old boy and a 5-month-old girl. After
3 months of discharge from the right nipple, an ipsilateral subcutaneous mastectomy was performed on the
boy. Histologically, this specimen was consistent with
mammary duct ectasia, a benign process revealing dilated ducts with eosinophilic infiltrate, and periductal
fibrosis with numerous inflammatory cells. One year
later, these symptoms recurred on the left side; a subcutaneous mastectomy was performed again, revealing
similar histologic findings. The 5-month-old girl had a
small nodule beneath the areola of the affected nipple;
she was observed carefully without intervention, and
the discharge resolved in 3 months. Miller et al5 reported
similar findings in a 4-year-old boy. A bilateral mastectomy was performed in this case, and both specimens
revealed histology indicative of mammary duct ectasia.
Olcay and Gokoz6 reported bloody nipple discharge in
a 2-year-old boy. After a 3-month history of discharge
from the right breast with hypertrophy, a subcutaneous
mastectomy was performed and the specimen revealed
similar histology as that described by Stringel et al.
Weimann7 reported an 8-month-old boy with a
4-month history of bilateral bloody nipple discharge and
no associated breast enlargement or evidence of infection. After determining normal levels of prolactin, thyrotropin, and estradiol and a normal head ultrasound, an
ultrasound of the breasts revealed dilated mammary
ducts on both sides. Six months later the discharge had
resolved completely.
The remaining 3 case reports included 2 letters to the
editor in response to Berkowitz and Inkelis3 that reported similar cases of spontaneously resolving bloody
nipple in infants. Fenster8 reported bloody discharge in
an 8-month-old boy that resolved without complication
by 15 months of age. In Greece, Sigalas et al9 found a
case of bloody nipple discharge in a 7-month-old boy
associated with a mildly elevated progesterone level; the
discharge resolved in 6 weeks, and progesterone levels
returned to normal. In 1992, a case of bloody nipple
discharge in a 3-month-old girl was published in the
Hebrew language10; the available English-language abstract reported resolution of symptoms by 9 months of
age without intervention.
Of the few case reports of bloody nipple discharge in
infants, the most common cause is mammary duct ectasia. This process consists of dilated mammary ducts and
periductal fibrosis and inflammation, with no clear eti-

ologic explanation. We found very few cases of breast

carcinoma in children between the ages of 3 and 18
years since 1917 and no reported cases in children
3.11,12 The chief presenting symptoms were breast
lumps and local pain, with only 1 report of bloody nipple
discharge in an adolescent.11,13 Pituitary adenomas, specifically prolactinomas, can present as nipple discharge;
however, the discharge is milky and usually bilateral. In
a 1998 study of the clinical presentation of prolactinomas in children and adolescents, patients were identified
between ages 7 and 17 with presenting symptoms of
headache, visual defects, and amenorrhea (in females);
galactorrhea was present in approximately half of the
patients. Bloody nipple discharge was not noted as a
presenting symptom in prolactinoma.14 Mastitis generally presents as unilateral breast pain and erythema but
can be accompanied by a purulent or multicolored nipple discharge if there is an underlying abscess.15,16 In
addition to the unlikely association of bloody nipple
discharge with mastitis, the condition is uncommon in
infants, and when it does occur, it usually occurs before
6 weeks of age (mastitis neonatorum).17
King et al1 and Jardines2 both published diagnostic
approaches to the evaluation of nipple discharge in men
and women over the age of 30. Unfortunately, neither of
these approaches seem applicable to infants. We propose
a diagnostic approach to the evaluation of bloody nipple
discharge in infants.
In an infant presenting with apparently bloody nipple
discharge, an initial workup should include Gram-stain;
cell count and culture of the discharge; serum levels of
prolactin, estradiol, and thyrotropin; and an ultrasound
of the affected breast(s). If hormone levels are abnormal,
especially if there is an elevated serum prolactin level, an
endocrine consultation and MRI of the head specifically
to evaluate the pituitary gland should be obtained.14 If
the culture is positive or if the clinical picture suggests
infection, the child should be treated for mastitis.17 If
ultrasound of the breast reveals a mass or abnormality
other than mammary duct ectasia, a pediatric surgical
consultation versus watchful waiting should be considered.1,2
If hormone levels are within the reference range, the
culture and Gram-stain are negative, and the ultrasound
reveals normal breast tissue or mammary duct ectasia,
we suggest expectant follow-up and reassurance to the
parents. Given unremarkable findings in all of the preceding investigations, both bilateral and unilateral discharge is likely to be benign in infants despite the higher
correlation of unilateral discharge with pathologic
changes in adults.1,2 Therefore, we do not suggest a
unique follow-up for bilateral versus unilateral discharge
in infants in the absence of other findings.
Presence of a palpable mass beneath the affected nipple is not included in the analysis, because the diagnosis
of mammary duct ectasia has been made with and withPEDIATRICS Volume 117, Number 4, April 2006

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e815

out the presence of breast hypertrophy or palpable

mass.5,7 Therefore, we did not feel that classification
based on this clinical finding was helpful in diagnosis.
Instead, we chose further clarification by ultrasound
with or without the presence of a clinically palpable
mass. Although there is little evidence to dictate the
necessity of an ultrasound, it is painless, noninvasive,
and without adverse effects. Additional investigations
such as ductography and additional cytology have been
used in the evaluation of nipple discharge; however,
they have not been shown to have a significant diagnostic benefit in adults.1,2 Although duct excision was performed in several of the case-patients, there does not
seem to be a clear benefit from the procedure, because
all of the excised specimens revealed benign duct ectasia,
and excision may cause permanent deformity or dysfunction of the breast tissue.46
The type of feeding (breastfeeding versus formula)
was ultimately not included in the evaluation of bloody
nipple discharge. Although our patient was breastfed
until 4 months of age, there is no evidence that breastfeeding is an important variable in the etiology of bloody
discharge, because it has been documented equally in
breastfed and formula-fed infants, as well as in significantly older children.
Finally, because most reported cases of ductal ectasia
resolved in 9 months, if the discharge does not resolve
in 6 to 9 months, a pediatric surgical consultation may be
considered regardless of other findings.
CONCLUSIONS
Given that the etiology of adult and infantile bloody
nipple discharge are dramatically different and that all
reported cases in infants have been benign, we suggest a
conservative approach to the problem. Our proposed
method of evaluation of apparently bloody nipple discharge in infants may lead to fewer invasive procedures
and less worry for parents over a condition for which

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KELLY, et al

there seems to be an exceptionally low likelihood of

serious pathology.
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Bloody Nipple Discharge in an Infant and a Proposed Diagnostic Approach

Victoria M. Kelly, Khuram Arif, Shawn Ralston, Nancy Greger and Susan Scott
Pediatrics 2006;117;e814
DOI: 10.1542/peds.2005-0794
Updated Information &
Services

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2006 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on February 13, 2012