Patient Presentation
A 34-day-old male came to clinic for his well-child visit. He was the third child and the family had no concerns except for clear to white discharge from both breasts when touched or palpated. This occurred frequently and a small amount was produced. The breasts did not appear red, indurated or painful. The galactorrhea had been noted at his 1 week visit and the family had been told that it should disappear with more time. His neonatal screening test was normal including for hypothyroidism. His family denied him taking any medications. They also denied using or taking any medications in the home except for the mother’s prenatal vitamins. The family did have emollient creams but all were standard brands with usual ingredients. Specifically there were no known hormone exposures. The past medical history revealed a term male without significant prenatal or natal history.
The pertinent physical exam showed normal vital signs and growth parameters around the 50th percentile. He had palpable breast tissue under the areolas bilaterally that was about 2-3 cm in size. There were no irregularities of the tissue such as a discreet mass and the tissue seemed proportional between the two breasts. With minimal palpation, a small amount of a thin, whitish discharge without odor could be produced bilaterally. There was no surrounding erythema or edema and the infant did not seemed bothered by the palpation. The rest of his examination was normal.
The diagnosis of of a healthy male with bilateral galactorrhea was made. The pediatrician thought this was a little long to have galactorrhea due to maternal hormones, but also thought that the infant did not have neonatal mastitis, abscess, or breast mass. The infant also didn’t appear to in an environment where there were medications or exogenous hormones as the cause. His neonatal screening test was normal and he didn’t appear to have any stigmata of midline defects or genetic syndromes. Pediatric endocrinology was consulted and recommended to monitor the infant without further evaluation because this was bilateral and spontaneous in an otherwise healthy infant. It was thought this was still within the normal time period for transplacental maternal hormones as the cause.
The patient’s clinical course showed athis 2 month visit the family said that the discharge had stopped about 1 week after the last appointment and the breasts had decreased in size since that time.
Discussion
Galactorrhea is a milky discharge from the breast in a non-lactating female.
Neonatal galactorrhea is sometimes called “Witch’s Milk” based on ideas from the 17th century or earlier that witches would steal the milk for use in their magic. Infant breasts were often compressed to express the fluid and prevent its collection. During the 19th century, reports of breast inflammation and even abscess were reported because of this practice and it was strongly discouraged, and continues to not be recommended today.
Enlargement of neonatal breasts and galactorrhea, both for males and females, is felt to be usually due to transplacental maternal hormone stimulation and fetal hormones. This stimulation decreases rapidly after birth, but for some infants breast enlargement continues with or without galactorrhea. The ongoing cause is not totally certain.
Galactorrhea is most often seen in term infants as premature infants have little breast tissue and therefore breast enlargement and/or galactorrhea are not seen usually.
Nipple discharge that is usually benign is described as “bilateral, not spontaneous, and occurs with breast manipulation or stimulation, whereas suspicious discharge is usually unilateral, spontaneous and persistent. Bloody breast discharge is potentially worrisome for breast cancer however, pediatric breast cancer is exceedingly rare, and bloody discharge can be see due to stimulation and irritation.
Mastitis or breast abscess are again not very common in infants and children. However, with signs or symptoms of infection these problems must be considered. Neonatal mastitis has a high rate of concurrent bacteremia and usually is treated with systemic antibiotics. A review can be found here.
Prolactin is produced in the anterior pituitary lobe due to dopamine signaling. Prolactin then acts on the mammary gland to increase tissue and produce milk. It also has several other functions on the gonads, adipose tissue, insulin secretion and immune system. “…[S]tress, suckling, estrogens, [thyroid releasing hormone], vasoactive intestinal polypeptide… and oxytocin… act as stimulants of prolactin release directly into the anterior [pituitary] or by reducing the inhibitory action of dopamine.”
Causes of galactorrhea in the pediatric population include:
- Transplacental maternal hormone
- Hypothyroidism
- Hyperprolactinemia
- Pituitary adenomas
- Polycystic ovarian syndrome
- Estrogen
- Oxytocin
- Thyroid releasing hormone
- Stress
- Suckling
- Vasoactive peptide
- Medications
- Antidopamineric
- Antidepressants
- Antipsychotics – a common cause
- Anticonvulsants
- Antiandrogens
- Antihypertensives
- Cholinomimetics
- Estrogen
- Opioids
- Prokinetic agents
- Other
- Obesity (probably partly due to increased lipid conversion to estrogen)
- Marijuana
- Self-stimulation of breast tissue
- Cancer – rare
Learning Point
Neonatal galactorrhea can last longer than usually thought. In a study of healthy newborns (N=640) examined from birth up to 12 weeks of age, 5.9% (N=38 infants) were found to have galactorrhea at some point. All of these infants were term infants and 55% were female. The incidence of galactorrhea was most common in the first 2 weeks of life (6.2% of 552 examinations), but still occurred at 2-5 weeks (3% of 265 examinations) and at 6-10 weeks (1.8% of 167 examinations) with decreasing incidence. One infant was examined at 12 weeks and still had persistent galactorrhea.
Questions for Further Discussion
1. What is in the differential diagnosis of breast masses in the pediatric population? A review can be found here
2. What are common problems associated with pituitary function?
3. What are other common parental concerns regarding neonatal breasts?
Related Cases
- Disease: Galactorrhea | Breast Diseases | Pituitary Disorders
- Symptom/Presentation: Mass or Swelling
- Specialty: Endocrinology | General Pediatrics | Neonatology
- Age:Newborn
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Breast Diseases and Pituitary Disorders.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
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Weimann E. Clinical management of nipple discharge in neonates and children. J Paediatr Child Health. 2003;39(2):155-156. doi:10.1046/j.1440-1754.2003.00118.x
Jain S, Sharma P, Mukherjee A, Bal C, Kumar R. “Witch’s milk” and 99mTc-pertechnetate uptake in neonatal breast tissue: an uncommon but not unexpected finding. Clin Nucl Med. 2013;38(7):586-587. doi:10.1097/RLU.0b013e318292aaba
Fernandez TF, Ashraf AP. An Unusual Case of Galactorrhea With Normal Serum Prolactin. Clin Pediatr (Phila). 2018;57(2):238-240. doi:10.1177/0009922816685821
Michail M, Ioannis K, Charoula M, Alexandra T, Eleftheria H. Clinical manifestations, evaluation and management of hyperprolactinemia in adolescent and young girls: a brief review. Acta Bio Medica Atenei Parm. 2019;90(1):149-157. doi:10.23750/abm.v90i1.8142
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 