What is the management approach for a pediatric male with unilateral gynecomastia and iron deficiency (low ferritin)?

Management of Unilateral Gynecomastia with Iron Deficiency in a Pediatric Male

The unilateral gynecomastia and low ferritin are likely unrelated findings that require separate, parallel evaluation and management—address the iron deficiency with oral iron supplementation at 3 mg/kg/day while pursuing urgent evaluation of the unilateral breast tissue to exclude pathologic causes.

Iron Deficiency Management

Diagnostic Confirmation

• Confirm iron deficiency by verifying serum ferritin <15 μg/L, which has 98% specificity for depleted iron stores in this population 1
• If ferritin is >15 μg/L, iron deficiency is unlikely to be the cause of any symptoms, and alternative diagnoses should be pursued 1
• Consider checking hemoglobin/hematocrit to determine if iron-deficiency anemia is present (not just iron deficiency alone) 1

Treatment Protocol

• Prescribe 3 mg/kg/day of elemental iron (ferrous sulfate or other ferrous preparation) to be administered between meals for optimal absorption 1
• Provide dietary counseling emphasizing iron-rich foods and correction of underlying dietary inadequacies 1
• Recheck hemoglobin/hematocrit in 4 weeks: an increase of ≥1 g/dL in hemoglobin or ≥3% in hematocrit confirms iron-deficiency anemia 1
• If confirmed, continue iron treatment for 2 additional months, then recheck levels 1
• Reassess approximately 6 months after successful treatment completion 1

Non-Response Evaluation

• If anemia does not respond after 4 weeks despite compliance and absence of acute illness, perform additional testing including MCV, RDW, and repeat ferritin 1
• Ferritin ≤15 μg/L confirms iron deficiency; >15 μg/L suggests another cause of anemia 1

Identify Underlying Causes

• Assess for dietary inadequacy: excessive cow's milk intake (>24 oz/day), inadequate iron-fortified foods, or restrictive diets 1
• Evaluate for chronic blood loss, malabsorption, chronic infection, or inflammatory disorders 1
• Consider medications that interfere with iron absorption 1

Unilateral Gynecomastia Evaluation

Critical Distinction

Unilateral gynecomastia requires different evaluation than bilateral gynecomastia because it has higher risk of pathologic causes including tumors, infections, or trauma. The iron deficiency is almost certainly coincidental rather than causative.

Immediate Assessment Required

• Perform focused breast examination documenting size, consistency, tenderness, skin changes, and nipple discharge
• Palpate for discrete masses versus diffuse glandular tissue
• Examine testes for masses, asymmetry, or abnormalities (testicular tumors can cause gynecomastia via hCG production)
• Assess for signs of hyperthyroidism, liver disease, or medication effects

Diagnostic Workup

• Obtain testosterone, estradiol, LH, FSH, hCG, prolactin, liver function tests, and thyroid function tests
• Consider testicular ultrasound if testicular examination is abnormal
• Breast ultrasound may help differentiate true glandular tissue from fat or identify masses
• If concerning features present (hard mass, fixed tissue, skin changes, bloody nipple discharge), urgent surgical referral is warranted

Key Clinical Pitfalls

Common Errors to Avoid

• Do not assume the two findings are related: Iron deficiency does not cause gynecomastia, and gynecomastia does not cause iron deficiency 2, 3
• Do not delay gynecomastia evaluation: Unilateral presentation requires more urgent assessment than physiologic bilateral pubertal gynecomastia
• Do not use ferritin alone in isolation: Ferritin is an acute-phase reactant and can be falsely elevated by infection, inflammation, or tissue damage, potentially masking true iron deficiency 1
• Do not over-supplement iron: Avoid creating iron deficiency anemia through excessive phlebotomy-like losses; target ferritin 50-100 μg/L, not complete depletion 1

Age-Specific Considerations

• For school-age children (5-12 years), iron supplementation dosing is one 60-mg iron tablet daily if anemia is confirmed 1
• For adolescent boys (12-18 years), dosing increases to two 60-mg iron tablets daily if anemia is confirmed 1
• Adjust based on specific age and weight using the 3 mg/kg/day guideline for younger children 1

Monitoring Strategy

• Do not recheck ferritin immediately after IV iron (if used): levels are falsely elevated for 8-10 weeks 1
• Serial ferritin measurements should occur every 3 months (after every 10-12 phlebotomies if treating hemochromatosis, though not applicable here) 1
• For oral supplementation, 4-week follow-up is appropriate to assess response 1