Breast masses are relatively common in children and adolescents. The vast majority of these lesions are benign, and many do not require surgical resection. Unlike in the adult population, standard guidelines regarding the management of pediatric breast masses do not exist, however emerging data from outcomes research can guide management decisions. As the profile of breast lesions in pediatric patients is considerably different than in adults, the complexity of caring for pediatric and adolescent patients with breast lesions lies primarily with decision making surrounding their care. Recommendations regarding imaging and the role of biopsy and excision in pediatric patients differ from those in adults. Most pediatric breast lesions are benign, and the prevalence of complex breast lesions such as borderline or malignant pathology is low. As such, few clinicians are likely to encounter many pediatric or adolescent patients with breast carcinoma or complex pathology without establishing a particular focus or “sub-specialization”. Despite this, children and adolescents with breast lesions may be referred to either pediatric surgeons, adult surgeons or breast-dedicated surgeons. In the absence of formal recommendations from the American Pediatric Surgical Association or American Society of Breast Surgeons, we will consider the question “which pediatric breast lesions are best managed by pediatric surgeons?” On the contrary, we will examine the evidence regarding the management of pediatric breast lesions by adult general surgeons and breast-dedicated surgeons.