Intervention in Lactation Associated Mastitis

A 28-year-old woman who is breastfeeding her healthy six-week-old term infant presents with a four-day history of generalized body aches, intermittent fever to 101.2 degrees Fahrenheit, and localized pain on the upper aspect of her left breast. She states that she's been attempting to nurse her infant as tolerated and pumps the affected breast when unable to nurse. Physical exam is consistent with lactation-associated mastitis. 

Which of the following is the most appropriate next steps? 

A. advise continued expressing of milk on the affected breast through pumping or nursing as tolerated

B. initiate antimicrobial therapy with oral cephalexin for five to seven days.

C. advise discontinuing breastfeeding on the left breast and apply ice packs to the affected area.

D. initiate antimicrobial therapy with oral ciprofloxacin for 10 days. 

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Transcript

Voiceover: Welcome to NP Certification Q&A, presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.

Margaret Fitzgerald: A 28-year-old woman who is breastfeeding her healthy six-week-old term infant presents with a 4-day history of generalized body aches, intermittent fever to 101.2° Fahrenheit, and localized pain on the upper aspect of her left breast. She states that she's been attempting to nurse her infant as tolerated and pumps the affected breast when unable to nurse. Physical exam is consistent with lactation-associated mastitis. Which of the following is the most appropriate next step? Choose two that apply.

A. Advise continued expressing of milk on the affected side via pumping or nursing as she tolerates.
B. Initiate antimicrobial therapy with oral cephalexin for five to seven days.
C. Advise discontinuing breastfeeding on the left breast and apply ice packs to the affected area.
D. Initiate antimicrobial therapy with oral ciprofloxacin for 10 days.

The correct answers are A, advise continuing expressing milk on the affected breast via pumping or nursing as she tolerates, and B, initiate antimicrobial therapy with oral cephalexin for 5 to 7 days.

Where do you start with this question? First, determine what kind of a question it is. We're given a diagnosis, so this is a plan question.

Let's look at some background information. The family boards have a small section on care during the antepartum and post-birth period, maybe about six questions now. However, the peds part is almost 20% of the exam, and this is a question that could be part of the OB section or the peds section. You can find the exact number of questions for these sections on your respective NP certification agencies' websites.

By definition, mastitis is an inflammation of the breast. When associated with breastfeeding, it's referred to as lactation mastitis or lactation-associated mastitis. It is sometimes referred to by a much older name, puerperal mastitis. And if we go way back, it could be called milk breast. To be honest, 100 years ago, it was not an uncommon reason for women to die in the postpartum period.

While the physical exam is generally within normal limits with the exception of the localized breast tenderness and redness, the symptoms for this condition are usually quite systemic, with generalized body aches and fever reported. The onset of signs and symptoms is usually rapid, often leading to confusion in the diagnosis, particularly if both patient and provider think that this is more a viral syndrome, like influenza or COVID-19. Please, please, please remember this: whenever you see a patient early postpartum who is breastfeeding or recently discontinued breastfeeding and comes in with fever and body aches, please include a breast exam. I have seen a number of patients over the years come in saying, "Oh, my baby is four weeks old. I guess I'm coming down with the flu. This is awful." If I ask, "Do your breasts feel sore at all?" quite often, four weeks into lactation, the breasts are generally still rather sore. Particularly if there's been any
challenges with breastfeeding or the baby's a particularly vigorous nurser. I always, always, always examine the breasts of a lactating woman who presents with fever and generalized body aches because sometimes what you discover is a very early mastitis in what can look like a viral syndrome. And while you're at it, swab for influenza, COVID-19, or whatever bug is going around in your community, but always examine the breasts.

Up to one in four breastfeeding women will develop this condition. So, one more time, common diseases occur commonly. While lactation-associated mastitis can occur at any time during breastfeeding, the first few months are by far the most common. You don't often see it in somebody who is comfort nursing a one-and-a-half-year-old.

Risk factors include infrequent and/or short-duration feedings, missed feedings, insufficient milk removal, and, less often, issues with attachment to the breast. Additional risk factors include rapid weaning and this is important to keep in
mind, illness with the mother or baby, like maybe mom did come down with COVID unfortunately one month postpartum and she is not feeling well at all and is just not the baby's not nursing as well as the baby did before she got sick and the breasts aren't emptying out as well. You have a baby that comes down
with RSV and is struggling to nurse. That could put the mom at great risk for the development of lactation mastitis.

What do many of these things share in common? They lead to milk stasis and subsequent bacterial infection in the breast. And where does the bacteria come
from? It's usually skin colonizing organisms such as staff orius and select streptocous species. There are a few other bugs that can come up as a cause of lactation mastitis. They're far less common. As a result, therapy for this condition always, always, always involves keeping milk flowing through the breast with direct feeding if tolerated.

Now an understandable concern is that the infant could become ill from the bacteria causing the infection. In reality, both members of the dyad are colonized with this organism, and the bacteria is more in the breast tissue than in the milk.If direct feeds cannot be tolerated, and sometimes they can't, they just can't. It's too painful for the nursing mom, and then pain limits let-down reflex and worsen the situation, then gentle milk expression via frequent pumping should be done. And
sometimes I I've seen patients where they can't even tolerate the breast pump on the lowest setting. And what I will do is show them how to just gently manually express milk from the breast but keep that milk flowing through.

Application of heat to the breast prior to feeding or pumping is helpful for milk flow, and cold packs post-feed or pump can be helpful with pain control. Over-the-counter meds can also be helpful in pain. One more time, the baby's got this bug anyway and is not getting sick from it. I will tell you, I've heard this many, many, many times, and you see it backed up in literature. Sometimes the babies don't like the milk from the affected breast. And you know, maybe it tastes differently, something like that, but I've heard this from many patients, but one more time, keep that milk moving.

As mentioned, the majority of infections with lactation mastitis are caused by Staphylococcus aureus, that can be MRSA or MSSA, so methasylan resistant staff orius or a methylin sensitive staff orius or a select streptococcus species. Primary regimens for outpatient treatment can include dicoxicylin or sephylaxin. And if you're not familiar with DLOX, it's an older penicellin that's stable in the presence of betalacttoase. It's always listed as one of the meds that you can use to treat this. In real life, we use sephilaxin a lot more often. Now, both of those will do a great job if MRSA is not present and or there is suspected MSSA. 5 to seven days of treatment is usually sufficient and recovery is surprisingly rapid. Um I've had patients that I've seen for this and I've done 24-hour followup and they're like 24 hours on their antibiotic. They are just feeling so much better. If MRSA is suspected then trimethopramoththoxysol or clintomy is advised and that's based on local patterns of resistance as dictated by local antibiogram.

One last piece of advice: remember, lactation mastitis is usually occurring in a newer parent, usually within the first couple of months postpartum, in a person who is already exhausted, up at night, and still recovering from childbirth. And on top of everything else you do, please offer your advice on recruiting helpers so mom can get some much-needed rest, because that's key to getting better.

With that information in mind, let's take a look at the question again. A 28-year-old woman who is breastfeeding her healthy six-week-old term infant presents with a 4-day history of generalized body aches, intermittent fever to 101.2 Fahrenheit, and localized pain on the upper aspect of her left breast. She states that she's been attempting to nurse her infant as she tolerates and pumps the affected breast when unable to nurse. Physical exam is consistent with lactation-associated mastitis.

Which of the following represents the most appropriate next steps? Choose two that apply. And remember, this format does come up on occasion, not all that often, on the NP boards,  but if it is a choose two that apply, they will always tell you choose two that apply. Okay? that they're not going to throw you a curveball and say, "Well, you should have chose to." They will tell you that you should choose two.

A. Advise continued expressing milk on the affected breast via pumping or nursing as she tolerates. Obviously this is one of the correct answers. As I mentioned, milk stasis contributes to the development of mastitis, therefore keeping the milk flowing is key to recovery. If milk is expressed via pumping, remember that it can be used in feeding. But also, I always advise that the baby might be a "breast milk connoisseur" and reject the milk that has extra white blood cells in it.

B. Initiate antimicrobial therapy with oral sephilaxin for 5 to 7 days. This is another the other correct answer. And oral seephilaxin is a first generation sephilisporin. And as I've mentioned in other podcasts, it's really really good to get in the groove of noticing drug classes by their prefix or their suffix. Oral sephilaxin is I one of I believe it's two sephilosporins that has the c suffix. The rest have the C E F suffix. And sephylexin brand name Kelex has been around since dinosaurs roamed the earth. It was actually the first oral sephilisporin. And remember the sephilisporins will have activity against methasylan sensitive staff orius and many streptocous species associated with lactation mastitis. Well, historically, if you go back even to books that are only like five, six years old, 10 days worth of antimicrobial therapy has been advocated for lactation mastitis. The Sanford guide advises that 5 to 7 days is usually adequate. Keep in mind, if you're saying to yourself, "Oo, but now there's going to be some of that antibiotic in the breast milk." Yep. and the baby will likely receive about 1% of the maternal dose of an antimicrobial. And one really important rule to remember in prescribing medications in lactation is if you would give the med to the baby if needed, you can prescribe this drug during lactation. We use sephilisporins in infants with select infections on a regular basis. Therefore, do not hesitate to prescribe this antimicrobial. Just good good practice there. 

Okay. So, obviously, since A and B are our correct answers, we're going to take a look at C and D. And what we're going to do when we're looking at C and D is to say, okay, these are our two incorrect answers. Why are they incorrect?

C advised to discontinue breastfeeding on the left breast and apply ice packs to the affected area. Obviously, that is not correct. At the same time, the ice packs after feed or pump can be used to provide some comfort and D initiate antimicrobial therapy with oral cyproloxisin for 10 days. Bunch of issues with this answer. One, cypro is a fluoroquinolone. How do I know that? Ploxin suffix, a drug class that's seldom first line for any common outpatient condition. This medication does not provide consistent activity against the pathogens that cause lactation, mastitis, more gram negative coverage like E.coli and the like. And in addition, the length of therapy is excessive. 

Key takeaways. As has been said many times in these podcasts, common conditions occur commonly. Lactation mastitis is a common condition caused by common organisms and with common risks for its development.

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