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Unfolding Case Scenario 7-1 for Sudden-onset breast pain after the newborn sleeps through the night

Learning Objectives

  1. List clinical signs associated with non-infectious and infectious lactational mastitis
  2. Describe conservative management strategies for inflammatory (non-infectious) mastitis
  3. Describe when it is necessary to avoid breastfeeding or to “pump and dump” following anesthetic or analgesic medications
  4. Propose a management and follow up plan for non-infectious lactational mastitis

Question 1

A breastfeeding mother of a healthy 5-month old girl woke up with very engorged breasts after her baby slept for 7 hours straight for the first time in months. Typically, the infant wakes up to breastfeed every 1-2 hours, so the mother never sets any alarms. The mother continued to breastfeed normally throughout the day, but toward the evening she noticed a plugged duct in the left lateral quadrant of the left breast which was exquisitely tender to palpation.  Which of the following is the pathophysiology underlying her condition?

Question 2

A breastfeeding mother of a healthy 5-month old girl woke up with very engorged breasts after her baby slept for 7 hours straight for the first time in months. Typically, the infant wakes up to breastfeed every 1-2 hours, so the mother never sets any alarms. The mother continued to breastfeed normally throughout the day, but toward the evening she noticed a plugged duct in the left lateral quadrant of the left breast which was exquisitely tender to palpation.

The lactating patient sends her care team an e-message that evening. She explains that for the last 12 hours, she has been taking advil and tylenol for her pain, aggressively massaging, applying vibration to the breast to get rid of the plugged duct, and pumping and dumping the milk from both breasts. When you write back to her, what can you tell her about medications and the need to “pump and dump”?

Question 3

A breastfeeding mother of a healthy 5-month old girl woke up with very engorged breasts after her baby slept for 7 hours straight for the first time in months. Typically, the infant wakes up to breastfeed every 1-2 hours, so the mother never sets any alarms. The mother continued to breastfeed normally throughout the day, but toward the evening she noticed a plugged duct in the left lateral quadrant of the left breast which was exquisitely tender to palpation. The lactating patient sends her care team an e-message that evening. She explains that for the last 12 hours, she has been taking advil and tylenol for her pain, aggressively massaging, applying vibration to the breast to get rid of the plugged duct, and pumping and dumping the milk from both breasts.

After learning that she doesn’t need to pump and dump after taking over-the-counter pain medications, she asks whether she should pump and dump after consuming alcohol or smoking marijuana. Since weed has been legalized in her state, she would like to smoke with her friends every once in a while now that she’s no longer pregnant. What can you tell her about pumping and dumping after alcohol consumption and the safety of marijuana use in lactating women?

“Since marijuana is now legal in your state, it is not illegal to consume it. If you are going to use marijuana products, I would advise that you consume edibles with marijuana instead of smoking marijuana to prevent the negative effect of smoke on your baby’s lung development. As for alcohol, you should pump and dump if you feel tipsy.”

Question 4

A breastfeeding mother of a healthy 5-month old girl woke up with very engorged breasts after her baby slept for 7 hours straight for the first time in months. Typically, the infant wakes up to breastfeed every 1-2 hours, so the mother never sets any alarms. The mother continued to breastfeed normally throughout the day, but toward the evening she noticed a plugged duct in the left lateral quadrant of the left breast which was exquisitely tender to palpation. The dyad sends her care team an e-message that evening. She explains that for the last 12 hours, the mother has been taking advil and tylenol for her pain, aggressively massaging and applying vibration to the breast to get rid of the plugged duct, and pumping and dumping the milk from both breasts.

The mother writes back, thanking you for explaining when to pump and dump. She asks if there is anything else she can do for her breast pain and if you think antibiotics are warranted at this point. What is your recommendation?

Question 5

A breastfeeding mother of a healthy 5-month old girl woke up with very engorged breasts after her baby slept for 7 hours straight for the first time in months. Typically, the infant wakes up to breastfeed every 1-2 hours, so the mother never sets any alarms. The mother continued to breastfeed normally throughout the day, but toward the evening she noticed a plugged duct in the left lateral quadrant of the left breast which was exquisitely tender to palpation. The dyad sends her care team an e-message that evening. She explains that for the last 12 hours, the mother has been taking advil and tylenol for her pain, aggressively massaging and applying vibration to the breast to get rid of the plugged duct, and pumping and dumping the milk from both breasts.

The patient says she had mastitis two months ago when her baby was 3 months old. Last time, she developed fever, muscle aches, and spent a few days in bed thinking she had the flu. Within 24 hours of antibiotics she started to feel better, but her milk supply took a big hit and it took her weeks to bring it back up. She wants to take antibiotics “just in case’ because she does not want a repeat of last time. What can you tell her?

Unfolding Case Scenario 7-2 for Sudden-onset breast pain after the newborn sleeps through the night

Learning Objectives

  1. Differentiate between the clinical presentation of  non-infectious and infectious mastitis and an abscess
  2. Determine a management strategy for infectious mastitis and infectious mastitis not responding to treatment
  3. Describe normal sleep patterns for infants between 0 and 6 months of age
  4. Describe whether breastfeeding is possible following a surgical procedure involving the lactating breast

Question 1

A 28 year-old G1P1 female three months postpartum presents to the doctor’s office with a painful lump in her left breast. The lump was very small at first and so the patient did not seek care. The lump has been there for about 7 days now and has gotten slightly larger. The patient also noticed a red, wedge-shaped patch of skin develop a few days ago in the area over the lump. She has been feeding less frequently from the affected breast due to pain. She admits that she is concerned that her baby doesn’t like that breast anymore and that she is producing a lot less milk from that side. Which of the following findings would support your suspected diagnosis?

Question 2

A 28 year-old G1P1 female three months postpartum presents to the doctor’s office with a painful lump in her left breast. The lump was very small at first and so the patient did not seek care. The lump has been there for about 7 days now and has gotten slightly larger. The patient also noticed a red, wedge-shaped patch of skin develop a few days ago in the area over the lump. She has been feeding less frequently from the affected breast due to pain. She admits that she is concerned that her baby doesn’t like that breast anymore and that she is producing a lot less milk from that side. 

On physical exam, the patient has a temperature of about 102 F. There is a palpable, tender, motile lump on the left breast near the nipple-areolar complex in the lower inner quadrant. There is a band of erythema directly over the lump. There are cracks visible in the left nipple-areolar complex. She denies any allergies to medication. She is prescribed a treatment course of dicloxacillin for infectious lactational mastitis. 

The patient reveals that she had mastitis once before and she believes that, like last time, her infant’s unpredictable sleep schedule is the culprit. Her first child had a predictable sleep schedule and started “sleeping through the night” at 2 months of age. With the new infant, she has been waking up every 1 to 2 hours to breastfeed. She wants to know if frequent awakenings are damaging to the infant’s neurological development. What can you tell her about normal infant sleep patterns for the first six months of life?

Question 3

A 28 year-old G1P1 female three months postpartum presents to the doctor’s office with a painful lump in her left breast. The lump was very small at first and so the patient did not seek care. The lump has been there for about 7 days now and has gotten slightly larger. The patient also noticed a red, wedge-shaped patch of skin develop a few days ago in the area over the lump. She has been feeding less frequently from the affected breast due to pain. She admits that she is concerned that her baby doesn’t like that breast anymore and that she is producing a lot less milk from that side.  On physical exam, the patient has a temperature of about 102 F. There is a palpable, tender, motile lump on the left breast near the nipple-areolar complex in the lower inner quadrant. There is a band of erythema directly over the lump. There are cracks visible in the left nipple-areolar complex. She denies any allergies to medication.

The patient calls back two days later for a follow-up and notes that the lump and erythema have not resolved. She has been compliant with the dicloxacillin regimen. She is still experiencing a fever, with a sublingual temperature reading today of around 102 F. Other vital signs are within the normal range.  Which of the following should be recommended to the patient?

Question 4

A 28 year-old G1P1 female three months postpartum presents to the doctor’s office with a painful lump in her left breast. The lump was very small at first and so the patient did not seek care. The lump has been there for about 7 days now and has gotten slightly larger. The patient also noticed a red, wedge-shaped patch of skin develop a few days ago in the area over the lump. She has been feeding less frequently from the affected breast due to pain. She admits that she is concerned that her baby doesn’t like that breast anymore and that she is producing a lot less milk from that side.  On physical exam, the patient has a temperature of about 102 F. There is a palpable, tender, motile lump on the left breast near the nipple-areolar complex in the lower inner quadrant. There is a band of erythema directly over the lump. There are cracks visible in the left nipple-areolar complex. She denies any allergies to medication.

The patient comes back two days later for follow-up, and notes that the lump and erythema have not resolved. She has been following your instructions. She is still experiencing a fever, with sublingual temperature reading today of around 102 F. Other vital signs are within the normal range.

Cultures and susceptibilities of the milk reveal methicillin-resistant staphylococcus aureus (MRSA). The patient is started on the appropriate therapy and her fever decreases. However, she still has a hard, tender, erythematous, tender area on her breast when she returns for follow-up two days later. Which of the following is the best next step for this patient?

Question 5

A 28 year-old G1P1 female three months postpartum presents to the doctor’s office with a painful lump in her left breast. The lump was very small at first and so the patient did not seek care. The lump has been there for about 7 days now and has gotten slightly larger. The patient also noticed a red, wedge-shaped patch of skin develop a few days ago in the area over the lump. She has been feeding less frequently from the affected breast due to pain. She admits that she is concerned that her baby doesn’t like that breast anymore and that she is producing a lot less milk from that side.  On physical exam, the patient has a temperature of about 102 F. There is a palpable, tender, motile lump on the left breast near the nipple-areolar complex in the lower inner quadrant. There is a band of erythema directly over the lump. There are cracks visible in the left nipple-areolar complex. She denies any allergies to medication.

The patient comes back two days later for follow-up, and notes that the lump and erythema have not resolved. She has been following your instructions. She is still experiencing a fever, with sublingual temperature reading today of around 102 F. Other vital signs are within the normal range.

Cultures and susceptibilities of the milk reveal methicillin-resistant staphylococcus aureus (MRSA). The patient is started on the appropriate therapy and her fever decreases. However, she still has a hard, tender, erythematous, tender area on her breast when she returns for follow-up two days later.

The patient is seen by a breast specialist, who aspirates the breast abscess and places a wick at the site. You talk to the patient after the procedure is done, and she is worried now about feeding her baby from the affected breast. Which of the following is the best advice for the patient?