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.
A 28-year-old woman who is breastfeeding her healthy three-month-old term infant presents with a 48-hour history of generalized body aches, intermittent fever to 101.2 Fahrenheit, and localized pain in the upper aspect of her left breast. Nursing her child worsens the breast pain while putting a cool compress on the area helps with pain control. She denies cough, GI symptoms, or other skin alterations and does not have allergies to any medication. Physical exam is consistent with the diagnosis of lactation mastitis. Which of the following represents her two best treatment options?
A. Discontinue breastfeeding on the affected side.
B. Prescribe an appropriate course of antimicrobial therapy.
C. Ensure that milk flow through the breast is encouraged via nursing as is tolerated or pumping.
D. Discard the milk from the affected breast.
The correct answers here are B and C: Prescribe an appropriate course of antimicrobial therapy and C. Ensure that milk flow through the breast is encouraged via nursing as is tolerated or pumping.
Where do you start with this question? First, determine what kind of a question this is. We're given a likely diagnosis and a patient history, and this then, of course, is a plan slash intervention question. I will also say that questions on the NP boards that have more than one correct answer are pretty rare, but not 100% absent, particularly with one of the certifying agencies. But a couple of question forms you'll never find on the boards: all of the above or none of the above. Nope. Those questions will not be on the boards. And if there is a question where more than one option is correct, you'll be told how many to choose. So, this case, we're told two. So, let's take a look at some background information.
The NP boards has a small section on care during the anti-partum and postpartum period. In addition, pediatrics is of course noted on the exam. The volume of each of these sections can be found on the respective NP certifying agencies. Mastitis is an inflammation of the breast. When associated with breastfeeding, it's referred to as lactation mastitis. While the physical exam is generally within normal limits, with the exception of localized breast redness and tenderness, the symptoms of this condition are often systemic, with generalized body aches and fever often reported. The onset of signs and symptoms is usually quite rapid, leading to confusion in the diagnosis.
If the patient and provider believe the problem is more viral, such as influenza or COVID 19, a history of breast pain should always, always be elicited from a breastfeeding woman. And regardless of what her presenting symptomatology is, the breast should be examined for any evidence of redness or warmth above and beyond the warmth we would find in a healthy lactating breast.
I cannot tell you over my many years of practice how many times I've had a new mom come in, particularly in very early lactation, who comes in with body aches and fever, but she's not coughing, and she doesn't have a sore throat and she doesn't have a runny nose. And she says something like, Oh, I must be coming down with the flu. Or I’m really worried about this being COVID. I don't want to expose the baby. Will you guys test me and examine me? You know, it's never a bad idea to do a COVID test, do an RSV test, do an influenza test, if you will. But always examine the breast because you might find that her breast pain is not that severe yet and her breasts have been tender simply from breastfeeding, particularly in the first few weeks of life, and that she didn't appreciate that she's got a mastitis growing.
Up to one in four breastfeeding women will develop mastitis. While this can occur at any time during lactation, the first few months post-birth are most common. What are risk factors for this condition? It can include infrequent and or short-duration feedings, missed feedings, inefficient milk removal, and less-than-optimal attachment to the breast. Additional risks include rapid weaning and illness in the mom or baby.
What do all these factors share in common? They lead to milk stasis and subsequent bacterial infection of the breast, usually from skin-colonizing organisms, including Staph aureus and select Streptococcus species. As a result, therapy involves keeping the milk flowing through the breast with direct feed if tolerated. Or if not tolerated, then gentle pumping from the breast. Just keep that milk flowing through. An understandable concern, that is, the infant could become ill with the bacteria causing the infection. In reality, both members of the dyad are colonized with the organism and the bacteria is actually in the breast tissue, but not in the milk. And as I said, if direct feeds can't be tolerated, then pumping should be done. The milk does not need to be discarded.
If the baby will take the breast that has the mastitis, and it usually is unilateral, and mom can tolerate it, then let that baby nurse from that breast. But that milk can actually even be saved if pumping is done. What you will sometimes read in the literature, and I've heard this in, shall we say, real life too, is that sometimes the babies will turn away the milk from the affected breast. It maybe it has a different flavor to it or whatever, but it's safe to give it to the little one. And you always want the baby to get as many of mom's antibodies and protection as possible. Application of heat to the breast prior to feeding or pumping is very helpful for milk flow, and cold packs post-feed or pump can help with pain control.
Over-the-counter meds can also be helpful with pain control like acetaminophen or the like. As mentioned, the majority of infections associated with mastitis are caused by Staph aureus, which can be MRSA or MSSA or a select Streptococcus species. Primary regimens for outpatient treatment, which is where most of this will be done, include dicloxacillin or cephalexin, dicloxacillin, being a penicillin, stable in the presence of beta-lactamase, or cephalexin, a cephalosporin, that will be stable in the presence of beta-lactamase. If MRSA is not present and or its suspected MSSA infection, those antibiotics will also cover the Streptococcus species. And truth be told, in the outpatient, it's mostly going to be strep or MSSA. Five to seven days of therapy is usually sufficient and recovery is quite rapid. I will add you will notice that these two antibiotics, diclox and cephalexin, are also indicated for the treatment of some skin and soft tissue infections such as impetigo. And that's because it's the same organisms that cause impetigo as cause lactation mastitis.
If MRSA is suspected, trimethoprim-sulfamethoxazole or clindamycin is advised. But please check local patterns of resistance as dictated by the local antibiogram. One last piece of advice: Lactation mastitis is usually occurring in a newer parent, a person who's already really tired, up at night, and often still recovering from childbirth. Ensure you offer sound advice about recruiting helpers so Mom and the baby can get some rest.
So, with that in mind, let's go back and take a look at this case scenario.
A 28-year-old woman who is breastfeeding her healthy three-month-old infant presents with a 48-hour history of generalized body aches, intermittent fever to 101.2 and localized pain in the upper aspect of her left breast. Nursing her child worsens the breast pain while putting cool compresses on the areas helps with pain control. She denies cough, GI symptoms, or other skin alterations and does not have allergies to any medication. Physical exam is consistent with a diagnosis of lactation mastitis. Which of the following represents the two best treatment options?
Discontinue breastfeeding on the affected side? Well, clearly this is incorrect because what do we want to do? Keep the milk flowing through the breast. Prescribe an appropriate course of antimicrobial therapy. That's one of the correct answers. It is fairly general. It doesn't say what bugs you're trying to cover or what antibiotics you would use, but that is a correct option. Ensure that milk flow through the breast is encouraged via nursing as is tolerated or pumping. Another one of the correct answers. Because what we want to do is ensure milk flowing through the breast. And that's going to help with the resolution of the condition. Discard the milk from the affected breast. That is incorrect. It is safe for the baby to take in that milk.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 with common risks.
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