A 39-year-old woman, gravida 1 para 1, comes to the office due to breast pain. She had an uncomplicated vaginal delivery a week ago and is breastfeeding her infant. Four days ago, the patient began to have bilateral nipple soreness with breastfeeding. However, for the past few days, the pain has worsened, is present between feeds, and has prevented breastfeeding. She has also developed bloody nipple discharge. The patient's pregnancy was complicated by gestational diabetes mellitus, but otherwise, she has no chronic medical conditions. Temperature is 37.5 C (99.5 F). Bilateral nipples and areolae have open, bloody, linear abrasions. The breasts are diffusely engorged and mildly tender to palpation, but there are no palpable masses or lymphadenopathy. The remainder of the examination is unremarkable. Which of the following is the most likely underlying cause of this patient's presentation?

Question

A 39-year-old woman, gravida 1 para 1, comes to the office due to breast pain.  She had an uncomplicated vaginal delivery a week ago and is breastfeeding her infant.  Four days ago, the patient began to have bilateral nipple soreness with breastfeeding.  However, for the past few days, the pain has worsened, is present between feeds, and has prevented breastfeeding.  She has also developed bloody nipple discharge.  The patient's pregnancy was complicated by gestational diabetes mellitus, but otherwise, she has no chronic medical conditions.  Temperature is 37.5 C (99.5 F).  Bilateral nipples and areolae have open, bloody, linear abrasions.  The breasts are diffusely engorged and mildly tender to palpation, but there are no palpable masses or lymphadenopathy.  The remainder of the examination is unremarkable.  Which of the following is the most likely underlying cause of this patient's presentation?

Quizplus · Accepted Answer

Proper breastfeeding technique promotes maternal comfort, ensures adequate infant nutritional intake, and facilitates long-term breastfeeding. Most breastfeeding patients experience nipple pain in the immediate postpartum period as they become accustomed to nursing 8-12 times/day or more, but this typically resolves after a few weeks. Nipple pain that worsens and persists between feedings is commonly due to nipple injury caused by poor infant positioning and improper latch-on technique. On examination, patients can have open, linear areolar abrasions that cause a bloody-appearing nipple discharge; bruising, cracking, and blistering may also be present. Breast engorgement, as seen in this patient with bilateral, diffusely tender, and engorged breasts, can also develop because nipple pain limits breastfeeding. Proper breastfeeding technique Initial management is with the observation of breastfeeding and patient education. Nipple injury is a significant risk factor for multiple adverse outcomes (eg, plugged milk ducts, mastitis, breast abscess), which often lead to premature cessation of breastfeeding. (Choice A) Lactational mastitis is caused by bacterial overgrowth of stagnant milk in blocked ducts; it is a common cause of breast pain in breastfeeding patients. In contrast to this patient, those with lactational mastitis typically have fever and localized warmth or erythema over a single breast. Lactational mastitis (Choice B) Candida mastitis can be caused by spread from infant oral flora. Patients typically have nipple pain that radiates across the breast with latching; however, the pain is described as sharp and shooting and is usually out of proportion to the examination. In addition, it is typically unilateral, and the affected breast often has flaky, scaling skin over the nipple. (Choice C) Inflammatory breast cancer can cause unilateral, not bilateral, breast pain and tenderness. Patients typically have a breast mass with associated skin thickening and erythema (peau d'orange appearance) with axillary lymphadenopathy, which is not seen in this patient. Inflammatory breast cancer (Choice D) An intraductal papilloma, a papillary tumor involving the breast duct, typically presents with bloody nipple discharge but no associated breast pain. Educational objective: Persistent nipple pain with breastfeeding is typically due to nipple injury, which can present with bilateral nipple abrasions and bloody nipple discharge. The most common underlying causes are poor infant positioning and improper latch-on technique. References: Nipple pain in breastfeeding mothers: incidence, causes and treatments. (http://www.ncbi.nlm.nih.gov/pubmed/26426034) Interventions for treating painful nipples among breastfeeding women. (http://www.ncbi.nlm.nih.gov/pubmed/25506813)

A 39-Year-Old Woman, Gravida 1 Para 1, Comes to the Office