A 2-day-old boy is in the newborn nursery. He was born full term via normal spontaneous vaginal delivery to a 25-year-old woman, gravida 2, para 2. The mother had regular prenatal care and the pregnancy was uncomplicated. She has a history of postpartum lactational mastitis with her first child but feels comfortable breastfeeding her new baby. The boy has normal vital signs and appropriate urine and stool output. On examination, he has small, palpable masses of soft tissue under each nipple. There is some white discharge from both nipples. His circumcised penis is healing well and the testes are descended bilaterally. Which of the following is the most appropriate next step in the management of this neonate?

Question

A 2-day-old boy is in the newborn nursery.  He was born full term via normal spontaneous vaginal delivery to a 25-year-old woman, gravida 2, para 2.  The mother had regular prenatal care and the pregnancy was uncomplicated.  She has a history of postpartum lactational mastitis with her first child but feels comfortable breastfeeding her new baby.  The boy has normal vital signs and appropriate urine and stool output.  On examination, he has small, palpable masses of soft tissue under each nipple.  There is some white discharge from both nipples.  His circumcised penis is healing well and the testes are descended bilaterally.  Which of the following is the most appropriate next step in the management of this neonate?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c028_eacf_8f63_49cd13e04fef_MD0005_00 Neonatal breast hypertrophy is a common finding in up to 70% of male and female neonates. High levels of maternal estrogen cross the placenta during the third trimester, but the level in the newborn's blood decreases after delivery, stimulating the neonatal pituitary to produce prolactin. Prolactin stimulation causes unilateral or bilateral breast enlargement in the neonate. Breast tissue is palpable and milk may be expressed when manipulated (galactorrhea). Neonatal breast hypertrophy and galactorrhea are self-limited and usually resolve within 6 months. In newborn girls, other effects from maternal estrogen include labial swelling, leukorrhea, and uterine withdrawal bleeding. Parents should be discouraged from expressing the milk, which can prolong galactorrhea by stimulating prolactin and oxytocin release from the pituitary. Inappropriate breast manipulation can also predispose to infection or galactocele formation. (Choices A, B, and E) Blood tests and imaging are inappropriate given the benign nature of this condition. Workup should be considered if the breast enlargement began after infancy. (Choice D) In addition to antibiotics, Gram stain and culture of purulent nipple discharge and blood are indicated when mastitis or breast abscess is suspected. This neonate has no signs of inflammation (eg, erythema, tenderness), which makes infection unlikely. Educational objective: Neonatal breast hypertrophy is a common finding in newborns of both sexes and is usually self-limited. No workup is indicated. References: Establishment of normative data for the amount of breast tissue present in healthy children up to two years of age. (http://www.ncbi.nlm.nih.gov/pubmed/20493740)

A 2-Day-Old Boy Is in the Newborn Nursery