CASE REPORT

Case Report of Recurrent Bilateral

Mastitis in a Woman Who Is
Exclusively Pumping Breast Milk for an
Infant in the NICU
Jessica Schwarz, Elizabeth B. Froh, and Diane L. Spatz

Correspondence ABSTRACT
Elizabeth B. Froh, PhD, RN,
Children’s Hospital of In this report, we describe a case of bilateral lactational mastitis in a primigravid, Spanish-speaking woman who
Philadelphia, 3500 Civic exclusively pumped breast milk for a hospitalized, critically ill infant in the NICU within a free-standing children’s
Center Blvd., Level P1, hospital. The case follows her clinical presentation, assessments, diagnostics, and therapeutic interventions during the
Suite 1182, Philadelphia, 45-day postpartum period. This case report highlights the situational and environmental context of the woman’s ex-
PA 19104.
periences and emphasizes potential disconnections of care. Regarding her mastitis, the maternity care providers relied
frohe@chop.edu
on the woman to provide all relevant information without knowledge of her hospitalized infant’s health status. Tradi-
Keywords tionally during the postpartum period, infants hospitalized in the NICU and their mothers are cared for by separate
breast abscess provider teams. Clinicians must acknowledge that when women transition from recent patients to parent visitors after
breast pumping birth, they will likely have ongoing medical, obstetric, and psychosocial care needs.
mastitis
MRSA JOGNN, -, -–-; 2021. https://doi.org/10.1016/j.jogn.2021.07.002
NICU Accepted July 7, 2021; Published online xxx

Jessica Schwarz, MSN,
CNM, MBA, is a nurse-
midwife, Department of
Nursing & Clinical Care
Services, Children’s
Hospital of Philadelphia,
Philadelphia, PA.
Elizabeth B. Froh, PhD, RN,
is a nurse scientist,
Department of Nursing &
Clinical Care Services,
Children’s Hospital of
Philadelphia, Philadelphia,
PA, and an adjunct assistant
professor, School of
Nursing, University of
Pennsylvania, Philadelphia,
PA.
Diane L. Spatz, PhD, RN-
BC, FAAN, is a professor,
School of Nursing,
University of Pennsylvania,
Philadelphia, PA, and a
nurse scientist, Department
of Nursing & Clinical Care
Services, Children’s
Hospital of Philadelphia,
Philadelphia, PA.
T he purpose of this case report is to follow
Adela (alias), a healthy 28-year-old primi-
gravid woman, who exclusively pumped breast
milk for her critically ill infant in the NICU and
developed severe recurrent bilateral mastitis and
abscesses. Mastitis occurs in 3% to 20% of
lactating women depending on the diagnostic
criteria used (Boakes et al., 2018). The clinical
presentation of mastitis is characterized by fever
and a tender, firm, reddened area on the affected
breast. Mastitis is commonly caused by milk
stasis, and the recommended first-line treatment
is effective evacuation of milk from the breast.
Less commonly, mastitis can be caused by an
infectious organism; therefore, the second-line
treatment consists of antibiotic therapy (Amir &
Academy of Breastfeeding Medicine Protocol
Committee, 2014). Bilateral lactational mastitis is
rare and more likely to be associated with path-
ogenic organisms. A rare complication of mastitis
is breast abscess, which is a collection of fluid in
the breast tissue, which is treated with surgical
incision and drainage or ultrasonographically
guided needle aspiration. Risk factors for mastitis
include oversupply of milk, nipple abrasions or
trauma, the presence of Staphylococcus aureus
on the breast or nipple, and maternal stress and
fatigue (Mediano et al., 2014). Although nipple
trauma associated with difficult latch has been
associated with mastitis, there is little research to
indicate the impact of exclusive pumping on the
risk or clinical course of mastitis (Cullinane et al.,
2015).
Recurrent bilateral lactational mastitis is rare, and
in this article, we describe the clinical presenta-
tion, assessments, diagnostics, and therapeutic
interventions so that clinicians may recognize
potential cases among mother–infant dyads in
their care. We emphasize the situational context
of Adela’s case and the complexities of managing
postpartum care for a woman with an infant in the
NICU. Often, a woman will be discharged from
hospital care while the infant remains an inpatient.
Within most health systems, there are limited
numbers of shared providers between recently
discharged women and their infants in the NICU.
Even in hospitals similar to the one in which this

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CASE REPORT Recurrent Bilateral Mastitis in a Woman Who Is Exclusively Pumping Breast Milk
Recurrent bilateral lactational mastitis is a rare
condition with unique considerations related to
assessment, diagnosis, and treatment in women with
hospitalized infants.
case occurred (with the birthing unit and NICU in
the same physical hospital), provider silos affect
the subsequent care of the mother–infant dyad.
We acknowledge the environmental context of
Adela’s bilateral mastitis and its significance to
women who pump and express milk in the hos-
pital, often at the bedside, and describe nurse-
focused implications for care.
We present Adela’s case from the perspective of
her nursing team, including advanced practice
providers. Adela’s infant was cared for in the
NICU within the same hospital where she had
prenatal care and gave birth but with a distinctly
different health care team. Data sources used to
support the description of Adela’s recurrent
bilateral mastitis case were extracted from the
electronic health record. These data sources
included progress notes from the maternal care
providers and the hospital’s lactation consultants.
Case
Patient Information
The following case details the clinical presenta-
tion of Adela, a healthy, Spanish-speaking, 28-
year-old, primigravid woman after the uncompli-
cated vaginal birth of a 27-week preterm neonate.
Her pregnancy was complicated by a prenatal
diagnosis of a fetal cervical teratoma. She was
referred prenatally to a specialized center for the
care of families with pregnancies affected by a
diagnosis of a birth defect. This practice offers a
highly specialized labor and birth setting for
healthy women whose fetuses will require in utero
intervention or whose neonates will require im-
mediate medical or surgical care after birth. The
practice strives to offer optimal care for the high-
risk neonate while minimizing maternal–infant
separation. A key goal is the preservation of the
maternal–infant bond in the setting of a critically ill
fetus. Prenatal care is provided by a multidisci-
plinary team that includes maternal–fetal medi-
cine physicians, obstetricians, women’s health
nurse practitioners, and certified nurse-midwives.
Postpartum care is primarily provided by certified
nurse-midwives and women’s health nurse prac-
titioners with support from obstetricians as
needed for medically complex patients. In this
report, the team caring for Adela during the
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postpartum period is referred to as “maternity
care providers.”
In this setting, in-person interpretation is offered
for scheduled visits for patients who do not speak
English. For unscheduled visits or bedside con-
sultations, interpretation is available using a
Health Insurance Portability and Accountability
Act–compliant, Web-based virtual platform. Vir-
tual interpretation is accessed on a designated
computer that is shared among several units so is
not always available. Telephone interpretation is
available 24/7.
Lactation support is offered in a variety of ways.
In the prenatal period, patients are scheduled to
meet with a member of the hospital’s lactation
program, who takes a detailed history and pro-
vides education tailored to the patient’s history
and the specific fetal diagnosis. The prenatal
consult focuses on the importance of early,
frequent pumping for establishing milk supply
when maternal–infant separation occurs. Specific
details of this prenatal consultation have been
previously published (Froh et al., 2017; Spatz,
2020). Bedside nurses in labor and delivery and
the NICU undergo a required 8-hour training in
lactation support, and 4-hour re-education is
required every 2 years (Spatz, 2018).
Adela had an initial consultation at the specialty
center at 26 6/7 weeks gestation in which the
fetal diagnosis of cervical teratoma was
confirmed. She relocated from another state to
stay at a Ronald McDonald house close to the
referral site in preparation for birth there. She
had one additional follow-up visit at the center
that included ultrasonography, a maternal–fetal
medicine visit, and a prenatal visit with a nurse
practitioner. Subsequently, she presented to the
labor and delivery unit in preterm labor at 27 3/
7 weeks and gave birth shortly after admission.
After the birth, her preterm neonate was
admitted directly to NICU. Breast pumping was
initiated within 2 hours postpartum. Because
Adela spoke Spanish, all communication
occurred through an interpreter in person or via
telehealth.
Clinical Findings, Assessment, and
Interventions
At 16 days postpartum, Adela returned to the
hospital’s maternity care outpatient office with a
complaint of bilaterally painful breasts, chills, and
the inability to fully empty breasts because of
pain when pumping. She reported taking
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Schwarz, J., Froh, E. B., and Spatz, D. L. CASE REPORT

Table 1: Outpatient Course of Care: Postpartum Days 16 to 33

Postpartum Assessment and Therapeutic

Day Event Clinical Presentation Diagnostics Interventions
16 Presented to outpatient  Bilaterally painful breasts Mastitis  Started on dicloxacillin
maternity care office  Chills
 Inability to fully empty
breasts because of pain
when pumping

29 Presented to outpatient  Reported initial resolution of Recurrent  Repeat course of

maternity care office symptoms mastitis dicloxacillin
 Recurrent (new) symptoms:
painful breasts and fever
 Rash over chest and
breasts
 Breast fullness
 Left breast warm and
erythematous

29 Reported her infant had been — — —

diagnosed with MRSA

32 Returned to the outpatient  Discolored milk —  Encouraged

maternity care office  Inability to pump because to continue
of worsening pain ibuprofen and
 Bilateral erythema dicloxacillin
 Engorgement  Comfort measures
 Multiple round, scaly patches reviewed
present on sternum and be-
tween breasts

33 Returned for scheduled follow-  Reported no relief in —  Referred to adult

up visit symptoms outside hospital
 Afebrile emergency depart-
 Marked erythema over ment for further
lower two thirds of breast evaluation and care
 Extreme
tenderness to palpation
 Bilateral
breast engorgement

Note. The maternity care team located at the hospital where the patient gave birth provided outpatient care. MRSA ¼ methicillin-
resistant Staphylococcus aureus.

ibuprofen, but the dosage and frequency were
not documented. She had been seen earlier in
the day by one of the hospital’s International
Board-Certified Lactation Consultants (IBCLCs),
and the progress note described a milk supply of
480 ml/day with six pumping sessions per day.
The IBCLC reported large clogs in both breasts,
appropriate flange/shield size for pumping, and
an inadequate pumping schedule. In the mater-
nity outpatient care office, the IBCLC’s assess-
ment was confirmed by Adela. Adela was
examined by a certified nurse-midwife, and her
physical examination was significant for an
elevated temperature of 100.4
F and bilateral
breast erythema on the left breast on the upper
inner quadrant and on the right breast on the
lower outer quadrant. She was started on a
course of dicloxacillin and comfort measures.
Instructions to fully empty her breasts were
reviewed, and she was instructed to call back if
symptoms persisted or worsened within the next
48 hours (see Table 1).

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CASE REPORT Recurrent Bilateral Mastitis in a Woman Who Is Exclusively Pumping Breast Milk

borders. She was afebrile, with a temperature of

The recurrence of mastitis symptoms within a short time 98.1
F. Her breasts were moderately firm and
may be indicative of treatment failure or incomplete acutely tender to palpation. Adela was encour-
resolution of symptoms rather than a true recurrence. aged to continue to take dicloxacillin and
ibuprofen and to attempt to empty her breasts.
Techniques and comfort measures were
Adela was seen by the IBCLC at the neonate’s
reviewed, and a follow-up visit was scheduled
bedside the following day, postpartum Day 17
for the following day. At her infant’s bedside in
(milk supply, 500 ml/day with seven pumping
the NICU, the IBCLC followed up and docu-
sessions per day). The IBCLC’s progress note
mented her milk supply of 1,100 ml/day with
documented that the flange/shield size was still
eight pumping sessions per day. The IBCLC
appropriate for pumping, slight improvements in
noted that her breasts were bilaterally red on the
the sizing of the clogged area, pain, and a sig-
bottom two thirds, associated with a reported
nificant decrease in redness. The IBCLC advised
pain of 10 out of 10. At this visit, Adela
Adela to pump as much as possible with a goal of
expressed that she would no longer like to ex-
eight sessions per 24 hours; to use warmth and
press milk because she was uncomfortable, not
massage while pumping; to complete the full
sleeping enough, and not spending enough time
course of antibiotics; and to get sufficient sleep,
with her infant. The IBCLC instructed Adela to
hydration, and nutrition.
pump until the infection resolved, and then
assistance with weaning would be offered.
On postpartum Day 29, Adela presented with a
recurrence of symptoms to the maternity care
On follow-up examination with a midwife the next
outpatient office. At this time, her neonate
day, Adela reported no relief in symptoms and
remained hospitalized in the NICU. She reported
continued to report bilateral breast pain with
to the midwife that her infant was diagnosed with
decreased milk flow. Her physical examination
methicillin-resistant S. aureus (MRSA) and
findings were notable for marked erythema
placed on contact precautions. A progress note
covering the lower two thirds of breast skin
from the IBCLC on the same day, postpartum
bilaterally; tenderness to palpation; and bilateral
Day 29, described a milk supply of 750 ml/day
breast engorgement with firmness, warmth, and
and seven pumping sessions per day. The infant
shiny skin. Multiple 1-cm pustules were noted on
was still not enterally feeding; however, Adela
her sternum and between breasts. Her tempera-
continued to provide oral care with expressed
ture was 98.1
F. She was referred to a neigh-
milk. Adela complained of a recurrence of breast
boring outside adult hospital emergency
pain and fever of up to 100
F 2 days earlier. She
department for evaluation and management of
also complained of a rash over her chest and
mastitis refractory to treatment (see Table 2).
breasts that she reported to be associated with a
Adela underwent two bilateral incisions and
food allergy to pork. She was treating the rash
drainages for breast abscesses. Breast milk cul-
with topical hydrocortisone and believed it was
tures grew MRSA, Staphylococcus lugdunensis,
resolving. On physical examination, the midwife
and Enterococcus faecalis, and she was treated
noted a dry, patchy rash over both breasts. Both
with intravenous vancomycin.
breasts were full, and the left breast was slightly
firmer, red, and warm to the touch. Based on
Adela’s report that her symptoms had fully Follow-Up and Outcomes
resolved with the first course of dicloxacillin, the Adela was discharged from the outside adult
midwife made a diagnosis of recurrent mastitis, hospital on postpartum Day 45 with surgical
prescribed a repeat course of dicloxacillin, and drains in place and wounds left open with pack-
encouraged the continued use of ing. She received daily home nursing visits for
hydrocortisone. wound care. She was seen 2 weeks later, post-
partum Day 57, for a postoperative visit. Her
Three days later, Day 32 postpartum, Adela wounds were noted to be healing well, and the
returned to the office complaining that her milk drains were removed. On postpartum Day 65,
was green and brown in color. She reported pain supportive care for the infant was withdrawn, and
of 10 out of 10 bilaterally and was unable to he passed away. As Adela did not live close to
pump because of pain. Her physical examina- the children’s hospital or the neighboring outside
tion findings were significant for a rash over both adult hospital, she transitioned her care back to
breasts described as round patches with scaly her home community shortly afterward.

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Schwarz, J., Froh, E. B., and Spatz, D. L.

Table 2: Inpatient Course of Care: Postpartum Days 33 to 45

Outside Postpartum Assessment and

Hospital Day Day Event Clinical Presentation Diagnostics Therapeutic Interventions
1 33 Referred to outside adult hospital’s  Afebrile and normal vital signs —  Admitted for treatment
emergency department  White blood cell count, 25.6  103/mcL  Started on intravenous vancomycin and
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 No abscesses or drainable collections ceftriaxone, as well as morphine as needed

were noted with bilateral breast before pumping
ultrasonography  Blood and milk samples sent for culture

4 36 Inpatient  Febrile and tachycardic Bilateral  Ceftriaxone discontinued

 White blood cell count, 32  103/mcL abscesses
 Repeat ultrasonography: multiple fluid col-
lections consistent with abscesses,
including a 12-cm collection in the right
breast and 6-cm collection in the left breast
 Milk cultures (sent on postpartum Day 33)
grew MRSA, Staphylococcus lugdunensis,
and Enterococcus faecalis

5 37 Surgery  Bilateral abscesses —  Bilateral circumareolar incision and

drainage of multiple abscesses
 Wounds left open and packed
 Adela advised to discontinue pumping

6 38 Inpatient  Afebrile —  Intravenous antibiotics discontinued

 White blood cell count trending down  Transitioned to oral sulfamethoxazole-
trimethoprim and amoxicillin

7–8 39–40 Inpatient  White blood cell count slightly elevated —  Treated for hyperkalemia with furosemide
and intravenous fluids

CASE REPORT
10 42 Inpatient  Repeat breast ultrasonography showed Bilateral  Continued treatment
residual bilateral abscesses abscesses

11 43 Dermatology consult  Rash on chest Tinea corporis  Started on topical ketoconazole

11 43 Surgery  Residual bilateral abscesses —  Repeat incision and drainage via prior
incisions
 Penrose drains sutured in place

13 45 Discharged with home care — — —

Note. A different health care team located at an outside hospital provided inpatient care for the patient. MRSA ¼ methicillin-resistant Staphylococcus aureus.
5
CASE REPORT Recurrent Bilateral Mastitis in a Woman Who Is Exclusively Pumping Breast Milk
Discussion
Atypical Bilateral Mastitis
Adela’s experience of a rare condition, bilateral
lactational mastitis, highlights the need for pro-
viders to consider the possible involvement of an
atypical pathogen and the complexities of
providing care for a mother–infant dyad within a
children’s hospital. Common pathogens impli-
cated in symptomatic mastitis include coagulase-
negative staphylococci, viridians streptococci,
S. aureus, Group B streptococci, and E. faecalis
(Amir & Academy of Breastfeeding Medicine
Protocol Committee, 2014). However, women
without symptomatic mastitis may also have
potentially pathogenic bacteria in their milk
(Huang et al., 2019). Obtaining milk cultures is
not indicated in the initial evaluation of uncom-
plicated mastitis because there is frequently poor
correlation between positive culture results, bac-
terial colony counts, and clinical manifestations
(Boakes et al., 2018).
A limitation of care in Adela’s case is that she
presented with severe, persistent mastitis re-
fractory to treatment; therefore, milk cultures
should have been considered at several points.
S. aureus is a common isolate in breast milk in
mothers with mastitis and has been associated
with greater rates of abscess formation and more
severe clinical presentation (Rimaldi et al., 2019).
Adela’s initial presentation with bilateral symp-
toms and her treatment failure with dicloxacillin
could have been indicative of the presence of
MRSA as a causative agent and warranted the
collection of milk cultures, particularly in the
setting of a hospitalized neonate.
However, a strength of care in Adela’s case was
her ability to be seen outpatient within the chil-
dren’s hospital by maternity care providers and
by the NICU’s lactation consultants. This level of
access to care within a children’s hospital is not
common. On postpartum Day 16, Adela was seen
by the maternity care providers, diagnosed with
mastitis, and prescribed dicloxacillin. The mater-
nity care providers instructed Adela to call if her
symptoms did not improve in the next 48 hours.
On the following day, postpartum Day 17, Adela
was seen by one of the hospital’s lactation con-
sultants in the NICU and reported she was feeling
better. During this encounter, the lactation
consultant documented that she reminded Adela
to finish the course of antibiotics and to again call
the consultant directly if her symptoms did not
improve. In the days following, neither the
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maternity care providers nor the lactation
consultant received any calls or notifications from
Adela. Therefore, the maternity care team
concluded that she was doing well and that she
did not need any other care or support related to
her mastitis.
This lack of direct communication from Adela was
interpreted by her care providers as a good sign,
and they assumed that her symptoms resolved.
However, approximately 2 weeks passed, and the
next point of contact with Adela was on post-
partum Day 29, 13 days after the initial diagnosis
of mastitis and the start of the initial dicloxacillin
course. At that encounter, Adela reported a
worsening of symptoms. Given her clinical pre-
sentation, the maternity care providers acknowl-
edged that it was unclear if Adela’s symptoms
from postpartum Day 16 ever truly resolved or if
her symptoms persisted and she had not sought
help. Her unknown health status between her
physical visits is an additional limitation of care.
The recurrence of mastitis symptoms within a
short time may be indicative of treatment failure or
incomplete resolution of symptoms rather than a
true recurrence. In Adela’s atypical case, she
completed the first 7-day course of dicloxacillin
but then returned to the outpatient maternity care
office with recurrent symptoms. Thus, this was
treated as a case of recurrence and not treatment
failure. However, given the language barrier pre-
sent, it is possible that there was an inability to
elucidate the subtle differences between recur-
rence and treatment failure.
Silos of Care
Adela’s clinical presentation was further compli-
cated by the inability of the maternity care pro-
viders to be informed of the full picture of the
maternal–infant dyad. The maternity care pro-
viders were seeing Adela as an outpatient
because she had been discharged from the
birthing unit after the birth her infant. She was
seen alone in the office, and her providers relied
on Adela to share all elements of essential infor-
mation related to her symptoms. A significant
piece of missing information and an additional
limitation of care was detailed knowledge of the
health status of Adela’s infant and his diagnosis of
MRSA. Adela did not share this information until
postpartum Day 29, 13 days after her initial
diagnosis of mastitis. Furthermore, the infant’s
health care team did not share this information
with the maternity care provider team.
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Schwarz, J., Froh, E. B., and Spatz, D. L. CASE REPORT

Beyond these limitations of verbal communica-

tion, written documentation also presented Care for new mothers and their neonates should be
numerous challenges, all of which speak to silos colocated and provided by cross-functional teams.
of care. Once they are discharged from their
inpatient hospital stays, mothers of neonates in
the IBCLC staff do not document whether the
the NICU are parental visitors in the NICU.
providers, nurses, or IBCLCs reviewed and
Therefore, their health care needs are not docu-
demonstrated the process for cleaning pump
mented on the electronic health records of their
parts, handwashing, or maintaining a clean
infants. The electronic health records of the
environment for breast pumping. Divergence
woman and the infant are distinctly separate, and
from recommended cleaning practices was
this separation, especially in the context of
associated with greater bacterial colony counts in
lactation-related care, was a contributing factor to
pumped milk (Carré et al., 2018). Adela might
the disconnection of care.
have benefited from additional reinforcement of
recommendations, which may have been limited
Given Adela’s clinical presentation, knowledge of
by the language barrier.
her infant’s diagnosis may have warranted earlier
collection of breast milk for culture, consideration
This lack of documentation regarding the safe
of the potential presence of a resistant organism,
handling of the breast pump accessory pieces is
or empirical treatment with an antibiotic typically
of particular concern because Adela’s neonate
effective against MRSA, such as clindamycin
was MRSA positive. On her third outpatient visit,
(Amir & Academy of Breastfeeding Medicine
3 days after the start of the second course of
Protocol Committee, 2014).
dicloxacillin, she presented with clear treatment
failure because her symptoms worsened after
Potential Risks of the Hospital
restarting the antibiotics. Again, the issue of the
Environment for Breastfeeding and
language barrier is relevant because the provider
Breast Pumping
notes indicated that Adela did not follow recom-
For women who are breastfeeding and breast
mendations related to breast pumping and pain
pumping, the environmental context of express-
management. If Adela was not able to follow the
ing milk in the hospital must be a consideration in
providers’ instructions, this lack of adherence
the evaluation and management of mastitis. In
may have contributed to her worsening symp-
Adela’s case, her infant was critically ill, and she
toms. Because she was afebrile and reported that
did not live near the children’s hospital. Therefore,
she was not pumping because of pain, the clini-
like many NICU parents, Adela spent most of her
cian may have believed that the infection was
days at her infant’s bedside and would often ex-
resolving and that the pain was persisting
press her milk at the bedside or in one of the
because of milk stasis. However, regardless of
hospital’s dedicated lactation rooms.
pumping frequency or other management stra-
tegies and per the Academy of Breastfeeding
Within the children’s hospital where Adela gave
Medicine’s guidelines, milk cultures should have
birth and where her infant was in the NICU, the
been obtained and an alternate antibiotic
standard of care regarding the cleaning and safe
regimen considered (Amir & Academy of
handling of breast pump kit pieces is supported
Breastfeeding Medicine Protocol Committee,
by several internal nursing procedures, stan-
2014).
dards, and patient and family education sheets
(Froh et al., 2018). This established culture sup-
porting breastfeeding and breast pumping is a Nursing Care and Implications
great strength of care. All breastfeeding and Clinical and advanced practice nurses play a
breast-pumping internal documents are reviewed crucial role in the daily and continuous commu-
and supported by the setting’s department of nication between families and the clinical health
infection prevention and control. Standard, care team. In this case, Adela was discharged
evidence-based infection control practices from the birthing unit at the children’s hospital and
related to breastfeeding and breast pumping became a parent visitor in the NICU, which is an
were in place. important distinction in the context of maternal–
infant care. Hospitals and providers are typically
A limitation of this case report is its retrospective organized to deliver care to mothers and hospi-
nature and the reliance on documentation in talized neonates as two separate entities when, in
clinical progress notes. The progress notes from fact, they remain a dyad, and the status of one

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CASE REPORT Recurrent Bilateral Mastitis in a Woman Who Is Exclusively Pumping Breast Milk
affects the other, even after birth. Although there
is increasing recognition of the need for special-
ized maternity care in the postpartum period, the
unique health care needs of women with hospi-
talized neonates remain largely unaddressed
(McKinney et al., 2018). Care delivery systems
within hospitals do not typically provide a context
for nurses or other clinicians to collaborate across
units and subspecialties.
The mother of a hospitalized neonate is a recent
patient and thus is likely to have ongoing medical,
obstetric, and psychosocial care needs related to
her postpartum status. However, most of her en-
counters in the postpartum period are with NICU
clinicians, whose expertise and focus may not
extend to adult patients. Addressing such struc-
tural barriers to optimal care is daunting and would
require changes to communication processes,
documentation in the electronic health record,
care team structure, billing and revenue models,
and the physical environment. Ideally, new
mothers and their neonates should be cared for in
the same place by cross-functional teams. With
the widespread implementation of Baby-Friendly
initiatives, this model is a reality for most healthy
maternal–infant dyads (Munn et al., 2016). Imple-
mentation of similar models (so-called single-room
NICUs) for hospitalized neonates have primarily
focused narrowly on the provision of human milk
and neurobehavioral outcomes for neonates, with
less consideration for the health care needs of the
mother or the recognition of a broader paradigm
shift away from viewing the mother and neonate as
separate entities (Jobe, 2017; Vohr et al., 2017;
O’Callaghan et al., 2019). Incremental changes
to improve the provision of care to the maternal–
infant dyad in hospital settings could include
bedside rounding by maternity care providers on
women in the NICU, documentation that allows
visibility between maternal and neonatal charts,
and interdisciplinary learning collaboratives or
rounds between neonatal and obstetric providers.
In this case, care of the maternal–infant dyad was
hampered by the fact that the maternity care
providers remained unaware of Adela’s infant’s
infection status. Similarly, the infant’s health care
team may not have been aware of Adela’s chal-
lenges with lactation and mastitis and therefore
were not able to offer additional support. Even in
this setting, which offers adequate interpretation
services, the language barrier between Adela
and her providers may have also contributed to
this failure of information sharing. Finally, this
case highlights the unique role of care providers
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such as NICU IBCLCs, who function as a bridge
between maternity care providers and neonatal
care teams.
The present case highlights the unique consid-
erations related to the assessment, diagnosis,
and treatment of mastitis among women with
hospitalized neonates. Hospital-acquired patho-
gens require earlier consideration of alternative
antibiotic regimens. In addition to high levels of
stress associated with NICU stays, prolonged
exposure to hospital-acquired pathogens can
affect the health of women who are breastfeeding
and/or breast pumping, as well as hospitalized
neonates.
CONFLICT OF INTEREST
The authors report no conflicts of interest or
relevant financial relationships.
FUNDING
None.
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