JOGNN
CASE REPORT
A Case Report of Pink Breast Milk Jenny Jones, Joan Crete, and Robin Neumeier
Correspondence Joan Crete, DNP, MSN, WHNP-BC, Tripler Army Medical Center, Department of Ob-Gyn, Honolulu, Hi 96859-5000. [email protected]
ABSTRACT
Keywords Serratia marcescens pink breast milk breastfeeding
JOGNN, 43, 625-630; 2014. DOI: 10.1111/1552-6909.12492
Jenny Jones, APRN, NP-C, is a contract nurse practitioner, Tripler Army Medical Center, Department of Ob-Gyn, Honolulu, HI. Joan Crete, DNP, MSN, WHNP-BC, is a nurse practitioner, Tripler Army Medical Center, Department of Ob-Gyn, Honolulu, HI. Col. Robin Neumeier, MSN, CNM, is Director of Nursing, Tripler Army Medical Center, Department of Ob-Gyn, Honolulu, HI.
A woman presented for her postpartum examination alarmed about pink stains on her breast pads and on her infant’s burp pads and diapers. The stains were also found in her breast pump and the infant’s bottles. Out of concern, she stopped breastfeeding. The diagnosis was colonization of mother and infant with Serratia marcescens. They were managed conservatively without antibiotics. The mother was guided to restart breastfeeding. The infant resumed nursing and continued to thrive.
Accepted May 2014
erratia marcescens (S. marcescens) also known as Chromobacteriaviolaceum, is a member of the entero-bacteriaceae family. Chromobacteria are described as nonsporulating, aerobic, motile gram-negative bacilli that are insoluble in water. The organism has been isolated from water, soil, sewage, and animals. The bacilli also grow well on ordinary mediums. Some strains, including S. marcescens, have the capability of producing conspicuous pigments in the presence of oxygen that range from yellow to bright pink (Hejazi & Falkiner, 1997; Wheat, Zuckerman, & Rantz, 1951; Yu, 2010).
S
S. marcescens is an opportunistic pathogen with a role in nosocomial infections. It has been cultured from hospital equipment, including breast pumps and respiratory devices (Cullen, Trail, Robinson, Keaney, & Chadwick, 2005; Gransden, Webster, French, & Phillips, 1986; Moloney, Quoraishi, Parry, & Hall, 1987).Archibald and colleagues (1997) reported a S. marcescens outbreak in a newborn intensive care unit (NICU) that was traced to the contamination of health care workers’ personal bottles of 1% chlorxylenol soap that were left open in work areas.
garding S. marcescens extends to the population that contract active infections and suffer serious morbidity or mortality from these bacteria. This population includes individuals with compromised immune function. Infected newborns, particularly in the NICU, are included in this group. These bacteria have been isolated from cerebral spinal fluid, urine, and blood, in addition to respiratory and gastrointestinal tracts of infants (Bizzarro, Debmry, Baltimore, & Gallagher, 2007; Gransden et al., 1986; Jones et al., 2000; Voelz et al., 2010).
Patient Presentation A woman presented to a nurse practitioner for her routine 6-week postpartum visit. She was concerned about bright pink stains found on her breast pads and on her infant’s burp pads and diapers that persisted even after washing. The bright pink color also was found in the infant bottles and breast pump when left in room air. Out of concern, she searched the Internet for information about “pink breast milk” and found a video that documented the course of events of a young mother with an acute infection from S. marcescens. Although the presentation was clearly different than the video, the mother questioned the safety of her breast milk. Consequently, she stopped breastfeeding and began pumping and discarding her breast milk. According to the mother, viewing the video strongly influenced her course of action.
The authors report no conflict of interest or relevant financial relationships.
Colonization of S. marcescens has been documented in expressed breast milk, breast pumps, and infants’ gastrointestinal tracts and endotracheal tubes. In these reports the mothers and/or infants did not demonstrate signs or symptoms of illness (Braver, Hauser, Berns, Siegman-Igra, & Muhlbauer, 1987; Faro, Katz, Berens, & Ross 2011; Gransden et al., 1986). The concern re-
http://jognn.awhonn.org
C 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
Neither infant nor mother had signs or symptoms of illness. The woman’s current review of systems was unremarkable. Her recent medical history was positive for right breast mastitis, diagnosed at
625
CASE REPORT
S. marcescens is an opportunistic pathogen associated with nosocomial infections. It has been cultured from hospital equipment, including breast pumps and respiratory devices.
postpartum day four. The infection resolved after a 10-day course of Dicloxacillin. She confirmed that her infant was up to date with his pediatric visits and was healthy and thriving. The mother was initially seen by the nurse practitioner, who consulted with the attending physician and lactation specialist. All were perplexed by the mother’s presentation. The work-up, diagnosis, and management of this unusual presentation expanded to a multidisciplinary team of clinicians from obstetrics and gynecology, infectious disease, general surgery, and pediatrics. Examinations of the mother and infant were performed. Cultures were taken of the mother’s breast pads, milk, and breast pump. S. marcescens was isolated in one of the breast milk cultures. Common gram-negative and positive bacteria were also isolated. These results, together with the clinical presentation of the mother and infant, provided support for the diagnosis of colonization with S. marcescens without acute infection. The mother was encouraged to resume breastfeeding. The mother and the infant had several follow-up visits and remained free of active infections.
Patient/Infant Information This was the first pregnancy and child for this 20year-old White woman. She was married to an active duty service member stationed in Hawaii. Her antenatal care began at 7 weeks, and she maintained the Department of Defense prenatal scheduled appointments throughout her pregnancy. She had an uneventful prenatal course. The findings from the antenatal visits, screenings, testing, and examinations reflected a low-risk pregnancy with a healthy mother and fetus. She remained in Hawaii during her entire pregnancy and immediate postpartum period. Prior to this pregnancy, in 2012, the woman’s medical history revealed Clostridium Difficile Colitis. She was treated at that time and has remained symptom free. She also reported a history of urinary tract infections with only one confirmed infection in 2012. The sexually transmitted infection history was positive for genital herpes simplex virus 2 (HSV-2). Her single outbreak was 6 years prior to the current pregnancy. Late in her third trimester she reported prodromal symptoms of HSV-2, but 626
JOGNN, 43, 625-630; 2014. DOI: 10.1111/1552-6909.12492
Pink Breast Milk
her clinical presentation was negative. Following the current guidelines from the Center for Disease Control (2010), she was treated with a 3-day course of Valacyclovir 1000 g twice a day, and then maintained on Valacyclovir 1000 g daily until delivery. The infant was delivered by a scheduled primary low transverse cesarean section at 40 1/7 weeks gestation. This is the hospital’s protocol based on the mother’s report of prodromal HSV-2 symptoms. It was an uncomplicated delivery of a healthy male infant with an appropriate birth weight of 3635 g. The Apgar scores were 8 at 1 minute and 9 at 5 minutes. The basic newborn screening panel for thyroid disease, adrenal disorder, hemoglobin and glucose disorders was negative. His screen for HSV 1 and 2 was also negative. The mother and infant roomed in together, and the infant was breastfeeding exclusively. They had an uneventful postpartum stay and were discharged together on day 2 after delivery.
Timeline and Clinical Findings There were several medical visits during the first week after delivery. The first was the infant’s routine 3-day follow-up exam with pediatrics. The infant was nursing exclusively and had experienced a drop in weight to 3450g, which is well within the 5% acceptable weight loss range for newborns. His physical exam and review of systems were unremarkable. The mother did not express any concerns for herself or infant during the visit. The following day the mother presented to the emergency room concerned that she may have mastitis. She reported not feeling well with a temperature of 101.4 degrees and self-medicated with Ibuprofen prior to going to the emergency room. She was initially evaluated by the staff physician, then by the obstetrical resident; her vital signs and temperature when taken were within the normal range. The evaluation included a physical examination, as well as blood cultures, complete blood count, and urinalysis. The lab tests were all within normal range, but the examination was positive for right breast erythema and bilateral cracked nipples. The resident physician provided the diagnosis of right breast mastitis and treated her with a 10-day course of Dicloxacillin. She was encouraged to continue breastfeeding. The next visit was the routine 2-week pediatric well-baby visit. The infant’s weight was 4100 g. The physical examination and review of systems supported normal growth and development. At this http://jognn.awhonn.org
Jones, J., Crete, J., and Neumeier, R.
visit the mother reported that since her diagnosis of mastitis 10 days earlier, she was only pumping breast milk and bottle-feeding it to her infant. Her symptoms of mastitis had resolved, but her nipples remained cracked and tender. She was pumping every 3 hours. There was no mention in the note of a lactation consult. A month later the mother presented for her routine 6-week postpartum evaluation with the obstetric nurse practitioner. Her primary concern at that time was the bright pink stains she found on her infant’s diapers and burp pads. She first noticed the stains approximately 4 weeks earlier. In addition, she had recently noticed the stains on her breast pads after the breast milk dried. The bright pink color was also found in the infant bottles and breast pump when left at room air. The mother’s review of systems was negative for illness or infection. She reported that she was only feeding the infant pumped breast milk since her earlier diagnosis of mastitis. She confirmed that she had completed the antibiotics for the mastitis infection and that her symptoms had resolved. The mother stated that she researched for information online and watched a video that described a mystery diagnosis of pink breast milk. The video detailed a scenario of a postpartum woman whose breast milk turned pink when left in bottles. The mother and her infant portrayed in the video were acutely ill. The bacteria causing the illness and pink breast milk were identified as S. marcescens. The nurse practitioner began gathering information and inquired about the breast pump. The mother stated the pump was purchased from a friend and that she was concerned about the information learned from the video. She questioned whether it was safe to continue giving her infant breast milk. Responding to the mother’s concern, the nurse practitioner admitted that she was unfamiliar with S. marcescens and thereafter consulted the obstetric attending staff and lactation specialist. The lactation consultant did not have any suggestions and the attending physician recommended a consult with general surgery since he was also unclear of the diagnosis. The general surgery resident physician evaluated the mother the same day and he believed that the mother’s breast milk was reacting to a substance in the breast pads. On further discussion with her, specifically discussing the information that she brought forward regarding the video,
JOGNN 2014; Vol. 43, Issue 5
CASE REPORT
the preliminary diagnosis was colonization with S. marsescens. The physician indicated there was no clear recommendation for women with S. marsescens colonization regarding breastfeeding, and he encouraged her to continue breastfeeding. The mother’s clinical presentation that day was negative for infection or indications of breast pathology. Her breast examination was normal. The physician did not treat the mother with antibiotics because there was no evidence of an acute infection. The physician then consulted with infectious disease service regarding the decision not to give the antibiotics. The infectious disease physician supported this decision. The infant was growing appropriately with adequate weight gain, and he had no clinical presentation of infection. The mother was encouraged to continue breastfeeding and/or pumping at this time. During the following week, the mother’s breasts, breast milk, breast pump, and breast pads were cultured. The hand-expressed breast milk gram stain was negative. The breast culture was positive for bifidobacterium, propionibacterium, staphylococcus, and streptococcus. These bacteria are considered normal flora and rarely considered infectious. The specimen was negative for S. marcescens. Two days later a second collection of breast milk was positive for cocci, rods, and mixed growth with negative and positive bacteria, but again negative for S. marcescens. A third breast milk culture was positive for Pseudomonas aeruginosa and S. marcescens. The breast pump culture had no growth. Antibiotics were not offered because the overall consensus by the collaborating physicians was that there was no benefit in treating the mother or the infant at the time. Six days later the mother presented to the pediatric clinic to have her infant evaluated. She had been pumping and discarding the milk since her postpartum appointment but still desired to breastfeed. She stated that she had been sterilizing all of her bottles and breast pump parts in the dishwasher, and that the pink stain was occurring less often. At this 7-week pediatric visit the provider noted that the infant was growing and developing normally. It was presumed that the infant was colonized with S. marcescens but continued not to demonstrate any signs of acute illness. There was no indication for antibiotics. The pediatric staff reassured the mother and advised her to resume breastfeeding. They provided education and guidance regarding the care of pumped milk and the sanitizing of all bottles, nipples, and pump parts.
627
CASE REPORT
The mother and presumptively the infant were colonized with S. marcescens and free of illness.
The pediatrician did not culture the infant since he was assumed to be colonized with S. marcesens. At the 2-month well-baby check-up, the infant continued to demonstrate appropriate growth with the weight of 6400 gm. The mother reported that she was breastfeeding about 60% of the time and supplementing with formula the other 40%. She also noted that there was a decrease in the findings of the pink stain.
Discussion Based on our literature search, it is uncommon to isolate S. marcesens in the outpatient setting; case reports concerning S. marcesens are primarily found in the inpatient settings (Braver et al., 1987; Gransden et al., 1986; Hejazi & Falkiner, 1997; Voelz et al., 2010).Our search of the literature yielded limited information concerning mothers infected with S. marcescens, but the mothers that became colonized with these bacteria question whether they could, or should, continue breastfeeding .Faro et al. (2011) described a postpartum mother who became colonized from a hospital breast pump she used while her twin infants were in the NICU. Her initial complaint was that the tubing in her breast pump had turned a bright pink color. S. marcescens was cultured from the expressed breast milk and pump. Empirical management included antibiotic therapy for the mother. In a recent case study, a 28-yearold mother of twins found a bright pink residue in her infants’ bottles (Clifford et al., 2014).This mother fed her infants pumped breast milk and left the bottles overnight on the counter. A sample of the residue and a sample of freshly expressed breast milk were cultured for bacteria. The residue was positive for S. marcescens and Pseudomonas aeruginosa. The breast milk only grew out normal skin flora. The mother and both infants were negative for signs or symptoms of infection, and antibiotics were not indicated. In this case the lactation consultant encouraged the mother to continue breastfeeding and/or pumping. She also asked the mother to replace all the bottles she had been using, and the use of a countertop steam sterilizer was recommended.
628
Pink Breast Milk
with infections or colonization of S. marcescens. Due to the lack of published material our health care team primarily relied on empirical management. They deduced that the bacteria were transferred from the breast pump to the pumped milk and the mother’s breasts. They believed that the infant became colonized after ingesting the pumped milk. It is common for humans to harbor the bacteria in the gastrointestinal tract without causing illness. This case was a novel presentation for the medical team, and there was consensus for the conservative management. A multidisciplinary team approach to the formulation of the diagnosis and development of a management plan addressed the possible clinical concerns as well as the mother’s fears regarding breastfeeding. Input from the different disciplines excluded breast pathology and acute infection and led to the diagnosis of colonization of mother and infant with S. marcescens. The primary objective in the management of the mother and infant was to rule out active infection and support breastfeeding. We needed to reassure the mother that it was safe for her infant to have her breast milk. The health care team provided education and guidance about sanitizing the breast pump equipment and hand washing (specific instructions were not noted in the medical chart). Not providing this guidance for the mother either immediately postpartum or when she was diagnosed with mastitis in week 1 after delivery may have been a missed opportunity. The final pediatric visit summary mentioned that the mother believed she was sterilizing the pump parts in the dishwasher. The researchers addressing inpatient and outpatient infections and/or colonization of S. marcescens consistently identified a break in infection control as the primary cause for transmission of the bacteria (Berthelot et al., 1999; Braver et al., 1987; Gransden et al., 1986; Voelz et al., 2010).
Our case report adds to the small sample of outpatient reports that describe breastfeeding mothers
It is important to recognize that the mother was a significant member of the team, and she shared the information she had found on the Internet. This information provided an important piece to her unique presentation. People are increasingly using the Internet to access health information, and the information obtained affects their healthcare outcomes. The Pew Research Center reported that, “72% of internet users say they looked online for health information within the past year” (2014, paragraph 2). The report stated that many rely on the Internet for support when faced with a
JOGNN, 43, 625-630; 2014. DOI: 10.1111/1552-6909.12492
http://jognn.awhonn.org
CASE REPORT
Jones, J., Crete, J., and Neumeier, R.
diagnosis or medical condition, and that the Internet, a seemingly limitless resource of medical information, provides new opportunities and increasing challenges for health care practitioners and users alike. We believe that the primary challenge for providers is to filter through the information and identify which Internet sites provide reliable information relevant to their patients’ care. Krotostki (2011) added, “a public increasingly informed about medical options and their personal wellbeing is beginning to question the medicine man’s authority, thanks to the trove of healthrelated content online” (paragraph 4). Krotostki explained how the public’s use of the information obtained on the Internet supports the development of a partnership in which the medical provider facilitates a patient’s recovery rather than prescribes it. The providers who assisted with the management of this case welcomed the information the woman contributed and considered her a partner in her care. It is interesting to note that despite repeated suggestions and reassurances from the medical providers, the mother continued to discard her milk for several weeks.
The mother was provided with the guidance to resume breastfeeding. At 2 months the infant was breastfeeding 60% of the time and thriving.
and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.
REFERENCES Archibald, L. K., Corl, A., Shah, B., Schulte, M., Arduino, M. J., Aguer, S., . . . Jarvis, W. R. (1997). Serratia marcescens outbreak associated with extrinsic contamination of 1% chlorxylenol soap. Infection Control & Hospital Epidemiology, 18(10), 704– 709. Berthelot, P., Grattard, F., Amerger, C., Frery, M. C., Lucht, F., Pozzett, B., & Fargier, P. (1999). Investigation of a nosocomial outbreak due to Serratia marcescens in a maternity hospital. Infection Control and Hospital Epidemiology, 20, 233–236. Bizzarro, M. J., Debmry, L., Baltimore, R. S., & Gallagher, P. G. (2007). Case-control analysis of endemic Serratia marcescens bacteremia in a neonatal intensive care unit. Archives of Disease in Childhood, 92(2), 120–112. Braver, D. J., Hauser, G. J., Berns, L., Siegman-Igra, Y., & Muhlbauer, B. (1987). Control of a Serratia marcescens outbreak in a maternity hospital. Journal of Hospital Infection, 10, 129–137.
As in the other case presentations mentioned earlier, the continuation of breastfeeding for this mother was encouraged. The importance and benefits of breastfeeding are clearly documented. Breastfeeding is endorsed by the World Health Organization (WHO), as well as at the national level. The Surgeon General’s Call to Action to Support Breastfeeding (U.S. Department of Health and Human Services, 2011) stressed the health gains of breastfeeding and outlined steps to support mothers and infants.
Centers for Disease Control and Prevention. (2010). Sexually transmitted diseases treatment guideline. Morbidity and Mortality Weekly Report, 59 (RR12), 24–25. Clifford, V., Dyson, K., Jarvis, M., Erac, O., Jacobs, S. E., & Daley, A. J. (2014). Image of the month: My expressed breast milk turned pink. Journal of Paediatrics and Child Health, 50, 81–82. doi:10.1111/jpc.12448 Cullen, M. M., Trail, A., Robinson, M., Keaney, M., & Chadwick, P. R. (2005). Serratia marcescens outbreak in a neonatal intensive care unit prompting review of decontamination oflaryngoscopes. Journal of Hospital Infection, 59(1), 68–70. Faro, J., Katz, A., Berens, P., & Ross, P. J. (2011). Premature termination of nursing secondary to Serratia marcescens breast pump contamination. Obstetrics & Gynecology, 117, 485–486.
Conclusion Those of us who provide care to women and children are cognizant of how important our role is in supporting mothers who breastfeed. This role includes assisting mothers with navigating the challenges they encounter during breastfeeding. The challenges range from sore and cracked nipples, to managing infections, and dealing with uncommon findings such as the pink breast milk in this case study. Our patient was faced with a most unexpected challenge of S. marcescens, a little known diagnosis, and we were able to provide the guidance and reassurance she sought.
doi:10.1097/AOG.0b013e3182053a2c Gransden, W. R., Webster, M., French, G. L., & Phillips, I. (1986). An outbreak of Serratia marcescens transmitted by contaminated breast pumps in a special care baby unit. Journal of Hospital Infection, 7, 149–154. Hejazi, A., & Falkiner, F. R. (1997). Serratia marcescens. Journal of Medical Microbiology, 46, 893–912. Jones, B. L., Gorman, L. J., Simpson, J., Curran, E. T., McNamee, S., Lucas C., . . . Thakker, B. (2000). An outbreak of Serratia marcescens in two neonatal intensive care units. Journal of Hospital Infection, 46, 314–319. Krotostki, A. (2011, January 8). What effect has the Internet had on healthcare? The Observer. Retrieved from http://www.theguardian.com/technology/2011/jan/09/untangling -web-krotoski-health-nhs Moloney, A. C., Quoraishi, A. H., Parry, P., & Hall, V. A. (1987). Bacteriological examination of breast pumps. Journal of Hospital
Acknowledgement The views expressed in this publication/presentation are those of the author(s)
JOGNN 2014; Vol. 43, Issue 5
Infection, 9, 169–174. Pew
Research
Center.
(2014).
Health
fact
sheet.
Washing-
ton, DC: Author. http://www.pewInternet.org/Commentary/2011/ November/Pew-Internet-Health.aspx.
629
CASE REPORT
U.S.
Department
Pink Breast Milk
of
Health
and
Human
Services.
(2010).
Healthy people 2020. Retrieved from www.cdc.gov/nchs/ healthy_people/hp2020
630
and management. International Journal of Hygiene and Environmental Health, 213, 79–87. Wheat, R. P., Auckerman, A., & Rantz, L. A. (1951). In-
U.S. Department of Health and Human Services. (2011). The Surgeon
fection
due
General’s call to action to support breastfeeding. Retrieved from
cases.
A.M.A.
http://www.surgeongeneral.gov
461–466.
to
Chromobacteria: Archives
of
Report
Internal
of
eleven
Medicine,
88,
Voelz, A., Mueller, A., Gillen, J., Le, C., Dresbach, T., Engelhart, S., . . .
Yu, V. L. (2010). Serratia marcescens: Historical perspective and clini-
Simon, A. (2010). Outbreaks of Serratia marcescens in neonatall
cal review. New England Journal of Medicine, 300(16), 887–893.
and pediatric intensive care units: Clinical aspects, risk factors
doi:10.1056/NEJM197904193001604
JOGNN, 43, 625-630; 2014. DOI: 10.1111/1552-6909.12492
http://jognn.awhonn.org
CASE REPORT
A Case Report of Pink Breast Milk Jenny Jones, Joan Crete, and Robin Neumeier
Correspondence Joan Crete, DNP, MSN, WHNP-BC, Tripler Army Medical Center, Department of Ob-Gyn, Honolulu, Hi 96859-5000. [email protected]
ABSTRACT
Keywords Serratia marcescens pink breast milk breastfeeding
JOGNN, 43, 625-630; 2014. DOI: 10.1111/1552-6909.12492
Jenny Jones, APRN, NP-C, is a contract nurse practitioner, Tripler Army Medical Center, Department of Ob-Gyn, Honolulu, HI. Joan Crete, DNP, MSN, WHNP-BC, is a nurse practitioner, Tripler Army Medical Center, Department of Ob-Gyn, Honolulu, HI. Col. Robin Neumeier, MSN, CNM, is Director of Nursing, Tripler Army Medical Center, Department of Ob-Gyn, Honolulu, HI.
A woman presented for her postpartum examination alarmed about pink stains on her breast pads and on her infant’s burp pads and diapers. The stains were also found in her breast pump and the infant’s bottles. Out of concern, she stopped breastfeeding. The diagnosis was colonization of mother and infant with Serratia marcescens. They were managed conservatively without antibiotics. The mother was guided to restart breastfeeding. The infant resumed nursing and continued to thrive.
Accepted May 2014
erratia marcescens (S. marcescens) also known as Chromobacteriaviolaceum, is a member of the entero-bacteriaceae family. Chromobacteria are described as nonsporulating, aerobic, motile gram-negative bacilli that are insoluble in water. The organism has been isolated from water, soil, sewage, and animals. The bacilli also grow well on ordinary mediums. Some strains, including S. marcescens, have the capability of producing conspicuous pigments in the presence of oxygen that range from yellow to bright pink (Hejazi & Falkiner, 1997; Wheat, Zuckerman, & Rantz, 1951; Yu, 2010).
S
S. marcescens is an opportunistic pathogen with a role in nosocomial infections. It has been cultured from hospital equipment, including breast pumps and respiratory devices (Cullen, Trail, Robinson, Keaney, & Chadwick, 2005; Gransden, Webster, French, & Phillips, 1986; Moloney, Quoraishi, Parry, & Hall, 1987).Archibald and colleagues (1997) reported a S. marcescens outbreak in a newborn intensive care unit (NICU) that was traced to the contamination of health care workers’ personal bottles of 1% chlorxylenol soap that were left open in work areas.
garding S. marcescens extends to the population that contract active infections and suffer serious morbidity or mortality from these bacteria. This population includes individuals with compromised immune function. Infected newborns, particularly in the NICU, are included in this group. These bacteria have been isolated from cerebral spinal fluid, urine, and blood, in addition to respiratory and gastrointestinal tracts of infants (Bizzarro, Debmry, Baltimore, & Gallagher, 2007; Gransden et al., 1986; Jones et al., 2000; Voelz et al., 2010).
Patient Presentation A woman presented to a nurse practitioner for her routine 6-week postpartum visit. She was concerned about bright pink stains found on her breast pads and on her infant’s burp pads and diapers that persisted even after washing. The bright pink color also was found in the infant bottles and breast pump when left in room air. Out of concern, she searched the Internet for information about “pink breast milk” and found a video that documented the course of events of a young mother with an acute infection from S. marcescens. Although the presentation was clearly different than the video, the mother questioned the safety of her breast milk. Consequently, she stopped breastfeeding and began pumping and discarding her breast milk. According to the mother, viewing the video strongly influenced her course of action.
The authors report no conflict of interest or relevant financial relationships.
Colonization of S. marcescens has been documented in expressed breast milk, breast pumps, and infants’ gastrointestinal tracts and endotracheal tubes. In these reports the mothers and/or infants did not demonstrate signs or symptoms of illness (Braver, Hauser, Berns, Siegman-Igra, & Muhlbauer, 1987; Faro, Katz, Berens, & Ross 2011; Gransden et al., 1986). The concern re-
http://jognn.awhonn.org
C 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
Neither infant nor mother had signs or symptoms of illness. The woman’s current review of systems was unremarkable. Her recent medical history was positive for right breast mastitis, diagnosed at
625
CASE REPORT
S. marcescens is an opportunistic pathogen associated with nosocomial infections. It has been cultured from hospital equipment, including breast pumps and respiratory devices.
postpartum day four. The infection resolved after a 10-day course of Dicloxacillin. She confirmed that her infant was up to date with his pediatric visits and was healthy and thriving. The mother was initially seen by the nurse practitioner, who consulted with the attending physician and lactation specialist. All were perplexed by the mother’s presentation. The work-up, diagnosis, and management of this unusual presentation expanded to a multidisciplinary team of clinicians from obstetrics and gynecology, infectious disease, general surgery, and pediatrics. Examinations of the mother and infant were performed. Cultures were taken of the mother’s breast pads, milk, and breast pump. S. marcescens was isolated in one of the breast milk cultures. Common gram-negative and positive bacteria were also isolated. These results, together with the clinical presentation of the mother and infant, provided support for the diagnosis of colonization with S. marcescens without acute infection. The mother was encouraged to resume breastfeeding. The mother and the infant had several follow-up visits and remained free of active infections.
Patient/Infant Information This was the first pregnancy and child for this 20year-old White woman. She was married to an active duty service member stationed in Hawaii. Her antenatal care began at 7 weeks, and she maintained the Department of Defense prenatal scheduled appointments throughout her pregnancy. She had an uneventful prenatal course. The findings from the antenatal visits, screenings, testing, and examinations reflected a low-risk pregnancy with a healthy mother and fetus. She remained in Hawaii during her entire pregnancy and immediate postpartum period. Prior to this pregnancy, in 2012, the woman’s medical history revealed Clostridium Difficile Colitis. She was treated at that time and has remained symptom free. She also reported a history of urinary tract infections with only one confirmed infection in 2012. The sexually transmitted infection history was positive for genital herpes simplex virus 2 (HSV-2). Her single outbreak was 6 years prior to the current pregnancy. Late in her third trimester she reported prodromal symptoms of HSV-2, but 626
JOGNN, 43, 625-630; 2014. DOI: 10.1111/1552-6909.12492
Pink Breast Milk
her clinical presentation was negative. Following the current guidelines from the Center for Disease Control (2010), she was treated with a 3-day course of Valacyclovir 1000 g twice a day, and then maintained on Valacyclovir 1000 g daily until delivery. The infant was delivered by a scheduled primary low transverse cesarean section at 40 1/7 weeks gestation. This is the hospital’s protocol based on the mother’s report of prodromal HSV-2 symptoms. It was an uncomplicated delivery of a healthy male infant with an appropriate birth weight of 3635 g. The Apgar scores were 8 at 1 minute and 9 at 5 minutes. The basic newborn screening panel for thyroid disease, adrenal disorder, hemoglobin and glucose disorders was negative. His screen for HSV 1 and 2 was also negative. The mother and infant roomed in together, and the infant was breastfeeding exclusively. They had an uneventful postpartum stay and were discharged together on day 2 after delivery.
Timeline and Clinical Findings There were several medical visits during the first week after delivery. The first was the infant’s routine 3-day follow-up exam with pediatrics. The infant was nursing exclusively and had experienced a drop in weight to 3450g, which is well within the 5% acceptable weight loss range for newborns. His physical exam and review of systems were unremarkable. The mother did not express any concerns for herself or infant during the visit. The following day the mother presented to the emergency room concerned that she may have mastitis. She reported not feeling well with a temperature of 101.4 degrees and self-medicated with Ibuprofen prior to going to the emergency room. She was initially evaluated by the staff physician, then by the obstetrical resident; her vital signs and temperature when taken were within the normal range. The evaluation included a physical examination, as well as blood cultures, complete blood count, and urinalysis. The lab tests were all within normal range, but the examination was positive for right breast erythema and bilateral cracked nipples. The resident physician provided the diagnosis of right breast mastitis and treated her with a 10-day course of Dicloxacillin. She was encouraged to continue breastfeeding. The next visit was the routine 2-week pediatric well-baby visit. The infant’s weight was 4100 g. The physical examination and review of systems supported normal growth and development. At this http://jognn.awhonn.org
Jones, J., Crete, J., and Neumeier, R.
visit the mother reported that since her diagnosis of mastitis 10 days earlier, she was only pumping breast milk and bottle-feeding it to her infant. Her symptoms of mastitis had resolved, but her nipples remained cracked and tender. She was pumping every 3 hours. There was no mention in the note of a lactation consult. A month later the mother presented for her routine 6-week postpartum evaluation with the obstetric nurse practitioner. Her primary concern at that time was the bright pink stains she found on her infant’s diapers and burp pads. She first noticed the stains approximately 4 weeks earlier. In addition, she had recently noticed the stains on her breast pads after the breast milk dried. The bright pink color was also found in the infant bottles and breast pump when left at room air. The mother’s review of systems was negative for illness or infection. She reported that she was only feeding the infant pumped breast milk since her earlier diagnosis of mastitis. She confirmed that she had completed the antibiotics for the mastitis infection and that her symptoms had resolved. The mother stated that she researched for information online and watched a video that described a mystery diagnosis of pink breast milk. The video detailed a scenario of a postpartum woman whose breast milk turned pink when left in bottles. The mother and her infant portrayed in the video were acutely ill. The bacteria causing the illness and pink breast milk were identified as S. marcescens. The nurse practitioner began gathering information and inquired about the breast pump. The mother stated the pump was purchased from a friend and that she was concerned about the information learned from the video. She questioned whether it was safe to continue giving her infant breast milk. Responding to the mother’s concern, the nurse practitioner admitted that she was unfamiliar with S. marcescens and thereafter consulted the obstetric attending staff and lactation specialist. The lactation consultant did not have any suggestions and the attending physician recommended a consult with general surgery since he was also unclear of the diagnosis. The general surgery resident physician evaluated the mother the same day and he believed that the mother’s breast milk was reacting to a substance in the breast pads. On further discussion with her, specifically discussing the information that she brought forward regarding the video,
JOGNN 2014; Vol. 43, Issue 5
CASE REPORT
the preliminary diagnosis was colonization with S. marsescens. The physician indicated there was no clear recommendation for women with S. marsescens colonization regarding breastfeeding, and he encouraged her to continue breastfeeding. The mother’s clinical presentation that day was negative for infection or indications of breast pathology. Her breast examination was normal. The physician did not treat the mother with antibiotics because there was no evidence of an acute infection. The physician then consulted with infectious disease service regarding the decision not to give the antibiotics. The infectious disease physician supported this decision. The infant was growing appropriately with adequate weight gain, and he had no clinical presentation of infection. The mother was encouraged to continue breastfeeding and/or pumping at this time. During the following week, the mother’s breasts, breast milk, breast pump, and breast pads were cultured. The hand-expressed breast milk gram stain was negative. The breast culture was positive for bifidobacterium, propionibacterium, staphylococcus, and streptococcus. These bacteria are considered normal flora and rarely considered infectious. The specimen was negative for S. marcescens. Two days later a second collection of breast milk was positive for cocci, rods, and mixed growth with negative and positive bacteria, but again negative for S. marcescens. A third breast milk culture was positive for Pseudomonas aeruginosa and S. marcescens. The breast pump culture had no growth. Antibiotics were not offered because the overall consensus by the collaborating physicians was that there was no benefit in treating the mother or the infant at the time. Six days later the mother presented to the pediatric clinic to have her infant evaluated. She had been pumping and discarding the milk since her postpartum appointment but still desired to breastfeed. She stated that she had been sterilizing all of her bottles and breast pump parts in the dishwasher, and that the pink stain was occurring less often. At this 7-week pediatric visit the provider noted that the infant was growing and developing normally. It was presumed that the infant was colonized with S. marcescens but continued not to demonstrate any signs of acute illness. There was no indication for antibiotics. The pediatric staff reassured the mother and advised her to resume breastfeeding. They provided education and guidance regarding the care of pumped milk and the sanitizing of all bottles, nipples, and pump parts.
627
CASE REPORT
The mother and presumptively the infant were colonized with S. marcescens and free of illness.
The pediatrician did not culture the infant since he was assumed to be colonized with S. marcesens. At the 2-month well-baby check-up, the infant continued to demonstrate appropriate growth with the weight of 6400 gm. The mother reported that she was breastfeeding about 60% of the time and supplementing with formula the other 40%. She also noted that there was a decrease in the findings of the pink stain.
Discussion Based on our literature search, it is uncommon to isolate S. marcesens in the outpatient setting; case reports concerning S. marcesens are primarily found in the inpatient settings (Braver et al., 1987; Gransden et al., 1986; Hejazi & Falkiner, 1997; Voelz et al., 2010).Our search of the literature yielded limited information concerning mothers infected with S. marcescens, but the mothers that became colonized with these bacteria question whether they could, or should, continue breastfeeding .Faro et al. (2011) described a postpartum mother who became colonized from a hospital breast pump she used while her twin infants were in the NICU. Her initial complaint was that the tubing in her breast pump had turned a bright pink color. S. marcescens was cultured from the expressed breast milk and pump. Empirical management included antibiotic therapy for the mother. In a recent case study, a 28-yearold mother of twins found a bright pink residue in her infants’ bottles (Clifford et al., 2014).This mother fed her infants pumped breast milk and left the bottles overnight on the counter. A sample of the residue and a sample of freshly expressed breast milk were cultured for bacteria. The residue was positive for S. marcescens and Pseudomonas aeruginosa. The breast milk only grew out normal skin flora. The mother and both infants were negative for signs or symptoms of infection, and antibiotics were not indicated. In this case the lactation consultant encouraged the mother to continue breastfeeding and/or pumping. She also asked the mother to replace all the bottles she had been using, and the use of a countertop steam sterilizer was recommended.
628
Pink Breast Milk
with infections or colonization of S. marcescens. Due to the lack of published material our health care team primarily relied on empirical management. They deduced that the bacteria were transferred from the breast pump to the pumped milk and the mother’s breasts. They believed that the infant became colonized after ingesting the pumped milk. It is common for humans to harbor the bacteria in the gastrointestinal tract without causing illness. This case was a novel presentation for the medical team, and there was consensus for the conservative management. A multidisciplinary team approach to the formulation of the diagnosis and development of a management plan addressed the possible clinical concerns as well as the mother’s fears regarding breastfeeding. Input from the different disciplines excluded breast pathology and acute infection and led to the diagnosis of colonization of mother and infant with S. marcescens. The primary objective in the management of the mother and infant was to rule out active infection and support breastfeeding. We needed to reassure the mother that it was safe for her infant to have her breast milk. The health care team provided education and guidance about sanitizing the breast pump equipment and hand washing (specific instructions were not noted in the medical chart). Not providing this guidance for the mother either immediately postpartum or when she was diagnosed with mastitis in week 1 after delivery may have been a missed opportunity. The final pediatric visit summary mentioned that the mother believed she was sterilizing the pump parts in the dishwasher. The researchers addressing inpatient and outpatient infections and/or colonization of S. marcescens consistently identified a break in infection control as the primary cause for transmission of the bacteria (Berthelot et al., 1999; Braver et al., 1987; Gransden et al., 1986; Voelz et al., 2010).
Our case report adds to the small sample of outpatient reports that describe breastfeeding mothers
It is important to recognize that the mother was a significant member of the team, and she shared the information she had found on the Internet. This information provided an important piece to her unique presentation. People are increasingly using the Internet to access health information, and the information obtained affects their healthcare outcomes. The Pew Research Center reported that, “72% of internet users say they looked online for health information within the past year” (2014, paragraph 2). The report stated that many rely on the Internet for support when faced with a
JOGNN, 43, 625-630; 2014. DOI: 10.1111/1552-6909.12492
http://jognn.awhonn.org
CASE REPORT
Jones, J., Crete, J., and Neumeier, R.
diagnosis or medical condition, and that the Internet, a seemingly limitless resource of medical information, provides new opportunities and increasing challenges for health care practitioners and users alike. We believe that the primary challenge for providers is to filter through the information and identify which Internet sites provide reliable information relevant to their patients’ care. Krotostki (2011) added, “a public increasingly informed about medical options and their personal wellbeing is beginning to question the medicine man’s authority, thanks to the trove of healthrelated content online” (paragraph 4). Krotostki explained how the public’s use of the information obtained on the Internet supports the development of a partnership in which the medical provider facilitates a patient’s recovery rather than prescribes it. The providers who assisted with the management of this case welcomed the information the woman contributed and considered her a partner in her care. It is interesting to note that despite repeated suggestions and reassurances from the medical providers, the mother continued to discard her milk for several weeks.
The mother was provided with the guidance to resume breastfeeding. At 2 months the infant was breastfeeding 60% of the time and thriving.
and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.
REFERENCES Archibald, L. K., Corl, A., Shah, B., Schulte, M., Arduino, M. J., Aguer, S., . . . Jarvis, W. R. (1997). Serratia marcescens outbreak associated with extrinsic contamination of 1% chlorxylenol soap. Infection Control & Hospital Epidemiology, 18(10), 704– 709. Berthelot, P., Grattard, F., Amerger, C., Frery, M. C., Lucht, F., Pozzett, B., & Fargier, P. (1999). Investigation of a nosocomial outbreak due to Serratia marcescens in a maternity hospital. Infection Control and Hospital Epidemiology, 20, 233–236. Bizzarro, M. J., Debmry, L., Baltimore, R. S., & Gallagher, P. G. (2007). Case-control analysis of endemic Serratia marcescens bacteremia in a neonatal intensive care unit. Archives of Disease in Childhood, 92(2), 120–112. Braver, D. J., Hauser, G. J., Berns, L., Siegman-Igra, Y., & Muhlbauer, B. (1987). Control of a Serratia marcescens outbreak in a maternity hospital. Journal of Hospital Infection, 10, 129–137.
As in the other case presentations mentioned earlier, the continuation of breastfeeding for this mother was encouraged. The importance and benefits of breastfeeding are clearly documented. Breastfeeding is endorsed by the World Health Organization (WHO), as well as at the national level. The Surgeon General’s Call to Action to Support Breastfeeding (U.S. Department of Health and Human Services, 2011) stressed the health gains of breastfeeding and outlined steps to support mothers and infants.
Centers for Disease Control and Prevention. (2010). Sexually transmitted diseases treatment guideline. Morbidity and Mortality Weekly Report, 59 (RR12), 24–25. Clifford, V., Dyson, K., Jarvis, M., Erac, O., Jacobs, S. E., & Daley, A. J. (2014). Image of the month: My expressed breast milk turned pink. Journal of Paediatrics and Child Health, 50, 81–82. doi:10.1111/jpc.12448 Cullen, M. M., Trail, A., Robinson, M., Keaney, M., & Chadwick, P. R. (2005). Serratia marcescens outbreak in a neonatal intensive care unit prompting review of decontamination oflaryngoscopes. Journal of Hospital Infection, 59(1), 68–70. Faro, J., Katz, A., Berens, P., & Ross, P. J. (2011). Premature termination of nursing secondary to Serratia marcescens breast pump contamination. Obstetrics & Gynecology, 117, 485–486.
Conclusion Those of us who provide care to women and children are cognizant of how important our role is in supporting mothers who breastfeed. This role includes assisting mothers with navigating the challenges they encounter during breastfeeding. The challenges range from sore and cracked nipples, to managing infections, and dealing with uncommon findings such as the pink breast milk in this case study. Our patient was faced with a most unexpected challenge of S. marcescens, a little known diagnosis, and we were able to provide the guidance and reassurance she sought.
doi:10.1097/AOG.0b013e3182053a2c Gransden, W. R., Webster, M., French, G. L., & Phillips, I. (1986). An outbreak of Serratia marcescens transmitted by contaminated breast pumps in a special care baby unit. Journal of Hospital Infection, 7, 149–154. Hejazi, A., & Falkiner, F. R. (1997). Serratia marcescens. Journal of Medical Microbiology, 46, 893–912. Jones, B. L., Gorman, L. J., Simpson, J., Curran, E. T., McNamee, S., Lucas C., . . . Thakker, B. (2000). An outbreak of Serratia marcescens in two neonatal intensive care units. Journal of Hospital Infection, 46, 314–319. Krotostki, A. (2011, January 8). What effect has the Internet had on healthcare? The Observer. Retrieved from http://www.theguardian.com/technology/2011/jan/09/untangling -web-krotoski-health-nhs Moloney, A. C., Quoraishi, A. H., Parry, P., & Hall, V. A. (1987). Bacteriological examination of breast pumps. Journal of Hospital
Acknowledgement The views expressed in this publication/presentation are those of the author(s)
JOGNN 2014; Vol. 43, Issue 5
Infection, 9, 169–174. Pew
Research
Center.
(2014).
Health
fact
sheet.
Washing-
ton, DC: Author. http://www.pewInternet.org/Commentary/2011/ November/Pew-Internet-Health.aspx.
629
CASE REPORT
U.S.
Department
Pink Breast Milk
of
Health
and
Human
Services.
(2010).
Healthy people 2020. Retrieved from www.cdc.gov/nchs/ healthy_people/hp2020
630
and management. International Journal of Hygiene and Environmental Health, 213, 79–87. Wheat, R. P., Auckerman, A., & Rantz, L. A. (1951). In-
U.S. Department of Health and Human Services. (2011). The Surgeon
fection
due
General’s call to action to support breastfeeding. Retrieved from
cases.
A.M.A.
http://www.surgeongeneral.gov
461–466.
to
Chromobacteria: Archives
of
Report
Internal
of
eleven
Medicine,
88,
Voelz, A., Mueller, A., Gillen, J., Le, C., Dresbach, T., Engelhart, S., . . .
Yu, V. L. (2010). Serratia marcescens: Historical perspective and clini-
Simon, A. (2010). Outbreaks of Serratia marcescens in neonatall
cal review. New England Journal of Medicine, 300(16), 887–893.
and pediatric intensive care units: Clinical aspects, risk factors
doi:10.1056/NEJM197904193001604
JOGNN, 43, 625-630; 2014. DOI: 10.1111/1552-6909.12492
http://jognn.awhonn.org
