The
Link Between Infants’ Oral Thrush and Nipple and Breast Pain in Lactating Women
Fifth Edition
Introduction
Yeast infections that affect babies’ mouths and mothers’ breasts can
threaten the continuation of breastfeeding because of the extreme pain that may
occur.2 Yeast infections of the nipples and breasts are difficult to
diagnose.1 At present, internal breast yeast (mammary candidosis) is
a diagnosis of exclusion. Either the mother or the baby may appear uninfected,
but may be colonized with yeast. Unfortunately little information appears in
the medical literature about yeast infections causing breast and nipple pain.2
There are many species of yeasts. Some medicines work better on one than
on others. The presence of yeast does not reflect on personal hygiene.
Appearance of yeast
Yeast infections on the mucous membranes of the mouth and vagina are
white. Yeast skin rashes of the diaper area, under arms, under breasts, and in
the groin appear as red patches on light colored skin.18 Infected
nipple skin may not look different from normal healthy nipple skin or it may
look red or pink. Other times white growth can be seen, or the nipple may be
cracked.
Predisposing factors
Nipple damage, postpartum antibiotic therapy, and yeast vaginitis are
predisposing factors.1, 18 As pregnancy progresses the incidence of
vaginal yeast infections increases. Infants can acquire yeast infections from
their mothers at birth, so treatment of vaginitis during pregnancy is
important. Yeast infections have
increased dramatically over the past 20 years.
Detecting yeast infections of the nipple and breast
The severe pain experienced with a yeast infection on the nipples or in
the breasts can lead to premature weaning; so early detection and treatment are
important.2 Most women use the word “burning” as they describe their
pain. One mother said, “My nipple feels as if it has a piece of broken glass in
it.” Some mothers with yeast infections report shooting, burning pains in the
breasts during and/or after feedings.
Another woman described her breast pain in this way, “Fifteen minutes
after breastfeeding it felt as if my baby’s saliva were acid, which was slowly
working its way up my breasts and burning me.” Some women experience pain that
runs down the arm or across the back in addition to breast pain. One woman said
the pain felt like “nerve pain.” There is no good way to test for yeast on the
nipple, because it rarely cultures.1 There is no test that shows
whether the normal skin colonization of yeast has changed to an invasive
infection of yeast.4 Since there may be little to see on the
nipples, and the baby and/or mother may have no symptoms, it is important to
take a detailed history. Women describe shooting, burning pain of the breasts
caused by conditions other than yeast.
Differential
diagnosis
There are many problems that may cause
shooting, burning pain in the nipples and the breasts. Is the baby pinching the
nipple because he is not taking enough breast tissue into his mouth? Does the
mother have a rapid milk ejection causing the baby to slow the milk flow by
clamping down on the nipple? Are the mother’s nipples too large for the baby’s
mouth? Does the mother have a bacterial infection15 or eczema on her
nipples?11 Is there a crack requiring antibiotic treatment? Does the
face of her nipple turn white after a feeding? A warm compress should help
return the blood flow to the nipple. Are the nerves responding to previous
damage? Raynaud’s Phenomenon and fibromyalgia are two more examples of
conditions a woman could have in which she might describe shooting, burning
breast pain.19
Both mother and baby need treatment
Mother and baby should be treated at the same time, even if only one has
symptoms,14 because they will pass the infection back and forth. If
the baby sucks on his or her fingers or thumbs, they should be washed before
each breastfeeding. Treatment of any family member who has a fungal infection
such as diaper rash, vaginal yeast infection, finger or toenail fungus, jock
itch, dandruff, ringworm, etc. is essential. It can take many weeks, especially
in hot, humid weather, to clear up a yeast infection.
Treatment for the mother
The baby’s health care practitioner can prescribe medication for the
mother’s nipples as well as the baby. The mother with cracked nipples should
wash her nipples with soap and water daily. With nipple damage there can be a
bacterial infection along with the yeast infection.12 After feedings,
a mother’s nipples may be rinsed with water or with a solution of one cup of
water plus one tablespoon of white vinegar. Then she can dry her nipples and
apply the prescribed medicine. She should dress in a clean brassiere everyday.
If using breast pads, she should change them at each feeding. If the nipples
are so painful that it hurts to wear clothing, breast shells may be worn when
she is awake to provide comfort. If she needs pain medicine, she should consult
her primary care practitioner for the proper dose. Pain medicine is usually
compatible with breastfeeding. Sometimes nipple pain increases during the first
few days of treatment.
Many antifungal ointments and creams are
available for use on the skin. The primary care provider must be consulted
about their use.
Amphotericin B: Fungizone® 3% cream or ointment6
Ciclopirox olamine: Loprox® 1% cream6
Clotrimazole: Lotrimin® 1% cream
Clotrimazole and betamethasone: Lotrizone®6
Econazole nitrate: Spectazole® 1% cream6
Ketoconazole: Nizoral® 2% cream(Nizoral® also comes in a 2%
shampoo.)6
Miconazole nitrate: Monistat-Derm® 2% cream6
Mupirocin: Bactroban®5
Nystatin: Mycostatin®; Nilstat®; Nystex® cream or
ointment 100,000 units per gram.6
Some physicians find a combination of
antibacterial, antifungal, and steroid ointments works well. Jack Newman, MD,
prescribes mupirocin 2% ointment (15 grams), nystatin ointment 100,000 units/ml
(15 grams), and betamethasone 0.1% ointment (15 grams).16 The
ointment is applied sparingly to the nipples and areolae after each feeding.
There is no need to wash the ointment off, as most of it will have rubbed off
on the woman’s clothing or breast pads.16 The prescribing health
care practitioner could add 10% clotrimazole, miconazole, or ketoconazole cream
to the recipe for the pharmacist to mix with the other three ingredients.16
Doctor Newman finds ointments work better than creams.16 Sometimes
the powders themselves can be mixed for a stronger, more effective medicine.
Fluconazole: (DiflucanÒ) “After careful review of the diagnosis,
systemic therapy is appropriate when treatment with topical medication fails.”14
For shooting breast pain the mother may take a loading dose of 200 to 400
milligrams on the first day followed by 100 to 200 milligrams of fluconazole
once a day for a total of 14 to 21 days or more.7
Ketoconazole: is a
systemic treatment and along with fluconazole is on the AAP drug list as
usually compatible with breastfeeding.
Treatment for the baby’s thrush
·
Nystatin: (Mycostatin®, Nilstat®, Nystex® oral
suspension 100,000 units per ml6) has to come in direct contact with
the yeast to work. Yeast cells reproduce in about one hour, so using nystatin
oral suspension every three hours may be helpful when the infection is not
clearing up as quickly as anticipated.12 When treating with nystatin
oral suspension, it is important to shake the bottle well before using. Put a
small amount (one milliliter) into a small cup. Using a cotton swab, apply
nystatin well to all surfaces inside the baby’s mouth—between the cheeks and
the gums, on the tongue, under the tongue, on the roof of the mouth, and
between the lips and gums.
·
Fluconazole:
(Diflucan® oral
suspension) The amount of fluconazole the baby would get through breastfeeding
would not be enough to treat the infant.7 Fluconazole, 10 mg/ml
liquid, has been available for infants in the USA since 1995 and “has an FDA
safety profile for neonates one day and older.”7 The dose is based
on the baby’s age and weight.
·
Gentian
violet: Use a 0.5% or 1% solution once a day for no
more than three to seven days, because gentian violet can burn the baby’s
mouth.16 Gentian violet can be used at the same time as other
antifungal medicine. When treating the baby’s mouth, so little gentian violet
is used that the alcohol content is not a worry.16
·
Amphotericin
B: (Fungizone® oral
suspension6) has been available in the USA since 1996.
· Clotrimazole: (Mycelex® troche6) To make
a clotrimazole gel, the pharmacist crushes a ten-milligram clotrimazole troche
and mixes it with five milliliters of glycerin. The gel is applied to the
baby’s mouth and the mother’s nipples every three hours for five applications.13
There is enough medicine in this recipe for five applications. If the infection
remains, a second recipe can be used. Caution: Clotrimazole may cause elevated
liver enzymes in the baby.
· Miconazole: (Daktarin®, Daktar®) oral gel is more
effective than nystatin. It is not available in the USA.
If the infection
has not resolved after two weeks of medication, review the differential
diagnosis and suggest household measures.
Ways to cut down on the spread of yeast
Because
family members are in close contact, it is easy to spread a yeast infection.
·
Good hand
washing is important for all the family. Wash with warm soapy water, and use
lots of friction for at least 15 seconds.
·
Use paper towels
for hand drying, and then discard, since yeast can live on a moist towel.
Fingernails need to be natural and short.9
·
Use a bath towel
only once, and then wash it. Wash towels and clothing that come in contact with
the yeast in very hot water (above 50° Celsius or 122° Fahrenheit). Hang wash
in the sun to dry, if possible. Ironing will help kill yeast.
·
Boil items used
in the baby’s mouth (pacifiers, bottle nipples, teething toys) and anything
that comes in contact with the breast milk (pump kit parts, breast shells) for
20 minutes once a day or use a microwave sterilizer.
·
Milk expressed
during a yeast infection does not need to be discarded. Because freezing
does not destroy yeast,17 the milk could be a source of reinfection.
·
After one week
discard all bottle nipples and pacifiers and purchase new ones. Check pets and
farm animals for yeast, especially their ears. Get new toothbrushes for the
whole family. One woman found her dental retainer to be her source of
reinfection.
·
A bleach
solution of ¾ cup household bleach to one gallon of water (or 2 tablespoons to
2-2/3 cups of water) will disinfect surfaces such as a diaper changing pad,
baby furniture, and toys. Wipe with the bleach solution, let it sit for 20
minutes, rinse, and air dry.
·
If a yeast infection
is not resolving, tests to rule out anemia and diabetes might be a good idea.
Some women have found herbal or homeopathic remedies helpful. Other women
report that it helps to add acidophilus, garlic, zinc, more water, or B
vitamins (from a source other than nutritional yeast) and reduce sugar and
dairy products in her diet.10 Bifidus is used for babies.
·
If she uses a
steroid inhaler for asthma, she could rinse her mouth after each use to reduce
her chance of oral thrush.
·
Moisture left
behind by some baby wipes or cornstarch, an ingredient in some baby powders,
can promote the growth of yeast.
A healthy body is the best defense against an
overgrowth of yeast.8
Bibliography
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LH, et al.: Candida albicans: is it associated with nipple pain in
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17 Rosa
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Microbiol 21(4):361-363, 1990
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Family Physician 40:1407-1413, 1994
19 Wilson-Clay,
Hoover K: The Breastfeeding Atlas, 2nd edition. Austin, TX:
LactNews Press, 2002
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