Health Tip Spotlight - Thrush

For those Moms out there suffering from nipple pain, there's good news.  Nipple pain is NOT a normal part of breastfeeding!  As a matter of fact, it's downright frustrating and is one of the main causes Moms give up on breastfeeding, one of the most beneficial things you can do for your child.

Most causes of nipple pain are related to problems with positioning or poor latch-on of the baby at the breast.  However, if poor positioning and improper latch-on have been ruled out as the cause of your pain, or if you have been pain-free for weeks or months prior to the onset of soreness, then Thrush should be a consideration.

Thrush (candidiasis or yeast) is a fungal infection caused by an overgrowth of the candida organism.  Candida normally inhabits the mouth, gastrointestinal tract, and vagina, but can overrun almost any part of the body under the right conditions.  For breastfeeding mothers, this includes the breasts and nipples because thrush thrives in warm, moist conditions.

Predisposing Factors

Usually, the natural bacteria in and on our bodies keep the candida from overgrowth; however, certain factors can inhibit this natural protection.

Antibiotics

Antibiotic use by a mother or her baby can reduce the beneficial bacteria that normally keep the yeast in check.  Even antibiotic use weeks or months before the onset of thrush symptoms can have contributed to the disruption of normal intestinal flora.  In particular, broad-spectrum antibiotics and long-term usage for acne or for prophlaxis for urinary tract infection can diminish the beneficial bacteria and allow yeast to overgrow.  Many mothers receive antibiotics during labor or immediately following birth.  In some cases, they are not aware that they have been given these medications, particularly after a cesarean birth as the medication may be added to the IV.  Also, if a mother had a recent bout of mastitis that was treated with antibiotics, she will be at an increased risk for a yeast infection.

Nipple Trauma

Nipples that are sore or cracked can allow the normal yeast on our skin to invade the nipple and breast tissue.  While the cracked nipples do not cause the overgrowth, they allow the yeast to take hold.

Steroids

Use of steroids (such as for asthma) can alter the body's immune response making it susceptible to yeast overgrowth.  Other drugs or physical conditions that interfere with the functioning of the immune system can also increase susceptibility.

Chronic Illness

Conditions such as diabetes, anemia, HIC, endocrine disorders, PKU, and infections may predispose a breastfeeding mother or her baby to a yeast infection.

Pregnancy and Menstruation

Some women are particularly sensitive to the hormonal changes that occur during pregnancy and menstruation.  During these times, changes in the vaginal mucosa may encourage overgrowth of yeast.

Diet

A diet that contains excessive amounts of sugar or foods containing yeast (including alcohol), or a diet that is deficient in vitamins and minerals can contribute to yeast overgrowth.

Other Factors

Other potential risk factors include use of oral contraceptives, pacifier use, poor personal hygiene, and repeated exposure through intimate contact, including sexual contact.

Symptoms

When yeast overgrows in a baby's mouth, on a mother's nipples, or in the milk ducts within her breasts, the first symptom is usually pain.  Often, an initial problem with poor positioning or latch-on leaves a mother with a crack in her nipple that allows yeast to enter.  If pain continues once the other problems are corrected, it could be a yeast infection.  Other times, breastfeeding has been going fine for weeks or months before the onset of pain.  Many mothers describe the pain of thrush as a burning or stabbing pain that can be in the nipple, the breast, or both.  Usually both nipples are involved, but it is possible to have a yeast infection on only one nipple.  The pain may begin during the feeding and continue even after the baby is off the breast.  In fact, some mothers find that the pain is actually worse between feedings.  Pumping is usually painful as well, though less painful than breastfeeding.

Besides pain in the breasts and/or nipples, you may also experience nipple itching or flaking, redness, or shininess.  Rarely, there may be white yeast growth on the nipple.  Sometimes, there is a red or pink rash with small blisters on the nipple or areola.  Often, however, the nipple looks perfectly normal.  You may be experiencing a vaginal yeast infection or have experienced one in the recent past.  Signs that the yeast has traveled into the milk ducts of the breast include cramping in the breast or shooting pains deep within the breast.

Sometimes, white patches that look like leftover milk are visible in your baby's mouth, especially on the tongue or inside the cheeks.  If scraped gently, these white patches may bleed.  Your baby may have other symptoms of candida overgrowth such as a yeast diaper rash (characterized by small red dots around the edge of the rash), a "mother-of-pearl" look to the saliva, or apparent discomfort when feeding, as the baby's mouth may be itchy or sore.

Your baby may also be fussy or gassy.  If your baby has thrush in his mouth and it is itchy or sore, nursing may be uncomfortable or painful.  The baby may react to this discomfort by becoming fussy at the breast, refusing the breast, or coming "off and on" the breast frequently.

It is important to note, however, that there may be no visible symptoms in either you or your baby.  Pain may be the only symptom.

Treatment

If you suspect a yeast infection or thrush, an appointment should be made with your health care provider to confirm the diagnosis and discuss possible treatments.  In all cases it is wise to treat both the mother and child simultaneously even if only one of you appears to be experiencing any symptoms.  Possible treatments fall into three basic categories:

     1) medications requiring a physician's prescription

     2) over-the-counter and herbal remedies

     3) home management techniques that work in conjunction with other forms of treatment to reduce the yeast and prevent an infection from recurring.

Medications

If only your nipples appear to be involved, your health care provider may prescribe a topical antifungal (ointment or cream) such as nystatin or miconazole to be used on the nipples.  A liquid version also needs to be prescribed for treatment of the baby's mouth.  Because yeast multiplies as quickly as every hour, frequent treatment is needed.  Some health care providers recommend using the oral suspension every three hours and the nipple ointment every three hours or after every feeding.  If baby sucks his thumb or fingers, they should be washed often.  All treatments need to continue for at least two weeks, even though symptoms may disappear much sooner.

Systemic antifungals, which work throughout the body such as Diflucan (fluconazole), may be prescribed if the milk ducts also appear to be involved or topical treatment has been unsuccessful.  Many mothers find that a single dose is not effective.  Sometimes treatment needs to continue for as long as two weeks.

Gentian violet is an antifungal which does not require a prescription.  Although it is a highly effective treatment for nipple thrush, it should not be used without consulting your health care provider, as it can be dangerous if used improperly or for too long.  A water based solution of .5% to 1% gentian violet can be mixed by a pharmacist.  Applications of once or twice daily should be limited to no more than three days.

Gentian violet may cause staining, so care should be taken to protect clothing.  While using gentian violet, some mothers find it practical to use one set of nursing bras, nursing pads, and towels, and to wear old clothes.  If the gentian violet solution gets on clothing, aerosol hairspray or bleach has been effective in removing the stains.  Stains on the skin usually fade in one or two days.  Applying a thin coat of Lansinoh ® for Breastfeeding Mothers (a medical grade of anhydrous lanolin) around your baby's lips can minimize staining on the face when gentian violet is applied to the mouth.

Herbal / Alternative Treatments

Applying a vinegar and water solution to the nipples is an easy and effective treatment, especially when used in conjunction with other methods.  Mix one tablespoon of vinegar to a cup of water.  Apply to the nipples and areolae with a clean cotton ball after each feeding.  Allow the nipples to air dry.

Oral supplements of acidophilus, in either capsule or powder form, can be very helpful.  These supplements contain beneficial bacteria which can help to limit the candida in the digestive tract.  Acidophilus is available at Babiesandmoms.com (ours is in double strength and not grown on dairy, wheat, or corn so it's virtually allergy-free) or at health food stores in the refrigerator section in capsule form.  For best results, acidophilus should be taken for two weeks beyond the end of the symptoms.

There are many other herbal or natural remedies that are highly effective for some people.  A naturopathic doctor (N.D.) or a qualified herbalist can help determine the most appropriate treatment for each particular situation.

Home Care Measures

When treating for thrush, particularly if this is a recurrent problem, care of the environment to minimize yeast growth can be particularly helpful.  Any items that are damp or come into contact with the baby's saliva may harbor yeast.  All toys, pacifiers, bottle nipples, pump kit parts, breast shells, nipple shields, etc., that come into contact with your baby's mouth or your nipples should be boiled daily for twenty minutes.  Pacifiers and other rubber nipples need to be replaced weekly.

Freezing does not kill the candida organism.  Therefore, milk that has been expressed and stored during a thrush outbreak may reinfect the baby at a later date.  Bringing the milk to a boil will destroy the candida and thus limit the possibility of reinfection.

Your breasts should be kept as dry as possible, and bra pads should either be disposable or should be washed in hot, soapy water.  Bras and cloth diapers also need to be washed in hot, soapy water.  Bleach (one cup) in the wash water or vinegar (one cup) in the rinse water can be effective.  Items should be dried in a hot dryer or line dried in the sun.  The heat of an iron can kill yeast on clothing.

During an outbreak of yeast, particularly if it is persistent, paper towels can be used for hand washing and bath towels can be used only once  before washing.  Toothbrushes can harbor yeast, so it is important to change toothbrushes frequently.

All family members should be treated for yeast infections, of any kind including vaginal yeast, jock itch, finger/toe nail yeast infections and diaper rash.  Even pets can harbor yeast, so all members of the family should be examined for any unusual rashes or sores.  Because yeast can be passed during any type of intimate, sexual partners may need to be treated.  As yeast can be asymptomatic in some people, the entire family may need to be treated even if they exhibit no symptoms.

Dietary changes can help minimize yeast growth.  Many mothers find the addition of lactobacillus or acidophilus capsules taken daily may help as a preventive measure.  Yogurt alone may not be enough to knock out an established case of thrush.  Decreasing the sugars on which yeast thrives is also very helpful.  Reducing consumption of dairy products or yeast-containing foods, including alcohol, can also be helpful.  The addition of garlic to the diet may boost the immune system and help to keep yeast in check.

Although candidiasis can be painful and annoying, it does not have to disrupt your  breastfeeding relationship.  Prompt and appropriate treatment is essential.  Please contact your health care provider and local Licensed Lactation Consultant if you have a yeast infection or your baby has thrush.