Breastfeeding and Yeast Infections

General Information for Healthcare Providers

(Written by David A. Lee, MD, November 2001) 

Introduction:

Candida albicans infections (Candidiasis, “Thrush” or “Yeast”) of the nipples may occur any time while a woman is breastfeeding.  Babies can also develop candida infections in the mouth (oral thrush) or on the skin (most commonly in the diaper area) Candida albicans is a fungus that likes warm, moist, dark areas. It normally lives on the skin, and 90% of babies are colonized with it within a few hours of birth.  Candida only becomes a problem when it causes an infection.

Candida infections are more likely to occur when there is a breakdown in the integrity of the skin or mucous membrane.  A good latch is very important as this prevents trauma to the nipple.

The use of antibiotics also encourages the overgrowth of Candida albicans. It is not uncommon for pregnant women, women in labor, and new mothers, as well as their babies to receive antibiotics.

Signs of possible candida infection in the nipple or breast:

·        “Burning” nipple pain, rather than the sharp, stabbing or pinching pain associated with other causes such as improper positioning.

·        Pain that lasts throughout the feeding, and occasionally continues after the feeding has ended.

·        Pain in the breast which is "shooting" and which goes through to the mother’s back and shoulder.

·        Pain that appears after a period of pain free nursing.

·        Pink or red nipples that may appear peeled or shiny.

·        Nipples or areolas that have white patches or small red or white pustules on them.

·        Breast skin that itches, has a red rash or a weeping foul smelling discharge (especially under the breasts).

·        Cracks in the nipple and/or areola, which do not heal.

Signs of possible candida infection in the baby:

·        Oral thrush may appear as white patches inside the baby’s lips, mouth and/or back of the throat that do not wipe off with gentle rubbing, a thick white coating on the baby’s tongue.  Sometimes babies just refuse to nurse or have fussiness at the breast.

·        Skin infections may appear as a red rash or white pustules.  This may occur in the baby’s diaper area or in other wet moist areas on the body (neck creases, armpits).

Treating candida infections in the Mother:

General Care:

·        Prevent nipples from being moist between feedings by using absorbent breast pads and changing pads frequently.  Avoid pads that are perfumed.  Avoid wearing breast shells which can encourage leaking.

·        Wash your nipples daily with a mild soap and rinse them thoroughly, then blot dry with a fresh towel or tissue.  Alternatively you can air dry your nipples or use a very low setting on a hair dryer.

·        Do not use lanolin or rub breast milk into your nipples after a feed.

·        Use either the baking soda or vinegar treatment after every feeding as follows:

1.      To one cup (8 oz.) of Boiled water (cooled) dissolve one teaspoon of baking soda OR add two teaspoons of plain white vinegar.

2.      Keep this mixture in the refrigerator.

3.      Pour about 1/4 cup into a ziplock bag and then place cotton balls or squares into the bag.  Keep the bag with you.

4.      Make a new baggy each day or two.

5.      After each nursing or pumping gently wipe each nipple and areola using a fresh cotton ball for each breast.  Air-dry or gently blot your nipple dry with a clean tissue.

6.      Relief should be noted in a few days.  Continue this treatment for at least seven days.

·        While treating yourself for yeast or your baby for oral thrush, bras and any washable pads should be washed in HOT soapy water and then rinsed well.  Bras should be changed at least daily and pads should be changed once they have become wet with milk.

·        Boil any pacifiers or artificial nipples for 20 minutes each day while you treating are yourself for yeast or your baby for oral thrush.  Be aware that this boiling may damage or weaken the nipples and pacifiers.  Throw out any nipples and pacifiers that may have been damaged or weakened.

Dietary Adjuncts to treating yeast infections:

The addition of dietary changes and use of nutritional supplements are advocated by some lactation specialists.  While the exact mechanism for why these treatments work is not known, none of the treatments are harmful under normal circumstances and may be helpful.

·        Acidophilus capsules (active beneficial intestinal bacteria): 6 capsules of acidophilus taken evenly spaced throughout the day.  Capsules must contain live cultures and should be refrigerated.  Refrigerated capsule forms are usually available at health-food stores.  Recommended brands include Nature’s Way Primidophilus with Bifidus, DDS and Florgen.

·        Garlic (odorless) capsules.  6 tablets of Kwai or 4 capsules of Kyolic taken spaced throughout the day.  Kwai and Kyolic brand garlic is available in most pharmacies. Garlic has anti-fungal properties and is touted as a booster for the immune system.   Another alternative is for the patient to eat a lot of garlic.  Effective dosing is hard to determine and the patient will smell like garlic if this method is chosen over using the tablet forms.

·        Diet:  Reduce sugar intake to a minimum and use NO artificial sweeteners.  Eliminate dairy products until two weeks after all symptoms are gone. (Dairy products do not include eggs or mayonnaise, but include all products that come from cow’s milk.)

If no improvement is seen using this General Care approach for a reasonable amount of time, consider the use of an antifungal cream such as clotrimazole, 1% gentian violet or oral Fluconazole.

Common regimen for the use of antifungal cream:

·        After feeding or pumping, swab milk off the nipple with the baking soda or vinegar solution described above.

·        There are several over the counter antifungal creams available.  Clotrimazole (Lotrimin™) is very effective and safe.

·        Apply Lotrimin antifungal cream to the nipples.

·        Apply Lotrimin after every feeding or pumping for the first 24 hours and then four times a day after that.

·        Before feeding, blot Lotrimin off with a damp cloth.

·        Treat until relief is noted and then for at least 7 more days.

Common regimen for the use of Gentian Violet:

Gentian violet (1% solution in water) is an excellent treatment for Candida albicans.  However, it is messy, and will stain. The baby's lips will turn purple, but the purple will disappear after a few days.  It is safe.  Gentian violet is available without prescription, but is not available at all pharmacies. 

Gentian Violet Regimen (note: use 1% solution as the highest concentration or the baby will get mouth ulcers.  Some practitioners use 1/2%)

·        About 10 ml (two teaspoons) of gentian violet is more than enough for an entire treatment.

·        Many mothers prefer doing the treatment just before bed so that they can keep their nipples exposed and not worry about staining their clothing. The baby should be undressed to his diaper, and the mother should be uncovered from the waist up.  Gentian violet is messy.

·        Dip an ear swab (Q-tip) into the gentian violet.

·        Put the purple end of the ear swab into the baby's mouth and let him suck on the swab for a few seconds. The gentian violet usually spreads around the mouth quickly. If it does not, paint the inside of the mouth to cover as much of the inside of the cheeks and tongue as possible.

·        Put the baby to the breast. In this way, both the baby's mouth and your nipple are treated.

·        If at the end of the feeding you have a baby with a purple mouth, and two purple nipples, there is nothing more to do. If only one nipple is purple, paint the other one with gentian violet using an ear swab.

·        Repeat the treatment each day for three or four days.

·        There is often some relief within hours of the first treatment, and the pain is usually gone or virtually gone by the third day.  Do not continue the gentian violet if no relief occurs after 3-4 days of treatment.  Instead, consider other causes for the patient's symptoms (nipple trauma, nerve damage, etc.).

·        Uncommonly, babies who are treated with gentian violet develop sores in the mouth, which may cause them to reject the breast. If this occurs or if the baby is irritable while nursing, stop the gentian violet immediately. The sores usually clear up within 24 hours and the baby should return to feeding. 

·        If the infection recurs, treatment can be repeated as above. But if the infection recurs a third time, a source of reinfection should be sought out. The source of infection may be the mother who may be a carrier for the yeast (but may have no sign of infection elsewhere), artificial nipples the baby puts in his mouth or untreated oral thrush in the baby. Treatment of the mother with fluconazole with simultaneous treatment of the nipples with topical gentian violet will usually eliminate reinfection.  Be sure to have the patient sterilize (at least daily by boiling in water) any artificial nipples she may be using while treating herself or the baby for a yeast infection.

Fluconazole:

Fluconazole (Diflucan™) is a synthetic antifungal agent, which can be used for the treatment of a variety of Candida albicans infections. For the breastfeeding mother in particular, it can be used to treat recurrent Candida infections of the nipples and of the milk ducts.

Fluconazole is an antifungal agent that is taken by mouth. It is fungistatic, which means that it stops fungi (such as Candida albicans) from multiplying, but does not actually kill them. This accounts for the fact that sometimes it takes several days to have an effect.

Fluconazole is available only by prescription.  Some general information about Fluconazole is provided below:

Dose of Fluconazole:

The first dose of Fluconazole is usually 200 mg.  Subsequent doses will usually be 100 mg twice daily for at least two weeks. A patient should generally be symptom free for at least a week before stopping the medication. This seems to prevent most relapses. However, this means that although most mothers require only the usual two weeks, some need longer treatment.  There should be relief from symptoms within seven days of starting the medication.  If this does not occur, reconsider the diagnosis of yeast infection as the cause of the patient's symptoms.  A 2 week prescription is likely to cost between $100 - 200.

Fluconazole in breast milk:

Fluconazole does appear in breastmilk, and this is as it should be, since the idea is to treat infection in the ducts and nipples.  The baby nursing will obviously get fluconazole with the breastmilk.  There have been no complications reported in the babies from exposure to fluconazole in the breast milk.  In fact, Fluconazole is used to treat candida infections in babies.

Side Effects of Fluconazole:

Fluconazole is generally well tolerated, but there is no such thing as a drug, which never has side effects.  There have been concerns about liver injury, but this complication seems quite rare, and usually occurs in people who are taking other medications, who have taken fluconazole for months or longer, or who have immune deficiencies.  Still, liver injury is a possibility that needs to be kept in mind.  

Vomiting, diarrhea, abdominal pain and skin rashes are the most common side effects. These are not usually severe, and only occasionally is it necessary to stop the medication because of these side effects. Allergic reactions are possible but uncommon. Patients who are pregnant should not use fluconazole.

For more details on fluconazole and its use for breast, nipple or milk duct candida infections see the handout "The Use of Fluconazole to Treat Candida Infections of the Nipple and Breast Ducts, A Synopsis for Health Providers".

Treatment of Thrush in the baby:

If a baby has signs of thrush and is not treated, the infection can be passed back and forth between the mother and the baby.  Babies can be treated with oral nystatin suspension, 1% gentian violet or oral fluconazole (usually reserved for persistent, recurrent or very severe cases of oral thrush).

If either the mother or the baby goes onto a treatment that includes antifungal medication (nystatin, clotrimazole, 1% gentian violet or fluconazole), simultaneous treatment of both the mother and the baby should be considered. Infections can be asymptomatic or sub-clinical.  Fungal infection can be passed back and forth between the mother and her baby. Simultaneous treatment often provides the best chance for successful treatment.

This information is advisory only and is not intended to replace sound clinical judgement or individualized patient care.  This document has been produced by adapting and merging information from the references and information listed below:

·        Dr. Jack Newman (link through bflrc.com)

·        The Perinatal Education and Lactation Center at California Pacific Medical Center  (415-343-2229)

·        “Medications and Mother’s Milk”, Thomas Hale, Ph.D, 1999

·        Pat Gima, IBCLC, breastfeedingonline.com