Thrush on Nipples

Thrush is caused by an overgrowth of a fungus called Candida albicans which is normally kept in check by friendly bacteria in our bodies. Under certain circumstances a breastfeeding mother can get thrush on her nipples causing pain and soreness, and her baby might get thrush inside his mouth (seen as white patches that don’t wipe away) or in his nappy area (an inflamed nappy rash). The symptoms of thrush on nipples can be very similar to the symptoms experienced with a bacterial infection of the nipple or when a baby is not latched correctly—causing pinching or vasospasm of the nipple. This article looks at the symptoms, causes, diagnosis and treatments for thrush on nipples.

Symptoms of thrush on nipples

The most common symptoms of thrush on nipples are said to be itching or burning pain. Skin may be flaky or shiny, and pain will usually be in both nipples at the same time. There may not be any visible symptoms to see. Mother and baby can pass a thrush infection back and forth between them unless both are treated at the same time. The National Infant Feeding Network have issued a statement on thrush which lists the symptoms as follows:

Symptoms may include:

  • Burning sensation in nipples, especially after feeds
  • Itchy nipples which may also be extremely sensitive to any touch – even to loose clothing
  • Persistent loss of colour in the nipple/areola (or they may appear red and shiny)

Nipple pain which:

  • Becomes more intense as the feed progresses – and can last for up to an hour after the feed.
  • Occurs in both nipples, (except possibly in the early stages), because the baby transfers the infection during feeding.
  • Which does not respond to improved attachment, the application of heat, or alternative methods of milk removal.

Pain in the back and shoulders?

In Dr. Jack Newman’s Guide to Breastfeeding, 2014 p. 168, the authors mention that Candida infection usually causes pain of a shooting or burning nature—often throughout the breast and sometimes in the back and shoulders. They say the pain may feel worse in the evenings, and may last for minutes or even hours. Note that similar symptoms are also sometimes used to describe mammary constriction syndrome which is associated with poor breastfeeding latch and positioning.

Causes of thrush

The fungus Candida albicans is always on our bodies and normally kept in check by friendly bacteria. In warm, moist areas, such as inside your baby’s mouth or on breastfeeding nipples, it has the potential to grow to problematic proportions under certain conditions. The ideal conditions thought to be risk factors for thrush overgrowth include:

  • If a mother has cracked, damaged or sore nipples
  • If mother or baby are on antibiotics (antibiotics kill the friendly bacteria that keep thrush in check)
  • If mother or a family member has an existing Candida fungal infection such as vaginal thrush, athlete’s foot, nappy rash or jock itch 1
  • Mother or baby is on corticosteroids, or mother takes oral contraceptives 2
  • Using a dummy/pacifier or bottle teat (these are a source of reinfection) 3
  • Mother has diabetes and/or low iron levels (LLLGB, 2016)
  • Recurring blocked ducts (Newman, 2014)
  • If a mother is exhausted or stressed 4

Diagnosing thrush

An IBCLC lactation consultant can help rule out positioning as a cause of thrush-like symptoms and your health professional will advise whether a bacterial or fungal infection is likely.

Over diagnosis

Some practitioners believe thrush is over diagnosed. Jack Newman, MD, Canadian paediatrician and breastfeeding expert, explains:

Many mothers are being treated for Candida albicans when they don’t have it. If the mother took antibiotics, if the baby has thrush, or even if “we tried everything else,” she may be treated for Candida but not actually have it.

Diagnostic tools

The Breastfeeding Network (BFN) are also very concerned about over diagnosis of thrush. Wendy Jones PhD, MRPharmS and the BFN (2009) have developed a fact sheet and a diagnostic tool to help mothers self-diagnose if they have thrush. The article Causes of Sore Nipples may also be helpful.

To swab or not to swab

On their website, The Breastfeeding Network recommend swabbing nipples5 to check whether an infection is bacterial (Staphylococcus aureus) or fungal (Candida) before treatments are prescribed.

However the latest guidance on thrush from The National Infant Feeding Network, UNICEF, 2014 says swabs are not usually required unless the diagnosis isn’t clear or if bacterial infection is suspected, if treatment isn’t working or if systemic treatment6 is considered.

Diagnostic difficulties

The UNICEF statement also points out that at least half of all breastfeeding women have the bacteria Staphylococcus aureus (S. aureus or staph) on their nipples, often without symptoms, and therefore a mother may have both staph and Candida on her nipples. It also states that charcoal skin swabs may only pick up about 10% of Candida infections, and that it is hard to identify Candida in human milk because of lactoferrin7.

Thrush treatments

Places with the latest guidance on thrush treatment to discuss with your doctor include the UNICEF statement on Thrush, Dr Jack Newman’s Candida Protocol, NICE Guidelines8, Breastfeeding Network’s Thrush and Breastfeeding fact sheet and LLLGB’s information on Thrush and Breastfeeding.

#1 Unicef’s treatment of choice

The Unicef statement on thrush describes the following treatment:

The treatment of choice for topical thrush is Miconazole (Daktarin) cream (2%) applied sparingly to the mother’s nipples after every feed.

If nipples are very inflamed, hydrocortisone (1%) as well. A combination cream or ointment (Miconazole 2% with hydrocortisone 1%) may also be used.

Second line treatment: Fluconazole 150–300 mg as a single dose followed by 50–100 mg twice a day for 10 days. Continue topical treatment in both the mother and the infant.

Persistent or systemic/ductal Candida may require longer (14 – 28 days) treatment.

#2 Candida protocol (Dr Jack Newman)

Jack Newman describes the slightly different treatments he recommends in his Candida protocol below:

#3 NICE guidelines

The NICE guidelines are very similar to the UNICEF statement and refer to the Breastfeeding Network’s Thrush and Breastfeeding as their reference. They also include additional useful information:

  • Continue to breastfeed if you or your baby have thrush
  • Wash hands well after nappy changes, observe strict hygiene
  • Wash and sterilise nipple shields, dummies, teats, and toys that are put in baby’s mouth
  • Treat for bacterial infection at the same time if you have a cracked nipple
  • Treat mother AND baby

The full article is linked below with further information on how to treat a bacterial infection and specific advice about treatment for your baby.

#4 LLLGB protocol

Hygiene, diet, and supplements

LLLGB describe a treatment plan looking at each of hygiene (ways to eradicate thrush from the home), diet (excess sugar or yeasty foods in the diet can make symptoms worse), dietary supplements (e.g. acidophilus capsules, grapefruit seed extract, zinc and B vitamins are mentioned) alongside medication.

A note on fluconazole

Fluconazole (a prescription anti fungal drug for treating Candida) is not licensed for breastfeeding women and practitioners are required to take full liability for prescribing it (Wendy Jones, 2013).  The Breastfeeding Network is concerned about unnecessary treatment of the breastfeeding mother with fluconazole (see link) which they state could lead to adverse effects for the baby especially under six weeks of age. Unnecessary treatment is also associated with Vasospasm Symptoms.

Information about fluconazole on Lactnet, Medsmilk and e-Lactancia do not mention these concerns for a younger baby. Readers are recommended to discuss the safety information from all these reputable resources with their health care provider when deciding on treatment.

Can I store breastmilk during a thrush episode?

Freezing breastmilk containing Candida will not kill the fungal cells and it is not clear whether feeding milk expressed during a thrush episode could cause reinfection. Nancy Mohrbacher says:

Research indicates that freezing does not kill yeast, but no one is sure if expressed milk can cause a recurrence. Suggest the mother give the baby any milk that was expressed and stored during a thrush outbreak while they are being treated. If that is not possible or practical, suggest she boil the milk to kill any yeast before giving it to the baby.

The Academy of Breastfeeding Medicine’s protocol indicates there is no evidence that milk need be discarded during a thrush episode.

If a mother has breast or nipple pain from what is considered to be a bacterial or yeast infection, there is no evidence that her stored expressed milk needs to be discarded.

Summary

Thrush is a fungal infection that can sometimes develop on your nipples during breastfeeding causing pain and soreness. The symptoms can be very similar to those caused by a poor latch or a bacterial infection of the nipple making accurate diagnosis difficult. There are a number of treatment protocols for thrush including careful hygiene, dietary changes and antifungal medications. However, if thrush doesn’t resolve with treatment, perhaps it isn’t thrush! Your IBCLC lactation consultant can help you identify whether there are other causes for your painful nipples such as poor positioning or attachment, and your health professional will advise whether a bacterial infection could be present.

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