Thrush on Nipples

Thrush is the common name for a yeast infection caused by an overgrowth of Candida albicans (Candida), a type of fungus. Candida is normally kept in check by friendly bacteria in our bodies. A baby can get thrush inside his mouth (seen as white patches that don’t wipe away) or in his nappy area (an inflamed nappy rash) and it is thought that sometimes a breastfeeding mother can get thrush on her nipples causing pain and soreness. The symptoms of thrush on nipples are similar to the symptoms experienced with a bacterial infection of the nipple or when a baby is not not attached to the breast (latched) correctly. This can make diagnosis very difficult and there is controversy over whether the condition exists.¹²³⁴

This article

This article looks at the symptoms, causes, and treatments traditionally associated with a diagnosis of thrush on nipples and considers other possibilities to explain thrush like symptoms.

Symptoms of thrush

Symptoms for mother

Although there may not always be any visible symptoms to see, listed below are a number of symptoms that are often assumed to be due to a thrush infection. Note that many of these symptoms can also be associated with other causes of sore nipples (see below; “Not thrush? Alternative explanations”).

• Itching or burning nipple pain. Pain tends to be continuous not just during feeds and breast pain may be described as radiating.^{5  67}
• Thrush will usually affect both nipples because the baby is thought to transfer the infection from one nipple to the other (Amir et al, 2022).
• Nipples may feel very sore and sensitive to touch and nipple skin and areolae may appear deep pink (in lighter skin tones), flaky or shiny (ABM Protocol #26, 2016). White patches similar to oral thrush or tiny blisters are also said to be possible.⁸⁹
• There may be a loss of colour/skin discolouration in the nipple or areola (Wilson-Clay and Hoover, 2022. p67)
• Pain may be felt deep in the breast, sometimes as a stabbing or burning pain and sometimes in the back and shoulders.¹⁰ Note that deep breast pain is not an indication that Candida has overgrown in the milk ducts within the breast to cause “ductal thrush”. Several breastfeeding authors question the idea of ductal thrush as a condition.¹¹¹²
• Sudden onset of symptoms. Thrush is more likely if pain continues even after latching and positioning help from a breastfeeding specialist, or if nipple soreness develops after months of pain free breastfeeding (Amir et al, 2021).

Symptoms for baby

• Babies may have white patches of fungal growth inside their cheeks, or on their gums or tongue which don’t rub off. This may make a baby’s mouth sore so they may find feeding painful and appear fussy. Note that a white, milky coating just on a baby’s tongue is not necessarily thrush since thrush will quickly spread to lips, gums, inside the cheeks and the roof of baby’s mouth. Viral infections may also coat the tongue or change the appearance inside the mouth for example herpes infections  (Wilson-Clay and Hoover, 2022. p67).
• Baby may have a sore bottom and nappy rash. Note that a sore bottom and nappy rash can also be associated with a dietary intolerance see Milk Allergy in Babies.

Not thrush? Alternative explanations

As already highlighted, many of the symptoms listed above can be difficult to distinguish from other causes of sore nipples or deep breast pain. An IBCLC lactation consultant can be a helpful partner to identify possible causes of pain related to breastfeeding. Alternative explanations for nipple and breast pain include:

• Poor positioning and attachment at the breast—can cause burning nipple pain and soreness, friction blisters and milk blisters (blebs), deep breast pain (mammary constriction syndrome) or lead to breast engorgement and inflammation. A poorly fitted breast pump can also cause sore nipples.
• Vasospasm of the nipple (constriction of blood vessels in the nipple due to baby pinching and distorting the nipple)—may cause burning nipple pain and/or colour changes of the nipple and may also be associated with Raynaud’s Syndrome. Some medications for thrush could make nipple vasospasm worse (see below).
• Damaged nipples that are healing from a poor latch may feel itchy or experience nipple vasospasm due to the injury (Thomas, 2013)
• A bacterial infection causes similar symptoms particularly if there is obvious nipple damage and is usually a more likely culprit than yeast (Amir et al, 2013; Thomas, 2013).
• Eczema or dermatitis on the nipple and areola can cause itching, burning and a red or crusty appearance.¹³¹⁴
• Differences in anatomy such as a baby with a tongue-tie or a mother with flat or inverted nipples can make attachment more difficult resulting in sore nipples.

Thrush or subacute mastitis?

Another hypothesis for thrush like symptoms by Jiménez et al is that specific strains of bacteria overgrow in the breast causing inflammation in the ductal system but without causing the typical mastitis symptoms associated with bacterial infection.¹⁵ Some researchers call this condition subacute mastitis and while the idea has gained support in some circles¹⁶¹⁷ others say the theory is not supported by evidence.¹⁸¹⁹

Causes of thrush

The fungus Candida albicans and other Candida species generally live on our bodies without causing a problem. The ideal conditions thought to be risk factors for thrush overgrowth on nipples or in a baby’s mouth include:

• If a mother has cracked, damaged or sore nipples. Damaged skin, generally from a poor latch, is thought to be an underlying cause of thrush and must be solved, alongside any medical treatments, to eradicate thrush.²⁰
• If mother or baby have another illness, low resistance to infection or have received antibiotics or corticosteroids.²¹ Antibiotics can change the balance of friendly bacteria in our bodies that normally regulate fungal overgrowth—making vaginal thrush more likely for example. Diabetes can be a risk factor ²² as can taking oral contraceptives²³.
• If mother or a family member has an existing topical fungal infection such as vaginal thrush, athlete’s foot, nappy rash, jock itch, ringworm or even a fungal infection in a family pet (Wilson-Clay and Hoover, 2022. p67).
• Frequent use of lanolin as a nipple cream may be associated with fungal infections see Treatments for Sore Nipples for more information about using lanolin.
• Using a dummy/pacifier or bottle teat especially in the early weeks after birth (these are a source of reinfection).²⁴
• If a mother is exhausted or stressed (ILCA, 2013).

Diagnosing thrush

It is important to rule out other reasons for painful nipples as there has been concern that thrush is over diagnosed for many years.²⁵ See Causes of Sore Nipples and Why Does Breastfeeding Hurt? on this website for more information. An IBCLC lactation consultant can help rule out attachment and positioning as a cause of thrush-like symptoms and your health professional will advise whether a bacterial or fungal infection (or both) is suspected.

To swab or not to swab

In the study by  Jiménez et al taking swabs from nipples or culturing samples of breast milk did not show an association between typical thrush symptoms and the presence of yeast. Both Candida species and Staphylococcus (a bacteria associated with mastitis) can be found on normal healthy skin. Amir et al says consider skin swabs for persistent infection to rule out methicillin-resistant Staphylococcus aureus or Herpes simplex (Amir et al, 2024).

Thrush treatments

Medical treatments

Most breastfeeding resources discuss how a mother and baby can pass a thrush infection back and forth between them and therefore both should be treated at the same time.²⁶²⁷ However others say there is no data to support this thinking (Thomas, 2013) and there is no reason to treat a baby’s mouth unless there are obvious signs of fungal growth.²⁸  Thrush usually responds well to treatment.

• Mothers should continue to breastfeed if they or their baby have thrush, breastfeeding can help the growth of friendly bacteria such as Lactobacillus which can limit fungal growth (Lawrence and Lawrence, 2016).
• Treat mother and baby at the same time to prevent recolonisation. Also treat sexual partners, use condoms to prevent cross-infection (Wambach and Spencer, 2021) and check other family members for signs of thrush. Treat pets if they should have symptoms of a fungal infection (Wilson-Clay and Hoover. 2022).
• Consider treating for a bacterial infection if symptoms persist (NICE, 2022). Staph infections are associated with cracked nipples and may be present at the same time as thrush (BFN, 2020).
• Prolonged treatment is not appropriate (Douglas, Vol 18: 1–29 2022).

Places with the latest guidance on medications for thrush treatments to discuss with a mother’s doctor include:

#1 National Institute for Health and Care Excellence (NICE)

NICE guidelines 2022 recommend topical miconazole 2% (an anti fungal medication) and hydrocortisone 1% (a steroid medication) if there is severe inflammation.²⁹

#2 International Breastfeeding Centre (Dr Jack Newman)

Jack Newman, a Canadian paediatrician, recommends a similar combination treatment in his Candida protocol below. Dr Newman uses All-Purpose Nipple Ointment (a compounded topical ointment with antibiotic (mupirocin 2% ointment), antifungal (miconazole powder ) and anti-inflammatory (Betamethasone 0.1% ointment)) ingredients.

Treatment for babies and children

For suggested treatment of oral thrush in babies and children from birth to 15 yrs, refer to Treatment of Oral Candida in Children (NICE, revised 2023). Pharmacist Wendy Jones discusses oral thrush treatments for babies in her 2018 discussion video: Breastfeeding and Thrush (jump to 14 minutes 56 seconds).

Cautions on fluconazole

The prescription antifungal drug fluconazole is sometimes recommended for the mother when her symptoms persist despite topical treatments. The amount of fluconazole reaching the baby via breast milk alone, would be insufficient to treat the baby (Wambach and Spencer, 2021) and in certain persistent cases, fluconazole could be prescribed for both mother and baby (Wambach and Spencer, 2020, p 293). However, a number of concerns are to be noted:

• Accumulating levels. Pharmacist Wendy Jones cautions that fluconazole has a long half life (88 hours) in babies under six weeks of age and daily treatment of the mother could accumulate to undesirable levels in the younger baby and fluconazole is not given to babies under six weeks of age for this reason.³⁰ NICE guidelines What are the contraindications and cautions for oral fluconazole?  reiterate that high or repeated doses of fluconazole should not be given to breastfeeding women.
• Fluconazole and vasospasm. Fluconazole can also be associated with worsening vasospasm symptoms. The Goldfarb Breastfeeding Clinic explains:

Nipple vasospasm may sometimes feel like a thrush infection of the nipple or breast. If you are prescribed Fluconazole/Diflucan for thrush, but your real problem is nipple vasospasm, this treatment may make your vasospasm worse.

For more information about fluconazole during lactation see Lactmed, Halesmeds.com [paywall] and e-Lactancia and discuss treatment options with your health care provider.

Non medical treatment options

• Check the latch. If breastfeeding is painful this can be a cause of sore nipples/nipple thrush.
• Keep nipples dry. Wambach and Spencer recommend air drying nipples and if possible expose them to the sun for a few minutes twice a day, change breast pads often/as soon as they become wet, and wear 100% cotton bras and underwear that can be washed in hot water to kill spores—see next point (Wambach and Spencer, 2021).
• Use hot washes for washing underwear and towels to kill fungal spores (Wambach and Spencer 2021). As C. albicans can survive at temperatures below 50ºC wash laundry at 50ºC or above to prevent possible reinfection from yeast lurking in clothes. Ironing clothes with a hot iron will also kill Candida. ³¹
• Wash hands well after nappy changes (Wilson-Clay and Hoover. 2022. p67). Ensure any family members with a fungal infection get this treated.(Wilson-Clay and Hoover. 2022. p67)
• Wash and sterilise nipple shields, dummies, teats, and toys that are put in baby’s mouth, replace toothbrushes regularly along with breast pump parts, bras and breast pads (Wambach and Spencer, 2021).
• Eat healthily. Avoid sugary food and drinks, grains (including wheat products such as bread, cake, biscuits and cereals) artificial sweeteners, caffeine, alcohol, processed foods and dairy products.  There are lots of suggestions for antifungal foods to boost your immune system online.
• Probiotic bacteria such as Lactobacillus acidophilus may help reestablish a normal flora ³² so that mother will be resistant to infection. Some brands of natural yoghurt contain probiotics and Wambach and Spencer discuss taking acidophilus daily (found at health food stores) and for two weeks beyond the disappearance of symptoms (Wambach and Spencer, 2021). See Mastitis Symptoms and Treatment for more information on probiotics.
• Virgin coconut oil. A natural treatment that has helped some mothers is topical virgin coconut oil on the nipples. Virgin coconut oil has antibacterial, antifungal, anti-inflammatory and pain relieving properties.^3334353637
• Soaking or bathing in diluted solutions of baking soda or vinegar are said to be traditional cures for mild topical fungal infections (Wilson-Clay and Hoover. 2022. p66).

Persistent thrush

Fungal infections can be persistent, especially during hot and humid weather and may take several weeks to clear. Resistant infections may resolve with prescription treatment (Wilson-Clay and Hoover. 2022) unless it is not thrush after all.

If thrush doesn't resolve with treatment, perhaps it isn't thrush!Click To Tweet

Persistent thrush, NOT thrush?

If the medications suggested in the above protocols—or alternatives recommended by your health professional—do not work, consider that the cause of your sore nipples may not be thrush after all.

Can I store breast milk during a thrush episode?

Although freezing Candida may not kill yeast, there isn’t any evidence to suggest breast milk stored during a thrush outbreak could cause reinfection later.³⁸ The Academy of Breastfeeding Medicine’s protocol says:

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.

If parents are still concerned about possible reinfection, they could heat any milk stored during the infection period to temperatures that will kill yeast (Mohrbacher 2020). Yeast will be killed by pasteurisation (62.5ºC or 144.5ºF for 30 minutes) (Wambach and Spencer, 2020; Mohrbacher, 2020) but also within minutes at temperatures above 50ºC or 122ºF.³⁹⁴⁰

Summary

Thrush is a fungal infection that, under certain conditions, is thought to cause painful sore nipples in breastfeeding mothers. The symptoms are very similar to those caused by a poor latch, nipple vasospasm, nipple eczema, dermatitis or a bacterial infection of the nipple making accurate diagnosis difficult. Treatment protocols include careful hygiene, dietary changes, natural remedies, topical antifungal creams and oral 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.