Thrush is the common name for a yeast infection caused by an overgrowth of Candida albican (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.123
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. Some resources say pain from a thrush infection begins after every breastfeed and lasts for about an hour.4 Conversely a Thrush statement from the National Infant Feeding Network (NIFN) says pain may be felt throughout a breastfeed and may worsen as the feed progresses.
- Thrush will usually affect both nipples because the baby is thought to transfer the infection from one nipple to the other.
- 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. White patches similar to oral thrush or tiny blisters are also said to be possible.56
- There may be a loss of colour in the nipple or areola.7
- Pain may be felt deep in the breast, sometimes as a stabbing or burning pain and sometimes in the back and shoulders.8 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.910
- Sudden onset of symptoms. Thrush is more likely if pain continues even after latching and positioning help from a breastfeeding specialist, or if thrush symptoms come on suddenly after pain free breastfeeding (NIFN, 2014).
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.11
- 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.1213
- 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.14 Some researchers call this condition subacute mastitis and while the idea has gained support in some circles1516 others say the theory is not supported by evidence.1718
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.19
- If mother or baby have another illness, low resistance to infection or have received antibiotics or corticosteroids.20 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 21 as can taking oral contraceptives22.
- 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.23
- 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).
It is important to rule out other reasons for painful nipples as there is a growing concern that thrush is over diagnosed.25 See Causes of Sore Nipples and Why Does Breastfeeding Hurt? on this website for more information and The Breastfeeding Network (a breastfeeding charity in the United Kingdom) has a web page to help with diagnosis; Differential Diagnosis of Nipple Pain. 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
The Breastfeeding Network26 recommend swabbing nipples and babies’ mouths to check whether an infection is bacterial (Staphylococcus aureus or staph) or fungal (Candida) before treatments are prescribed. This involves taking samples from the surface of the nipple to see what grows in the laboratory. Conversely, older guidance on thrush from The National Infant Feeding Network says that swabs are not very accurate and not usually required unless a bacterial infection is suspected, a treatment isn’t working or if systemic treatment—eg a prescription medicine rather than a topical cream—is considered. At least 50% of breastfeeding women have staph on their nipples yet many don’t have any symptoms (NIFN, 2014).
Some references state it is hard to identify Candida in human milk because of lactoferrin (NIFN, 2014). Lactoferrin is a glycoprotein in breast milk that carries iron. It prevents the growth of many bacteria and is also antiviral, antifungal and prevents inflammatory reactivity. However others maintain Candida species can be easily isolated in the laboratory when they are present in milk (Jiménez et al, 2017) and that milk does not seem to inhibit Candida growth (Hale, 2009).
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.2728 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.29 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. 2017).
- 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 The Breastfeeding Network
The Breastfeeding Network is a breastfeeding charity in UK with guidelines for medicating thrush:
Miconazole cream applied to your nipples after every feed – sparingly and without washing off before the next feed
Miconazole oral gel applied gently to your baby’s mouth 4 times a day a small amount at a time
If symptoms persist you may need fluconazole 150-400mg as a loading dose followed by 100-200mg daily for at least ten days. This is rarely necessary if your baby is less than 6 weeks old and could cause vomiting and stomach pains.
More detailed information can be found at Thrush (of the breast/nipple) and Breastfeeding.
#2 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.30
#3 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, 2022). Pharmacist Wendy Jones discusses oral thrush treatments for babies in her 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; Breastfeeding Network, 2020). 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.3132 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.
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. 33
- Wash hands well after nappy changes (BFN, 2020) Washing hands for at least 15 seconds helps to prevent fungal cross-infection. Ensure any family members with a fungal infection get this treated.34
- 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. Antifungal foods to boost your immune system include garlic, cinnamon, vegetables and leafy greens.35
- Probiotic bacteria such as Lactobacillus acidophilus may help reestablish a normal flora 36 so that mother will be resistant to infection however more research is needed. Some brands of natural yoghurt contain probiotics (Winder, 2022) 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 worked for some mothers is topical virgin coconut oil on the nipples (Winder, 2022). Virgin coconut oil has antibacterial, antifungal, anti-inflammatory and analgesic properties.373839
- Soaking or bathing in diluted solutions of baking soda or vinegar are said to be traditional cures for mild topical fungal infections.40
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. 2017) 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.41 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.4243
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.