Thrush on Nipples

Thrush is the name for a yeast infection caused by an overgrowth of a fungus, usually Candida albicans. C. albicans 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 under certain circumstances it is thought that a breastfeeding mother can get thrush on her nipples causing pain and soreness. 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 not attached to the breast (latched) correctly—causing pinching or vasospasm of the nipple. This can make diagnosis very difficult and there is some controversy over the condition.1

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.

Mother looking at baby
If pain continues even after latching and positioning help from a breastfeeding specialist, thrush is more likely to be a possibility

Symptoms of thrush

Symptoms for mother

Although there may not always be any visible symptoms to see, there are a number of symptoms that are often assumed to be a thrush infection. However, it is worth noting 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, especially after breastfeeds. For many women with thrush, breastfeeding itself can be relatively pain free with pain felt after each and every breastfeed and lasting for an hour or so.2 For others, pain may also be felt throughout a breastfeed3 and according to The National Infant Feeding Network’s Thrush handout, pain may worsen as a breastfeed progresses.
  • Thrush will usually affect both nipples because the baby transfers 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. Sometimes tiny blisters are present.4
  • There may be a loss of colour in the nipple or areola.5
  • Pain may be felt deep in the breast, sometimes as a stabbing pain and sometimes in the back and shoulders.6
  • Sudden onset of symptoms. The National Infant Feeding Network suggest that if symptoms fitting the description of thrush come on suddenly after pain free breastfeeding, or if pain continues even after latching and positioning help from a breastfeeding specialist, thrush is more likely to be a possibility (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 on the tongue alone is not necessarily thrush and can have other causes (see below). Thrush will quickly spread to lips, gums, inside the cheeks and the roof of baby’s mouth.7
  • Baby may have a sore bottom and nappy rash.
baby lying on father's hands with mouth open
A white milky coating on the tongue alone is not necessarily thrush

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. Poor attachment at the breast (a shallow latch), a bacterial infection, eczema or dermatitis can all be causes of painful sore nipples. An IBCLC lactation consultant can be a helpful partner to identify possible causes of pain related to breastfeeding.  Alternative explanations for some of the symptoms in the list above include:

  • Burning nipple pain and colour changes of the nipple can be associated with vasospasm of the nipple and Raynaud’s Syndrome.
  • Deep breast pain can be associated with poor latch and positioning—mammary constriction syndrome—and there is also research around bacterial infections as a cause of deep breast pain (see next section “Thrush or subacute mastitis?”).
  • Friction blisters and milk blisters (blebs) can be caused by poor attachment at the breast.
  • A white coating on baby’s tongue could be due to staining of the tongue by milk8 and may be more likely with poor tongue function9. Viral infections may also coat the tongue or change the appearance inside the mouth for example herpes infections.10
  • A sore bottom and nappy rash can sometimes be associated with a dietary intolerance see Milk Allergy in Babies.

Thrush or subacute mastitis?

Some researchers believe mammary candidiasis (breast thrush) lacks scientific evidence as a medical condition and bacteria are the cause of symptoms.11 Jiménez et al have identified specific strains of bacteria that can overgrow under certain conditions. They argue that these bacteria do not produce the toxins seen with Staphylococcus aureus (the bacteria most often associated with mastitis) and therefore they do not trigger the flu like symptoms and flushing of the breast of classic mastitis. However they can cause inflammation in the ductal system which narrows the ducts and this could be the cause of the characteristic shooting and burning pains often assumed to be thrush. These researchers favour calling this condition subacute mastitis.

Graves et al 12 also found Staph aureus can cause an infection of the nipples and lactiferous ducts with symptoms similar to those previously assumed to be “breast thrush”.

The Academy of Breastfeeding Medicine explains;

Subacute mastitis, or mammary dysbiosis, also may cause nipple flaking, erythema, blebs, and scabbing of the nipple and areola with associated deep breast pain. This condition has been termed “mammary candidiasis” in [the] past, but newer research is disproving the causative agent as yeast and implicating bacterial imbalance instead

Causes of thrush

The fungus Candida albicans and other Candida species generally live on our bodies without causing a problem. In warm, moist areas, such as inside a baby’s mouth or on breastfeeding nipples, it is thought to have the potential to grow to problematic proportions under certain conditions. However the precise role of Candida versus other organisms in the breast may not be straightforward 1314.

The ideal conditions thought to be risk factors for thrush overgrowth include:

  • If a mother has cracked, damaged or sore nipples. Damaged skin, generally from a poor latch, is usually the underlying cause of thrush and must be solved, alongside any medical treatments, to eradicate thrush.15
  • If mother or baby have another illness or low resistance to infection or have received antibiotics or corticosteroids.16 Antibiotics can change the balance of friendly bacteria in our bodies that normally regulate fungal overgrowth—making vaginal thrush more likely for example. Whether antibiotics have the same effect on nipple thrush is unclear.
  • If mother or a family member has an existing Candida fungal infection such as vaginal thrush, athlete’s foot, nappy rash or jock itch.17
  • 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.
  • If the mother takes oral contraceptives18
  • Using a dummy/pacifier or bottle teat especially in the early weeks after birth (these are a source of reinfection)19
  • Mother has diabetes and/or anaemia (low iron levels)20
  • Recurring blocked milk ducts (Newman, 2014).
  • If a mother is exhausted or stressed.21

Diagnosing thrush

As there are many other potential causes of sore nipples, it is important to consider all possibilities. An IBCLC lactation consultant can help rule out attachment and positioning as a cause of thrush-like symptoms and your health professional will advise which of a bacterial or fungal infection (or both) is most likely.

Over diagnosis

There is a growing concern that 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 have developed a fact sheet 22 and a diagnostic tool 23 to try to help mothers self-diagnose if they have thrush. The article Causes of Sore Nipples may also be helpful and see the Academy of Breastfeeding Medicine’s Protocol #26: Persistent Pain with Breastfeeding.

To swab or not to swab

On their website, The Breastfeeding Network recommend swabbing nipples (take samples from the surface of the nipple and see what grows in the laboratory) and babies’ mouths to check whether an infection is bacterial (Staphylococcus aureus) or fungal (Candida) before treatments are prescribed. Conversely, the guidance on thrush from The National Infant Feeding Network (NIFN) says swabs are 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 considered24.

Fungal or bacterial infection?

The NIFN thrush statement 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 lactoferrin 25. However, Jiménez et al maintain Candida species can be easily isolated in the laboratory when they are present in milk.

baby with black hair breastfeeding
Sore nipples while breastfeeding can have many causes

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 time2627. Thrush usually responds well to treatment.

  • Mothers should continue to breastfeed if they or their baby have thrush, breastfeeding can help the growth of bacteria such as Lactobacillus which can limit fungal growth (Lawrence and Lawrence, 2016).
  • Treat mother and baby at the same time to prevent recolonisation. Treat sexual partners also, use condoms to prevent cross-infection (Wambach and Spencer, 2020) and check other family members for signs of thrush. Also treat pets if they should have symptoms of a fungal infection (Wilson-Clay and Hoover. 2017).
  • Consider treatment for bacterial infection if symptoms persist alongside topical treatments (NICE, 2017). Staph infections are associated with cracked nipples and may be present at the same time as thrush (BFN, 2020).

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

#1 The National Infant Feeding Network

The National Infant Feeding Network (NIFN) has funding from the Department of Health (UK) and is supported by UNICEF UK. The NIFN statement on thrush is available to download from the UNICEF website,  and 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 National Institute for Health and Care Excellence (NICE)

NICE guidelines 2017 [accessed 20 November 2020] are very similar to #1 above; recommending topical miconazole 2% and hydrocortisone 1% if there is severe inflammation. For ductal thrush they reiterate the above dose of fluconazole depending on clinical judgement.

#3 The Breastfeeding Network

The Breastfeeding Network is a breastfeeding charity in UK.  Thrush and Breastfeeding—Information for Mothers (June 2020) written by pharmacist Wendy Jones discusses other causes of nipple pain that are mistaken for thrush, self-help measures, and treatment options for mother and baby. More detailed information is also available in their information sheet geared towards health professionals (May 2020).

  • 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.

#4 International Breastfeeding Centre (Dr Jack Newman)

Jack Newman, a Canadian paediatrician, describes slightly different treatments in his Candida protocol below. These include All-Purpose Nipple Ointment (a compounded topical ointment containing antibiotic, antifungal and anti-inflammatory treatments), Grapefruit Seed Extract and probiotics:

Treatment for babies and children

For a detailed protocol for suggested treatment of thrush in babies and children from 0 months to 12 years, refer to Treatment of Oral Candida in Children (NICE, 2017). Pharmacist Wendy Jones discusses oral thrush treatments for babies in her discussion video: Breastfeeding and Thrush (jump to 14 minutes 56 seconds).

A note on fluconazole

The prescription antifungal drug fluconazole is 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, 2020) and in certain persistent cases, fluconazole could be prescribed for both mother and baby (Wambach and Spencer, 2020, p 293; Breastfeeding Network, 2020). However, 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.2829

For further information about fluconazole use for babies see the NICE guidelines Treatment of Oral Candida in Children. And 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

  • Keep nipples dry: air dry nipples, change breast pads often/as soon as they become wet, wear 100% cotton bras and underwear. 30
  • Observe strict hygiene, wash hands well after nappy changes (BFN, 2020) Washing hands for at least 15 seconds helps to prevent fungal cross-infection.31
  • Use hot washes for washing underwear and towels to kill fungal spores (Wambach and Spencer 2020; LLLGB, 2016). 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. 32
  • Wash and sterilise nipple shields, dummies, teats, and toys that are put in baby’s mouth, replace toothbrushes regularly (LLLGB, 2016).
  • Limit excess sugar and other refined carbohydrates in mother’s diet including excess fruit, and fruit juice (LLLGB, 2016). Restrict consumption of honey, alcohol, cheese, products with wheat, and bread (Wambach and Spencer. 2020). Some mothers find foods containing yeast, dairy products or artificial sweeteners can exacerbate their symptoms (LLLGB, 2016).
  • Probiotic bacteria such as Lactobacillus acidophilus may help reestablish a normal flora 33 so that mother will be resistant to infection however more research is needed (see Mastitis Symptoms and Treatment for more information on probiotics).
  • Other supplements may be helpful see La Leche League Great Britain’s information sheet Thrush and Breastfeeding for suggested dietary supplements and doses (grapefruit seed extract, garlic, zinc and B vitamins) that some mothers have found helpful. Wambach and Spencer discuss taking acidophilus daily (found at health food stores) and for two weeks beyond the disappearance of symptoms (Wambach and Spencer, 2020)
  • Soaking or bathing in diluted solutions of baking soda or vinegar are said to be traditional cures for mild topical fungal infections.34
baby asleep in mother's arms
Thrush can be over diagnosed. If thrush doesn’t resolve with treatment, perhaps it isn’t thrush.

Persistent thrush

Fungal infections can be persistent, especially during hot and humid weather and may take several weeks to clear. Resistant infections will benefit from prescription treatment (Wilson-Clay and Hoover. 2017) unless it is not thrush after all (see below).

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. Unnecessary thrush medication can also be associated with vasospasm symptoms.

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.

Can I store breast milk during a thrush episode?

Although freezing Candida may not kill yeast, there isn’t any evidence to suggest human milk stored during a thrush outbreak could cause reinfection later.35 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 (64ºC or 144.5ºF for 30 minutes) (Wambach and Spencer, 2020; Mohrbacher, 2020) but also within minutes at temperatures above 50ºC or 122ºF.3637

Summary

Thrush is a fungal infection that, under certain conditions, is thought to develop on nipples during breastfeeding causing pain and soreness. 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. There are a number of treatment protocols for thrush including topical antifungal creams, careful hygiene, dietary changes and antifungal medications. However, if thrush doesn’t resolve with treatment, perhaps it isn’t thrush! New research offers an alternative theory for some of the symptoms of deep breast pain involving infection by certain strains of bacteria. 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.