I’m Breastfeeding and I Think I Have Thrush!

Oral Thrush. Photo by James Heilmen, MD.

What is thrush?

Thrush can be defined as a parasitic overgrowth of organisms that are considered normal body flora, such as Candida albicans. The most common cause of thrush is C. albicans, but other yeasts in the genus Candidas may also contribute to the symptoms of thrush. The normal body locations that harbor yeast tend to be places that are moist and sheltered enough to prevent sun exposure. Candida is found in the vagina, in the oral cavity and in the intestinal tract in great numbers, it may also occur on the skin of the body in folds or creases. Unfortunately it may also like to live in cloth diapers, bedding, or in material that touches an infected area of skin.

In most cases a person’s relationship with their normal flora is benign (harmless), during administration of antibiotics or systemic corticosteriods an overgrowth of yeast may be seen. The normal bacteria and flora of the body work together to keep harmful bacteria and yeasts from taking hold in the tissues of the body. They do this by preventing any uncolonized space for intruders to grow on.

Thrush is common after a course of antibiotics (the resulting inhibition of both good/bad bacteria allows the yeast organisms such as candida to grow unimpeded). The balance that is typically struck between helpful bacteria and Candida is disrupted during antibiotic use, where the unusual absence of bacteria leaves room for more development by the flora. As a preventitive measure, a mother might consult her health care provider about the use of a probiotic supplement in her diet in conjunction with her prescribed antibiotic. In some adults the long term use of corticosteriods for inflammation or asthma may suppress the immune system enough to prevent an adequate response to candida overgrowth. Mothers who are diabetic or HIV positive may also be at greater risk for thrush.

Serious cases of thrush may require antifungal medications for both the baby and the mother at the same time (so no cross transference happens).  Treating just the baby or just the mother for symptoms of thrush fails to account for the close and repeated contact between the nursing baby’s mouth and the mother’s breast. In situations when the mother is having repeated thrush infections, a consultation with her health care provider is recommended so they can review her iron levels, immune status, diet, and a culture of her nipple may be done to ascertain what type fungal infection she carrying. In some cases C. albicans may develop a resistance to particular antifungals and other methods or medications must be tried. In the last few years it appears that thrush is more resistant to Diflucan ( a medication used to treat thrush) and I see more and more women needing two full courses of the medication.

If a mother has been under a lot stress, her immune system function may be low and it is possible to see thrush occurring in a population of women without prior use of antibiotics or medical issues. Lack of sleep, worries about infant health or other stress inducing parenting behaviors can all contribute to a weakened immune system. Higher levels of the stress hormone cortisol can produce a mother who is more vulnerable to illness or candida overgrowth.

If a mother has a baby who is teething, or who has recently bitten an area on the nipple, or maybe she is just getting started and she has cracked nipples- the mother may have a break in the skin that becomes either infected with bacteria or C. albicans. With acute symtoms of fever and pain, a visit to her health care provider will help rule out mastitis, which presents with a high fever and pain in the breast. Thrush typically does not produce a fever, but if it effects specific places in the body it can result in a fever. For oral and breast thrush, a fever is not usually present.

If the mother has a compromised immune system due to HIV status, other medical issues, or medicines, she should consult her health care provider about appropriate measures and medications to treat thrush.

What are some of the maternal symptoms of thrush?

  • Pain that occurs during nursing, and continues after the feeding
  • Sharp stabbing pain in the breast, a feeling of “broken glass”
  • Burning and itching of the nipple and areola
  • A rash that appears with small raised bumps on the nipple
  • A glassy or shiny look to the nipple, it may appear iridescent like mother of pearl
  • The nipple may appear red or pink, the skin may be flaky
  • Mom may have a concurrent vaginal yeast infection, or thrush under the breast
  • The pain may radiate deep in the mother’s breast
  • Sore or cracked nipples that do not resolve with effective latch and positioning
  • Recurrent breast infections and plugged ducts

What are the infant symptoms of oral thrush?

  • A thick white cottage cheese like coating may appear on a baby’s tongue, and he may have white patches in his mouth that won’t wipe away. (View the photo on the top of this article.) If the tongue is scraped and the white patches uncover to show inflamed red skin it’s time to contact your HCP! Regular milk tongue can be wiped off, thrush cannot.
  • Baby may have some trouble with nursing, feel uncomfortable nursing, or the baby may refuse the breast or act fussy during/after nursing
  • Baby may have a red bumpy diaper rash with/without pustules, or scalded red looking buttocks
  • The baby may have no sign of thrush inside the mouth or on the body, but this does not rule out thrush if the mother is diagnosed with it; the baby may be asymptomatic. Careful assessment by a qualified healthcare provider will ascertain whether treatment is advisable

How do I get rid of  thrush?

  • Seek medical treatment and use all of your prescribed medication to avoid breeding an organism that is more tolerant of the medication. Consider treatment for both your baby and yourself, to avoid passing the infection back and forth between baby and mom.
  • Nystatin is commonly prescribed for thrush despite evidence that oral diflucan in a pediatric dose may be more successful at treating it, (Groins et al., 2002) showed evidence that nystatin was not as effective as Fluconazole. According to a study in 2011 Nystatin and Fluconazole were both effective antifungals, but fluconazole was more effective for treating invasive fungal infections. If the mother is treating a thrush infection for the first time around with Nystatin, it may still be effective, but if a second round of antifungals are needed, it may be a good choice to investigate another drug option.
  • Always talk to your health care provider and/or IBCLC before using any over the counter medication or home remedy for thrush.
  • Some strains of Candida are developing resistance to treatment and if symptoms continue without getting better after 2-3 days of treatment, a mother would be well advised to seek reevaluation by a skilled healthcare provider. *Many mothers report that their symptoms worsen during the first 1-2 days after treatment before getting better.
  • Many mothers find that taking probiotics while being treated for thrush supports the use of medication and possibly speeds the elimination of thrush infection. I’ve noted that there is a specific type (humorously named Raw Vaginal Probiotic) that is particularly helpful in restoring correct flora in the body.
  • Some mothers find that virgin coconut oil feels soothing on the nipples. It naturally contains caprylic acid, which has antifungal properties, however the empiric treatment for nipples is APNO cream (all purpose nipple ointment) that is compounded by a local pharmacist. You will need a prescription for it. Some Doctors will give you a way to make it over the counter yourself, but please ask for directions to do that. The medications in the ointment are compatable with breastfeeding providing you use as directed. Typically you put on about a 1/2 pea sized amount after each feed. You will usually feel better within about 6 hours.
  • Thrush enjoys moist areas of the body, and can be spread through casual contact with infected areas or sexual contact between partners. If thrush is reoccurring despite the treatment of a mother and baby pair, the mother’s sexual partner should be encouraged to be evaluated as a carrier of infection.
  • If you are using cloth diapers, you can use a combination of soap and antifungals to get rid of the yeast. Sunlight is very good at killing C. albicans, so consider line drying your cloth diapers if you can. Some research has been done on the effectiveness of natural antimicrobials like tea tree oil in the treatment of fungal infections. Most commonly, it is suggested to use the citrus derived grapefruit seed extract as it has been found to help eliminate Candida. Consult your diaper manufacturer to see if it would be safe to wash your diapers with a few drops of either of these essential oils.
  • Dedicate the same time you spend on cloth diapers to your nursing bras. They should be changed daily and washed in hot water, preferably dried in the sun. Consider going without a bra as much as possible, allowing the skin to “breathe”. Change nursing pads frequently, and keep your nipples as dry as possible. Specific care of clothes and everything that touches your breasts, your baby’s mouth, or even your baby’s bottom will help prevent colonization of Candida.
  • Boil all bottle nipples, pacifiers, and nipple shields for 20 minutes after each exposure to the baby’s mouth to reduce the colonization of Candida. If possible, replace these weekly until the infection is resolved. You could also use a steam sterilizer bag to reduce the time of the plastic being hot.
  • Eat well, including a variety of nutritious foods in your diet. Vitamin and mineral deficiencies can contribute to predisposing people to Candida infections.
  • Use good hygiene, including washing hands with non-antibacterial soaps after changing a diaper, using the restroom, or touching the breast.  Use disposable towels to dry hands, or thoroughly sanitize hand and bath towels after use. Shower or bathe daily.
  • Consider rinsing the nipples after feeding or expressing. You can use plain water, or talk to your health care provider or IBCLC about using a rinse made of 1 part vinegar to 4 parts water (1:4).It can help change the pH (acid level) of the skin, making it a less friendly environment for yeast to grow.
  • Wear cotton underwear, and avoid non-breathable clothes. Your skin will stay dryer with natural fibers.
  • Kill yeast spores on any washable materials in your home. Yeast Infections and the Breastfeeding Family by Karen Zeretzke, IBCLC offers a comprehensive list of practical ways mothers can reduce Candida in the home and prevent reinfection, as well as a variety of comfort measures for mom and baby. *Please note that this is an older resource, and some of the information about how Candida infection affect mothers, and how it should be treated, has been updated or changed due to new evidence. The practical suggestions offered are still invaluable.
  • If all that fails to treat the Thrush you can consider the use of gentian violet. It is a common mistake to assume that the dye is a more natural way to address thrush. It’s not. Please make sure to dilute the dye if it is at 2% strength.
  • Regarding Gentian Violet according to Dr. Jack Newman:“We believe that gentian violet (combined with “all purpose nipple ointment”, see the information sheet Candida Protocol) is a good treatment of nipple soreness due to Candida albicans for the breastfeeding mother. This is because it often works even when used alone (though we don’t recommend this, see first paragraph), and relief is rapid. It is messy, and will stain clothing (actually, it will usually wash out eventually or may be removed from clothing with rubbing alcohol), but not skin. The baby’s lips will turn purple, but the purple will disappear after a few days. Gentian violet is available without prescription but is not available at all pharmacies. Call around before going out to get it. If you are in the US: gentian violet seems to be sold commonly as a 2% solution rather than a 1% solution. This is too strong a concentration and probably accounts for the mouth ulcers that some babies get after being treated with it. The pharmacist should dilute it for you. It’s easy to do on your own: just add an equal amount of water to the gentian violet 2% and you have gentian violet 1%.
    1. About 10 ml (two teaspoons) of gentian violet is more than enough for an entire treatment.
    2. 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.
    3. Your baby will be less purple if, before you apply gentian violet, you rub some olive oil into the baby’s cheeks and around his mouth.
    4. Dip a clean ear swab (Q-tip) into the gentian violet.
    5. Paint one of your nipples and the areola and let dry for a few seconds.
    6. Put the baby to the breast. In this way, both the baby’s mouth and your nipple are treated.
    7. When baby is finished on that side, touch up the gentian violet on the nipple if necessary, place a breast pad over top, and cover up that side.
    8. Repeat for the other side
    9. 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 the ear swab and the gentian violet. In this way, the treatment is finished in one go.
    10. A cotton pad can then be used to wipe the excess gentian violet from baby’s face
    11. 11. Repeat the treatment each day for at least three or four days t see if it is working and then continue for the rest of the week if it is seen to be working (see the Candida Protocol information sheet for how long to use gentian violet).
    12. There is often some relief within hours of the first treatment, and the pain is usually gone or virtually gone by the third day. If it is not, it is unlikely that Candida was the problem, though it seems Candida albicans is starting to show some resistance to gentian violet, as it already has to other antifungal agents. Of course, there may be more than one cause of nipple pain, but after three days the contribution to your pain caused by Candida albicans should be gone. However, if your pain is virtually gone after three or four days, but not completely, you can use gentian violet a few more days if necessary.”

Is it thrush or something else?

A few other conditions can result in breast pain, such as a poor latch, vasospasms, dermititis, or bacterial infection. A study on breast pain (Thomassen 1998) spoke on deep breast pain being more likely the result of bacterial infection- best treated with antibiotic medication. Occasionally the symptoms of breast infection, mimic the symptoms of thrush. Making matters more complex, a mother may have both a staphylococcal infection (the most common bacterial infection found on the nipple) as well as a thrush infection.

Topical infections of the nipple, called comorbid infections (bacterial and fungal combined) have been identified. If a mother has early tissue break down from nursing trauma or fungal infection, bacteria and/or fungus may find entry through cracked or damaged skin. Seeking medical treatment and consulting an IBCLC will help a mother find the right tools to heal her first line of defense: her skin. Maintaining healthy intact skin is always the very best way to avoid disease or infection.

Storing milk during thrush outbreak

Milk expressed during a thrush infection can be fed to your baby immediately while you are both being treated. It is best not to freeze or store this milk for later use but new evidence says that the likelihood of reinfection from stored milk is very low. Please see milk storage and handling guidelines for more information.

 Sources:

Dugdale D. III, Vyas J. Zieve D. “Thrush“. A.D.A.M. Medical Encyclopedia. Division of General Medicine, Department of Medicine, University of Washington School of Medicine; and , Harvard Medical School, Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital. Also reviewed A.D.A.M., Inc. (Aug 2011)

Aydemir C et al., “Randomised controlled trial of prophylactic fluconazole versus nystatinfor the prevention of fungal colonisation and invasive fungal infection in very low birth weight infants.”  Arch Dis Child Fetal Neonatal Ed. 2011 May;96(3):F164-8. Epub 2010 Jul 21.  U. Neonatal Intensive Care Unit, Zekai Tahir Burak Maternity Hospital, Samanpazari, Ankara, Turkey.

Niimi M, Firth NA, Cannon RD. “Antifungal drug resistance of oral fungi.” Odontology. 2010 Feb;98(1):15-25. Epub 2010 Feb 16.  Department of Oral Sciences, School of Dentistry, University of Otago, New Zealand.

Goins RA, Ascher D, Waecker N, Arnold J, Moorefield E. “Comparison of fluconazole and nystatin oral suspensions for treatment of oral candidiasis in infants.”  Pediatr Infect Disease Journal. (Decemeber, 2002) 21(12):1165-7. Wilford Hall USAF Medical Center, San Antonio, TX, USA.

Thomassen P, Johansson VA, Wassberg C, Petrini B. “Breast-feeding, pain and infection.” Gynecol Obstet Invest. (August 1998) 46(2):73-4.  Department of Obstetrics and Gynecology, Stockholm Söder Hospital, Karolinska Institutet, Stockholm, Sweden.

Ignacio C, Thai D. “Comparative analysis of antifungal activity of natural remedies versus miconazole nitrate salt against candida albicans.” Biological Sciences Dept, College of Science and Mathematics, California Polytechnic State University, San Luis Obispo. (2005)

Heggers, J. P. et al., “The Effectiveness of Processed Grapefruit-Seed Extract as an Antibacterial Agent: II. Mechanism of Action and In Vitro Toxicity.” Journal of Alternative and Complementary Medicine, (2002) Vol. 8: No. 3, 333-340

O’Sullivan, G.C. “Probiotics”. British Journal of Surgery (2001) 88, 161-162. Department of Surgery, Mercy Hospital, and Department of Surgery and Cork Cancer Research Centre, University College Cork, National University of Ireland, Cork, Ireland

Wilson-Clay B, Hoover K. The Breastfeeding Atlas. 4th edition. Manchaca, Texas: LactNews Press, 2008.

Riordan J, Wambach K. Breastfeeding and Human Lactation. 4th edition. Sudbury, Massachusetts: Jones and Barlett Publishers. 2010.

(c) 2015 Serena Meyer RN, IBCLC. All Rights Reserved
Updated 3/2017

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