Candida and Breast Feeding
| Candida (also called
yeast, or thrush) is a fungus that occurs naturally in the mucous
membranes and on the skin. Use of antibiotics promotes the
overgrowth of yeast by killing off the ‘good’ bacteria that
normally keep the yeast from multiplying too quickly. During
pregnancy, yeast infections are more common because high levels of
estrogen lead to elevated levels of sugar, and yeast feeds on
sugar.
If you or your baby have recently been on antibiotics, if you
have had a vaginal yeast infection during the last several months
(or anytime during pregnancy), or if your nipples are cracked,
then you and your baby are at risk for developing a yeast
infection. Other factors that make you more susceptible to yeast
include use of steroids or hormonal contraceptives, or chronic
illness such as diabetes or anemia.
 Symptoms
of a yeast infection in your baby include creamy white spots or
patches on the mucous membranes inside the mouth (gums, cheeks, or
tongue). The spots may look pearly, and may be surrounded by
redness. If you gently scrape the spot, it may be reddish
underneath (unlike a coating of milk on the tongue). Sometimes the
inside of the lips or the saliva may have a ‘mother of pearl’
appearance. The baby may be fussy and gassy, and sucking may be
uncomfortable for him. He may pull off the breast, or may refuse
to nurse at all. It is also possible for him to have an
overgrowth of yeast but have no visible symptoms.
Yeast can also cause a rash in the baby’s diaper area. The rash
is red or bright pink, and may be scaly. The affected area may
contain small raised red spots or sore looking pustules. The rash
may be localized (the area looks like it has been dipped in
scalding water) or it may be diffuse and lacy, covering a large
area. Use of standard diaper rash medications like petroleum jelly
or Desitin does not clear up a rash caused by yeast, and may
actually make it worse, because yeast feeds on the oils found in
greasy ointments, and also on the starch found in baby powders.
 Symptoms
in the mother include severe stinging, burning pain, which may be
on the surface of the nipples, or may be felt deep inside the
breast. Pain often continues throughout the feeding and in between
feedings – especially immediately after. (Nipple pain caused by
incorrect positioning and latch on rarely hurts except when the
baby is nursing). Sometimes sharp, shooting pain radiates from the
nipple into the breast or into the back or arm. Nipples are
sensitive to light touch, so it may hurt to have clothes rubbing
against them, and it may be very painful to take a shower and have
the hot water spray touch the breast. Mothers describe the pain as
‘liquid fire’, ‘hot needles’, ‘razor blades’, ‘a piece of glass
stuck in my nipple’, etc. I’ve heard many mothers say that they
would rather go through labor again than have yeast on their
nipples or in their milk ducts, which gives you an idea of just
how painful this condition is.
The nipples may look puffy, scaly, flaky, weepy, or have tiny
blisters. They may be itchy. The color is often a deep pink. The
nipples may also look completely normal, but be terribly painful
(just as the baby’s mouth may be infected, but not have white
patches). Generally, the nipples don’t “look as bad as they feel”,
so there is often a tendency to underestimate the severity of the
problem based simply on visual examination of the nipples. If you
have yeast on your nipples, or if your baby has it in his mouth,
your milk supply will often decrease. Pain inhibits the let-down
reflex, and babies with yeast often do not nurse as efficiently as
they do when their mouths are not sore. Yeast infections may also
lead to plugged duct and mastitis.
Once the infection is cleared up, you should be able to build
your supply up again quickly. It is important to note that while
yeast on baby’s bottoms or in their mouths may be tender and
irritated, it does not seem to cause extreme pain like it does on
the mother’s nipples or in her milk ducts.
Mothers may also have a vaginal yeast infection (itching,
cottage cheesy discharge), sores at the corners of the mouth
(angular chelitis), swelling or tenderness of the tissue around
the toes or fingernails (candida paronychia), or a rash in the
moist areas of the body such as under the arms or in the groin (intertriginous
candiasis). Athlete’s foot is also a type of fungal infection.
Because yeast grows in warm, moist areas, it can be traded back
and forth between a mother and her nursing baby. Both mother
and baby must be treated together* in order to clear up the
infection. It is important to do this even if one of you does not
have symptoms. For example, your baby may have the white
patches in his mouth, but your nipples may not be sore – or, your
nipples may be sore but your baby’s mouth and diaper area may be
clear. If you treat one of you and not the other, you may clear up
the infection in one place only to have it reoccur a week or two
later in another. Occasionally, other family members (especially
your sexual partner)* may need to be treated at the same time.
*Treatments will vary
The diagnosis of yeast is most often made based on the
symptoms, and not on a definitive culture. It is sometimes
possible to culture for yeast from the surface of the nipple, or
from the milk, but the tests are not reliable and most often give
a false negative result.
If you or your baby have any of the symptoms described above,
(especially if you have been on antibiotics, or if your nipples
suddenly become sore after the first two weeks postpartum), you
may have a yeast infection. If you believe you may have a yeast
infection, here are some suggestions on how to treat it (always
consult your health care provider before beginning any treatment).
It is important to begin treatment only after ruling out other
possible causes of severe nipple soreness, such as improper latch
on and positioning, mastitis, eczema, herpes, ringworm, and
psoriasis.
If you have yeast on your nipples:
- Wash hands often (before and after nursing, after using the
bathroom, and before or after changing the baby’s diaper). Use
hot, soapy water and paper towels.
- Nurse frequently for shorter amounts of time. Start nursing
on the least sore side. Numb the nipple with ice wrapped in a
washcloth before beginning to nurse. Take Advil (unless you are
allergic to it) around the clock. If it becomes too painful to
nurse, you may want to pump your milk temporarily and feed it to
your baby by cup or bottle until the pain lessens.
- Try drinking green tea 3 or 4 times a day. It may help
cleanse your system of excess yeast, and all evidence points to
its benefits, so it certainly won’t hurt to try.
- Decrease consumption of foods containing high amounts of
sugar and/or yeast (such as beer, wine, sodas, bread, desserts,
etc.).
- After nursing, rinse the nipples with a solution of one cup
of water plus one TBSP of vinegar. Air dry well. Apply HCL
Colloidal Silver via a spray bottle or salve.).
Although Nystatin has been the most popular prescription
antifungal used for many years, it is no longer the first choice
of treatment due to resistant strains of yeast that have
developed.
- If pain is severe, apply the salve sparingly after each
feeding (6-8 times per day) for 24 hours. Then apply 3-4 times
daily. The salve is absorbed quickly, and does not have to be
removed before baby nurses. If you feel that some ointment
remains on your nipple, you may want to gently press a damp warm
washcloth on the nipple and areola before nursing. Avoid wearing
nursing pads, but if you have to use them be sure to change them
at every feeding. Keep the nipples as dry as possible.
After 24-48 hours, you should feel some improvement.
(Sometimes you can tell a difference after just one
application.) In some cases, symptoms temporarily get worse
before they get better - so be sure to continue the treatment
for at least the full 48 hours.
- Another effective antifungal treatment that is inexpensive
and available without a prescription is gentian violet. It can
be used on your nipples and in the baby’s mouth or diaper area.
Be sure to consult your health care provider before beginning
treatment, because it is strong medicine and be dangerous if
used improperly or too long. It is very messy (it looks like
purple ink and stains anything it touches, including baby’s
mouth and lips, and clothing or bedding). It usually comes in a
one percent solution, which you may want to dilute down to a 1/2
percent solution, especially if using it in the baby’s mouth.
Apply to nipples, baby’s mouth or diaper area once or twice
daily for no more than three days. You may continue to use a
topical ointment at the same time. Apply with a cotton swab,
especially at bedtime when the baby is more likely to go for a
longer stretch without nursing. Wear old clothing, since it does
stain. If you get stains on clothing, try alcohol, bleach, or
aerosol hairspray to remove them. Stains on the skin will
usually fade in a few days. Applying a thin coating of lanolin
to the baby’s lips may minimize staining on his face when
gentian violet is applied to his mouth or your nipples.
- Expressed milk should be fed to the baby while you are both
being treated for yeast, and not saved for later use, since
refrigerating and freezing the milk does not kill all the yeast.
- If chronic or extreme candida and yeast problems are present
or suspect, use our sledgehammer
Candida Elimination Kit
For a vaginal yeast infection, ask your doctor which medication
he suggests. Non-prescription medications like Gyne-Lotramin and
Monistat 7 are often effective, or your doctor may prescribe a
medication like Terazol 7 (tercoconazole). Rinsing the vaginal
area with a vinegar and water solution after using the toilet may
be helpful. Expose the affected area to air as much as possible by
wearing cotton (or no) panties and avoiding tight clothes like
pantyhose and swimsuits. A single dose of Diflucan oral medication
(fluconazole) is also often used to treat vaginal yeast
infections. It is available by prescription.
For yeast in the baby’s diaper area, ask your doctor which
medication he suggests. Often the same antifungal ointment used on
your nipples, whether prescription or over the counter, can be
effective in clearing up the baby’s bottom. If the area is
extremely inflamed, ask your doctor about an ointment containing
cortisone (such as Mycolog or Lotrisone). If the rash does not
seem to be responding to antifungal cream within a few days, ask
your doctor about using a 1/2 percent solution of gentian violet
in addition to the cream once or twice a day for a few days.
After each diaper change, wash the baby’s bottom with warm
soapy water. Rinse and dry well. Avoid using commercial baby wipes
(they keep the skin moist, and may contain irritating chemicals).
Expose the baby’s bottom to air as much as possible.
For yeast (thrush) in the baby’s mouth, your doctor will
probably prescribe oral nystatin drops. After each nursing session
(or however often your doctor suggests) rinse the baby’s mouth
with water, offer him a drink of water from a cup, or wipe the
inside of his mouth with a damp washcloth. Milk that remains in
the baby’s mouth can be a source of food for yeast. Then apply the
medication according to directions. Usually, the directions say to
use 2cc in each cheek four times a day. Since yeast multiplies so
quickly (as often as every hour), you may want to ask the doctor
if you can use 1cc for the whole mouth 8 times a day. Put the
medicine in a spoon or paper cup and use a Q-tip to swab it in the
baby’s mouth. Don’t put the dropper directly in his mouth and then
back in the bottle, to avoid contaminating the medication. Once
there are no visible signs of yeast in his mouth, ask your doctor
about cutting back to a lower dose. A complete course of treatment
usually takes several weeks. If there is no improvement in a few
days, ask your doctor about using a 1/2 percent solution of
gentian violet for a few days.
Boil any object that goes in the baby’s mouth (such as pump
parts, bottles, nipples toys, and pacifiers) for 20 minutes each
day. Add some vinegar to the boiling water. Continue using the
medication for at least 2 weeks after symptoms are gone. If
nystatin and gentian violet do not seem to be clearing up the
thrush in the baby’s mouth, ask your doctor about pediatric
Diflucan suspension. As of November 1995, it has been approved for
pediatric use in treating babies six months or older, and has an
FDA Safety Profile for newborns one day and older. The clinical
cure rate for oropharyngeal candidiasis in pediatric patients is
reported at 86% with Diflucan (2-3 mg/kg/day) as opposed to 46% of
patients treated with nystatin.
In certain cases, yeast infection on the mother’s nipples does
not respond to topical treatments. In these cases, pain is severe
and unrelieved. Pain may begin as burning or stinging on the
surface of the nipples, primarily during breastfeeding, and
progress to deep stabbing internal pain inside the milk ducts.
This type of deep, sharp pain continues throughout the day and may
be worse at night, interfering with the mother’s sleep. Pain may
radiate into the armpit or back. If topical treatments are
ineffective, you may need to talk to your doctor about the
possibility of using a systemic treatment which is taken orally,
and is available only by prescription. You may want to ask him to
prescribe a prescription painkiller as well. The systemic
treatment which seems to be most effective is Diflucan (fluconazole).
Discuss the following treatment plan with your doctor, as this is
strong medication and should be used only when topical treatment
has failed to prove effective, or when the yeast has spread into
the milk ducts.
Diflucan is often used to treat vaginal yeast. For treatment of
a vaginal yeast infection, 150 mg in a single dose is the current
FDA recommendation. Unfortunately, this therapy is not sufficient
for ductal candidiasis in lactating women. For the treatment of
systemic (ductal) yeast, 400 mg STAT (loading dose on the first
day) followed by 150-200 mg daily for periods of up to four weeks
is generally recommended by many clinicians.
Of antifungal medications, Diflucan is well tolerated. Adverse
effects (such as vomiting, diarrhea, stomach cramps, and rashes)
have only been reported in 5-30% of patients, and only 1-2% of
patients had side effects severe enough to require them to
discontinue the medication. In rare cases, adverse hepatic (liver)
effects have been reported, but usually in connection with high
doses of the medicine over long periods of time in severely ill
patients with immune-compromising diseases such as cancer or AIDS.
Diflucan is very effective, but also very expensive (over
$10.00 per tablet). Check with your insurance carrier for coverage
information. I don’t know of any cases of liver problems in
healthy nursing mothers at the doses recommended in this article.
Be persistent in treating yeast. Once you have it, it tends to
stick around and not go away by itself, because it thrives on
moisture and sugar, and nipples and baby’s mouths provide the
perfect environment for it to grow. Some women seem to be more
prone to developing yeast infections than others. Yeast infections
during lactation can be very painful, and it is easy to become
discouraged and even consider weaning your baby. Try to remember
that yeast is a medical condition that, with consistent treatment
of both mother and baby, can be cleared up completely, and
hopefully will not reoccur. It is also important to note that if
you have yeast on your nipples or in your milk ducts, weaning your
baby will not necessarily make it go away and you will still need
to treat the problem.
Be sure to remain in close contact with your health care
provider during treatment, because yeast presents a variety of
symptoms an requires continuing reassessment and adjustment of
treatments to provide optimal relief and effect a cure in the
shortest period of time. Try not to become discouraged.
Resources:
- Amir L, Hoover KL, Mulford CA:Candidiasis and Breastfeeding
(Unit 18). Lactation Consultant Series. New York: Avery
Publishing Group, Inc. 1995
- Bodey, Andriole V., 6pp in: Systemic Antifungal Therapy.
Scientific Therapeutics Information, 1994
- Briggs GG, Freeman RK, Yaffe SJ: Drugs in Pregnancy and
Lactation (4th edition). Philadelphia: Williams and Wilkins,
370-371, 1994
- Butler, R, Koch K, Treating Thrush in the Breastfeeding
Family. La Leche League Int., 1999
- Crook, William : The Yeast Connection and the Woman.
Jackson, Tennessee:Professional Books, Inc.1997
- Force, RW. Fluconazole Concentrations in Breastmilk.
Pediatric Infectious Disease 14 (3): 325-336, 1995
- Hale, Thomas: Clinical Therapy in Breastfeeding Patients,
1st edition, Pharmasoft Medical Publishing.1999
- Hale, Thomas: Medications and Mother’s Milk, 8th edition.
Pharmasoft Medical Publishing.1999-2000, pp.269-273
- Hancock KF, Spangler AK, Journal of Human Lactation, Vol.9,
#3, September 1994. Human Sciences Press, Inc. New York:179-180
- Huggins K, Billon SF: Twenty Cases of Persistent Sore
Nipples: Collaboration Between Lactation and Dermatologist.
Journal of Human Lactation, Vol. 9, #3, September 1994. Human
Sciences Press, Inc. New York
- Lawrence, RA: Breastfeeding: a Guide for the Medical
Profession, 4th edition. Philadelphia: CV Mosby co., 264-265,
492-494. 1992
- Paap, KC. Update on fluconazole Pharmacology Forum.
Infectious Disease in Children, pp. 19-21. April 1996.
- Pfizer, Inc. – U.S. Pharmaceuticals Group, New York, NY.
Data on file, Jan. 1996
- Riordan J, Auerbach K: Breastfeeding and Human Lactation,2nd
edition. Jones and Bartlett Publishers, 1999
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