Thrush (to indicate that within the baby’s mouth) and yeast (to indicate that on the mother’s nipples or within her breast) is a fungus that thrives on milk on the nipples, in the milk ducts, and in the baby’s mouth. Thrush and yeast can both be present in non-lactating women and men, too. The medical term for this condition is candidiasis.
Predisposing Risk Factors for Yeast Infections
All of the following have been known to increase mother’s and baby’s risks for yeast:
• Vaginal yeast infection in the mother either during pregnancy or shortly before or during time that other yeast symptoms occur. Mothers who have a history of frequent vaginal yeast infections are also more vulnerable.
• Antibiotics administered to the mother during pregnancy, during labor and delivery, or shortly before or during the time that yeast symptoms occur. Please note that antiobiotics are always administered when a cesearean section is performed or when GB Strep is diagnosed or is being treated preventatively prior to delivery. A history of long-term or frequent antibiotic use in the mother is also a predisposing factor for yeast.
• Antibiotics administered to the baby
• Long term or frequent use of steroids in either mother or baby
• Nipple trauma such as cracks. The breakdown of the skin allows for the entrance of yeast as well as bacteria. Cracking is not normal. This type of nipple trauma should be addressed quickly by a lactation consultant.
• Maternal use of oral contraceptives containing estrogen
• Allowing damp nursing pads or bras to stay up against nipple tissue for long periods of time
• Using plastic lined nursing pads which prevent good air flow to the nipple area
• Pacifier use in the baby
• Excessive consumption of dairy products, artificial sweeteners, or sweets in the mother
• Diabetes in the mother
• Anemia in the mother
Signs and Symptoms of thrush in the Nursing Mother
• intense nipple or breast pain that occurs from birth, lasts throughout the feeding, or is not improved with better latch-on and positioning
• sudden onset of nipple pain after a period of pain-free nursing
• cracked nipples
• nipples that are itchy and/or burning and that may appear pink or red, shiny, or flaky and/or have a rash and tiny blisters; nipples may also appear normal
• shooting pains in the breast during or after a feeding if the yeast has invaded the milk ducts
• nipple or breast pain with correct use of an automatic electric breastpump
• a vaginal yeast infection
Signs and Symptoms of thrush in the Baby
• diaper rash that does not respond to typical rash ointments
• creamy white patches that cannot be wiped off on the inside of the mouth, along the inside of the gums, inside of the cheeks, roof of mouth, throat, or tongue
• a shiny or “mother of pearl” look on the inside of the mouth
• breast refusal, pulling off breast, or a reluctance to nurse due to mouth soreness
• repeated clicking during nursing
• excessive gassiness due to the yeast’s invasion of the gut
• the baby may also be without visible symptoms.
How the Diagnosis of Thrush Is Made
There really isn’t a definitive way to diagnose yeast in the mother. Often it is visible in the baby’s mouth but may not always be so obvious, as in a persistent click, repeated pulling off the breast, or excessive gassiness. Diagnosis is best made after taking a thorough history of both mother and baby. If there are things in the history that predisposed the nursing couple to yeast and there are symptoms consistent with yeast it is appropriate to begin treatment. If the mother and/or baby begin to respond to yeast treatment then the diagnosis is confirmed. Treating with yeast medications, especially those that are topical, usually cannot hurt and can only help if yeast is suspected. If symptoms do not respond to treatment within 4 days, the treatment should be reevaluated. Failure to improve with aggressive treatment requires a look at possible other causes. Sometimes a bacterial infection can be present either alone or with yeast.
Treatment of Thrush
Please be advised that some doctors will not treat mother and baby simultaneously if one is free of symptoms. However, the breastfeeding literature states that this is crucial to complete healing. Not doing so increases the risk of reinfection.
Treatment in both mother and baby should continue for at least 1-2 weeks after all symptoms are gone. All of the following remedies are considered compatible with breastfeeding and do not necessitate any cessation of the nursing relationship.
When yeast is ductal, causing shooting or stabbing pains within the breast, often topical treatments (those applied to the nipple area) do not penetrate well enough to affect the overgrowth of yeast in the ducts. Almost always, systemic (the entire body) treatment with an oral medication/supplement is necessary. Occasionally, treatment with Gentian Violet (see below) will reach the milk ducts.
Many physicians will prescribe oral Nystatin drops as the first course of treatment for the baby’s mouth. This should be done even if the baby is asymptomatic and the mother is showing symptoms to prevent cross contamination. Half the dosage should be dropped into each side of the baby’mouth after a feeding so that the medication is not washed away with nursing. A cotton swab may be used to apply the medication to the other areas of the mouth using care not to insert a swab back into the bottle that has touched the baby’s mouth. A clean swab should be used each time it’s necessary to dip into the bottle or a small amount may first be poured out into a cup and any amount left over discarded after that application. The medication should be applied after all daytime feedings. The directions that come with the prescription may say to only use the Nystatin four times a day, but because yeast grows back in about 90 minutes, it is important to apply the Nystatin much more often than this.
For mother Nystatin cream may be recommended first. The doctor can prescribe this as well. It should be rubbed into the nipples and areolae after every feeding once the area has been rinsed with cool water and pat dried. It does not need to be washed off before nursing. Nystatin pills are sometimes recommended if symptoms still persist after a full course of treatment lasting two weeks or if a secondary yeast infection of the milk ducts causing shooting pains in the breast during or after a feeding is present.
Because yeast seems to be becoming highly resistant to Nystatin, it is helpful to know of other routes of treatment. Some practitioners recommend foregoing the use of Nystatin completely and going on to other methods because more times than not it is not effective.
Because traditional medications to treat thrush/yeast, such as Nystatin, often do not work, Gentian Violet is regaining popularity again among practitioners. It has been around for many years and is known to be an extremely effective yeast fighter. It can be purchased at the local pharmacy but calling ahead is advised as some pharmacies do not carry it. Gentian Violet can be used on the nipple area by painting the nipples and areolae once a day at night. As with the Nystatin care should be taken not to dip the same cotton swab back in the bottle after painting the nipple area. A clean swab should be used each time or a few drops poured out of the bottle into a cup and any leftovers discarded after that application. Very little is needed as it spreads quickly.
Gentian Violet may also be used to paint the baby’s mouth. The entire mouth – inside of lips, roof of mouth, sides of cheeks, tongue, etc. – should be painted with a clean swab once a day. The baby should then be turned over onto his stomach to lessen the amount that is swallowed.
Some mothers have been told that Gentian Violet is dangerous due to its alcohol content and should not be used by nursing mothers. Please understand that the amount of alcohol in the Gentian Violet is insignificant and thus the amount the baby ingests will also be insignificant. The contents of the bottle may be diluted with 50% water if there is still concern.
Gentian Violet should be used for 4 days. If symptoms have improved but not completely, application can continue for another 3 days. It should not be used longer than one week. If there is a need to continue with it after one week of treatment, a break of a few days should be taken before resuming its use. If symptoms are no better or in fact worse after 4 days of treatment with Gentian Violet follow-up should be made with a lactation consultant.
Old clothing should be worn when treating with Gentian Violet as it temporarily stains everything it comes in contact with purple. Many mothers need to be prepared for the site of the baby’s mouth. It will be bright purple. It helps to know that this does fade and rather quickly.
This 1% Gentian Violet solution is one we recommend
PROBIOTICS / ACIDOPHILUS
Acidophilus is the good bacteria that normally lives in the body keeping the overgrowth of yeast in check. Adding more of this to the diet when yeast is present or preventatively when antibiotics must be taken is an effective way to regrow the good bacteria. Because it does not kill yeast it is not an overnight treatment but a very important part of total treatment.
Probiotics can be purchased at most drugstores. Some pharmacists refrigerate it so it may be necessary to ask for it. While taking antibiotics or while treating yeast, the dosage is two capsules three separate times a day. Acidophilus may also be given to the baby at one capsule three times a day. The capsule can be broken open and the baby allowed to suck it off a clean finger or it can be put into the baby’s food. It should be taken while on antibiotic therapy and for 1-2 weeks thereafter. If using during an active yeast infection, it should be taken for 1-2 weeks after all symptoms are gone. This one by Enzymatic Therapy is one we like for breastfeeding moms.
Garlic is known to be a powerful yeast fighter. Consider adding 4-6 capsules/tablets of odourless garlic to your diet during a yeast outbreak and for 1-2 weeks after all symptoms are gone. We like this garlic supplement, a slight odour for some people, but effective
Echinacea is an immune system boosting herb. When there is a yeast overgrowth the immune system is somewhat compromised. Consider adding this herb to your diet during a yeast infection and for 1-2 weeks after all symptoms are gone. Here’s a favourite in capsule form
Yeast cannot survive in an acidic environment. Vinegar rinses of both the nipples and/or the baby’s bottom often bring relief and help slow the yeast growth. For either, mix a half vinegar, half water solution. Apply the solution to the nipples with a cotton swab after rinsing the nipples after a feeding and before applying any creams. The solution can be applied to the baby’s bottom with a squirt bottle before closing up the diaper. It can be applied to the vaginal area in the same way after a trip to the bathroom.
GRAPEFRUIT SEED EXTRACT
This treatment consists of the mother taking a 250 mg capsule or liquid orally three times a day. This can be taken in place of Diflucan (see below) or along with it if the yeast is especially resistant. Grapefruit Seed Extract in liquid form
Diflucan (fluconazole) is usually very effective against yeast when taken orally. Dosage is 200-400 mg on the first day (loading or stat) dose followed by 100-200 mg for 10-14 days after or longer if yeast is especially resistant. Some practitioners want to prescribe one 150 mg pill for treating nipple or breast yeast. This is the vaginal dosage and is seldom effective when the yeast is present on the nipples or within the breast ducts (intraductal yeast). Diflucan be used safely with any of the topical treatments discussed above. Very little of this drug passes into breastmilk so the amount the baby will be exposed to is clinically insignificant. Diflucan is available by prescription only. Please note that it may be necessary to share professional literature with your doctor which supports the use of the medication as well as that which outlines the effetive dosage and length of treatment.
OVER THE COUNTER ANTI-FUNGAL CREAMS
Several over the counter antifungal creams can be used in place of Nystatin for nipple application. These include Lotrimin AF, Micatin, or Monistat 7. These are all available at the local drugstore. As with Nystatin, the creams should be applied to the nipple area after a feeding and once the area has been rinsed with water and pat dry. The excess only needs to be wiped off with a dry cloth prior to nursing. These creams can also be applied to the baby’s bottom when a yeast diaper rash is present. Often the best clue that a diaper rash is due to yeast is that it does not respond to regular rash ointments over a period of a few days but responds rapidly to an antifungal cream.
ALL PURPOSE NIPPLE OINTMENT
This nipple ointment formula was developed by Dr. Jack Newman. It consists of two antifungals, an antibiotic, and a steroid. The three ingredients are mixed (compounded) together by a pharmacist to make a cream. This cream is then applied to the nipples after each feeding once the nipples have been rinsed with cool water and pat dry. A doctor will need to call this in as a prescription. The ingredients are as follows:
• 100, 000 units/ml Nystatin (15 grams)
• 0.1 % Betamethasone (15 grams)
• 2% Mupirocin ointment (15 grams)
• 10% Clotrimazole (vaginal ointment) (15 grams)
Some pharmacies do not stock the Clotrimazole and if this is the case, it is the one ingredient that can be left out if necessary. APNO (All Purpose Nipple Ointment) works especially well with Gentian Violet (see above). It can be applied after all feedings except the one when the Gentian Violet is used.
Comfort Measures While Waiting for Treatment to Work
Breastfeeding can and should continue throughout treatment. In mild cases relief may be felt within 48 hours. In severe cases, it may take 3-5 days to notice any improvement. Symptoms may appear worse for a day or two before they begin to improve. In cases where yeast has not been treated properly or not diagnosed quickly enough, or where it is especially resistant, relief may not come for several days and a combination of different treatments may be necessary before there is total clearance. Treatments may have to be aggressive with changes in diet and a boosting of the overall immune system even after all symptoms are gone.
In the meantime, following the measures listed in “Treatment Measures for Sore, Cracked, or Bleeding Nipples” may bring some degree of relief. Rubbing breastmilk into the nipples while yeast symptoms are present is not advised however, because yeast thrives in milk.
If nursing becomes too painful, pumping for a few days may be a good option. Optimally this will done with a hospital or professional grade pump such as the Medela Lactina or the Medela Pump In Style, especially if baby’s time away from the breast is longer than a few days. Pumping should be as frequent as baby was nursing so that the milk supply is maintained well. If the baby is younger than 4-6 weeks of age, expressed milk should be offered by way of an alternative feeding device to lessen the risk of nipple confusion.
Hygiene Guidelines to Prevent Reinfection
The following precautions should be followed during treatment to lessen the chances of reinfection:
• Hands should be washed often but not with antibacterial soap. This kills the “good” bacteria which helps keep yeast in check. Paper towels that are discarded after each use should be used for drying rather than cloth towels.
• Expressed milk should not be frozen during treatment. Yeast is deactivated during freezing but not killed. If frozen milk is given to the baby after the treatment, thrush may recur. The baby may be fed fresh or refrigerated expressed breastmilk, however.
• All bottle nipples, pacifiers, toys that the baby may mouthe, and pump parts that come in contact with breast or milk should be boiled 20 minutes each day during treatment. All bottle nipples and pacifiers should be replaced after one week.
• Disposable nursing pads should be thrown away as soon as they become damp. Cloth pads and bras should be changed as soon as they become damp and not worn again until they have been washed. If weather permits, bras and washable pads can be dried in the sun. The ultra-violet rays are additionally effective at killing the yeast. Adding a cup of bleach to the wash load if clothes are chlorox bleach safe or a cup of vinegar to other wash loads will also ensure that any lingering yeast on clothing is killed.
• Nipples should be rinsed with cool, clear water after each feeding and airdried 10-15 minutes before applying any topical ointments or creams.
• If baby has a yeast diaper rash, diaper wipes should be avoided (use a washcloth and plain water instead) and a vinegar rinse applied after each diaper change (see above). Baby should be allowed to go without a diaper as much as possible. Switching to cloth diapers if possible is preferable to disposable diaper use during a yeast infection.
• If vaginal yeast is present cotton panties should be worn and the area rinsed with a vinegar/water solution after each trip to the bathroom (see above). Sleeping without panties at night is advised as well.
Dietary Changes That May Be Necessary
Because yeast thrive on sugars (including artificial ones) and dairy products in the diet, it may be helpful to greatly limit or eliminate dairy foods and sweets from your diet during yeast treatment and for 1-2 weeks after all symptoms are gone.
Becky is a board certified, registered lactation consultant (IBCLC, RLC) in practice with Breastfeeding Essentials in Kingsport, TN. She is the mother of 4 children ranging in ages from 7-13 whom she all breastfed proudly!