Before discussing the Candida Protocol, it is worth understanding that Candida (“yeast”, “thrush”) does not grow on normal skin. Therefore, if Candida is difficult to treat or returns after treatment, there is an underlying problem which is not being addressed. We would like to emphasize that Candida (“yeast, “thrush”) is diagnosed far too often, and in many cases is not really the problem. The underlying problem is usually a poor latch and damage caused to the skin. Even if the damage is not obvious, if there is soreness, there is damage. The key to understanding is: why does the baby not latch on well?

Because of:

“Technique” of positioning and latching the baby on. See: http://ibconline.ca/painful-breastfeeding1/and http://ibconline.ca/latch-quiz/

More than occasional use of artificial nipples such as bottles and nipple shields. See http://ibconline.ca/nipple-shields/

The baby has a tongue-tie. Some tongue-ties are obvious, but many tongue-ties are more subtle and require an evaluation that goes farther than just looking, but includes feeling under the baby’s tongue and testing for upward mobility of the tongue as well and knowing what to feel for. Unfortunately, few health professionals, including some lactation consultants, know how to evaluate whether or not the baby has a tongue-tie.  Also, even if the tongue tie was released at one point, tongue ties are far too often only partially released and/or re-attach. See: http://ibconline.ca/tongue-tie/

The mother has had a decrease in milk supply. Late onset decreased milk supply and resulting slow flow is common and can also cause late onset sore nipples. Why? When the milk flow slows, the baby tends to slip down on the nipple and/or pulls at the breast or both. For more information on late onset decreased milk supply and what can be done, see the information sheet, “Late Onset Decreased Milk Supply or Flow”, as well as this link:  http://ibconline.ca/decreased/. Watch your baby at the breast and watch for drinking – see our video clips. This problem is frequently misdiagnosed as “thrush” or Candida. Late onset nipple pain is typical of late onset decreasing milk supply  and flow, and because often, the mother never had nipple pain before or the pain resolved after the first few days or weeks, “Candida” seems the only likely cause. It is not. The problem is that most health professionals, even lactation consultants, are not aware of the syndrome of late onset decreasing milk supply and flow. In fact, since we became aware of late onset decreasing milk supply and flow, we have not treated a mother for “candida of the nipples” at all. And success of treatment (dealing with late onset decreasing milk supply and flow) is far more definite.

Note that late onset decreasing milk supply and flow does not mean “not enough milk”. Mothers with this problem may still have a very good milk supply, and the baby may still be gaining weight well. But the baby may not be content, may fuss at the breast, especially late in the day. Often, however, the baby feeds very well at night.

Whatever the cause of sore nipples in your case, it is important to get the best latch possible. Even if the cause of sore nipples is Candida (yeast, thrush), improving the latch can decrease the pain. With the “ideal” latch, the baby covers more of the areola (brown or darker part of the breast) with his lower lip than the upper lip. Note also that the baby’s nose does not touch the breast. Of course, it is not always easy to change the latch of the baby older than 3 or 4 months, but it is worth a try, and it often does help. Also see this blog http://ibconline.ca/the-asymmetric-latch/ showing how to latch on a baby. See also the latch quiz: http://ibconline.ca/latch-quiz/.  For a fuller description of how to get the baby to latch on well, see the information sheet “Latching and Feeding Management”.

DIAGNOSING CANDIDA ALBICANS (YEAST)

An infection due to Candida albicans can be difficult to diagnose and mothers should not attempt to do so on their own. The pain due to Candida albicans is often confused with pain due to poor latching and/or pain due to vasospasm/Raynaud’s phenomenon See this video clip. Furthermore, more than one cause of sore nipples may be the source of your pain. A good practitioner will help you to differentiate between these conditions.

For Nipple Pain: Treatment applied to the nipple(s)

APNO (All-Purpose Nipple Ointment) is a compounded ointment mixed from the following ingredients:

• Mupirocin 2% ointment (15 grams)

• Betamethasone 0.1% ointment (15 grams)

• To which is added miconazole powder so that the final concentration is 2% miconazole. This combination gives a total volume of just more than 30 grams. Clotrimazole powder (not as good as miconazole in our opinion, as it often causes irritation) or fluconazole powder to a final concentration of 2% may be substituted for miconazole powder if miconazole powder is unavailable or difficult to get, or just the betamethasone and mupirocin may work well enough. Using powder gives a better concentration of antifungal agent (miconazole or clotrimazole) and the concentrations of the mupirocin and betamethasone remain higher

• We no longer use nystatin ointment in our recipe and haven’t for more than 20 years.

• Sometimes adding ibuprofen powder so that the final concentration of ibuprofen is 2% helps when the regular ointment does not. We do not prescribe this one routinely because it is even more difficult to get it made up and it is more expensive because of the extra ingredient. Furthermore, if the regular APNO works, as it usually does, then adding an extra ingredient is wasteful.

The ointment is applied sparingly after each feeding. “Sparingly” means that the nipple and areola will shine but you won’t be able to see the ointment. Do not wash or wipe it off, even if the pharmacist asks you to. The APNO can be used for any cause of nipple soreness (“all-purpose nipple ointment”), not just for Candida (yeast, thrush). Use the ointment until you are pain free for a few days and then decrease frequency over a few days until stopped. If you are not having less pain after 3 or 4 days of use, or if you need to be using it for longer than two or three weeks to keep pain free, get good help or advice but do not stop using the APNO.

The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.

This information sheet may be copied and distributed without further permission on the condition that you credit International Breastfeeding Centre it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!

©IBC, updated July 2009, June 2017, 2021

Questions or concerns?  Email Dr. Jack Newman (read the page carefully, and answer the listed questions).

Make an appointment at the Newman Breastfeeding Clinic.