IMPORTANT: Candida albicans, the microbe (“fungus”) that causes thrush in the baby and infections in adults, does not grow on normal skin in adults! In babies it can grow inside of the mouth, but what is frequently diagnosed as thrush is not thrush. Thrush is frequently diagnosed when the baby’s tongue has a white coating, but the tongue is an unusual place for thrush to occur. Typically, thrush appears most commonly as white areas on the inside of the cheeks, and less commonly on the roof of the mouth and the gums.
A white tongue only in a young baby is most commonly associated with a tongue tie, and should not be considered as due to Candida albicans.
Therefore if the mother has sore nipples, it should not be assumed that she has a candida infection of the nipples, simply because the baby has thrush. To repeat, if the mother has sore nipples there is damage to the skin of the nipples and areolas. Therefore it is “jumping the gun” to treat with fluconazole before other treatments have been tried. Indeed, fluconazole will not work if the underlying cause of the mother’s nipple pain is not dealt with first. And dealing with the underlying cause will often result in fluconazole not needing to be used at all.
What causes the mother to have sore nipples? A latch which is not as good as it could and should be. Too many mothers are being treated with fluconazole when the baby’s latch is the problem. A common cause of a poor latch is the baby’s having 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, and includes feeling under the baby’s tongue as well and knowing what to feel for. Unfortunately, few health professionals, including lactation consultants, family doctors and especially pediatricians, know how to evaluate whether or not the baby has a tongue tie. It is said that spitting up a lot is associated with tongue tie.
Therefore, it is important to deal with the baby’s latch before running off in all directions to treat Candida albicans.
Fluconazole (Diflucan™) is a synthetic antifungal agent that can be used for the treatment of Candida albicans and other fungal infections. For the breastfeeding mother in particular, it can be used but should only be used after other first interventions to treat recurrent Candida infections of the nipples. If a mother has sore nipples, the nipples must be treated aggressively first and only then is fluconazole (Diflucan) added if nipple treatment alone is unsuccessful.
There is no evidence that Candida albicans infects the milk ducts. Yes, this is not what we used to write here, but there is evidence that it just does not happen. See this article: Breastfeeding Medicine VOL. 4, NO. 2 The Absence of Candida albicans in Milk Samples of Women with Clinical Symptoms of Ductal Candidiasis
Candida infections of the nipples may occur any time while the mother is breastfeeding. Candida albicans likes damaged, warm, moist, dark areas. It normally lives on our skin and other areas, and 90% of babies are colonized by it within a few hours of birth. It, like many other germs that live on us normally, only becomes a problem under certain circumstances.
Candida infections of the skin or mucous membranes are more likely to occur when there is a breakdown in the integrity of the skin or mucous membrane—one of the reasons why a good latch is very important from the very first day. Many Candida infections would, perhaps, not have occurred if the mother had not, in the first place, had sore nipples and a breakdown of the skin of the nipples and areola. The oozing of liquid that occurs often from cracked nipples encourages Candida albicans to change from its harmless form to an invasive form.
The widespread use of antibiotics also encourages the overgrowth of Candida albicans. Many pregnant women, women in labour, and new mothers, as well as their babies receive antibiotics, sometimes with very little justification.
There is no good test which helps makes the diagnosis. A positive culture from the nipple(s) does not prove your pain is due to Candida, since most people are colonized with Candida albicans normally. Neither does a negative culture mean your pain is not due to Candida. The best way to make a diagnosis is by getting a good history.
Diagnosing the presence or absence of a Candida infection in the baby is not helpful. A baby may have thrush all over his mouth, but the mother may have no pain. A mother may have the classic symptoms of a Candida infection of the nipples, and the baby may have no thrush or diaper rash.
The most important steps in treating sore nipples due to any cause are:
Fluconazole is an antifungal agent that is taken systemically (by mouth or intravenously). It stops fungi (such as Candida albicans) from multiplying, but does not actually kill them. This accounts for the fact that sometimes it takes several days to have any effect. Fluconazole powder is also available and can be mixed with the all purpose nipple ointment instead of miconazole powder.
Fluconazole tends to work best when used in conjunction with probiotics.
Fluconazole is generally well tolerated, but there is no such thing as a drug that never has side effects. Concern about liver injury is exaggerated, since this complication seems quite rare, usually occurs in people who are taking other medications as well, who have taken fluconazole for months or longer, and who have immune deficiencies. But it is a possibility that needs to be kept in mind and if it does occur, it can be serious.
Vomiting, diarrhea, abdominal pain and skin rashes are the most common side effects. These are not usually severe, and only occasionally is it necessary to stop the medication because of these side effects. Allergic reactions are possible but uncommon. Email immediately if you have any concerns.
We should mention immediately that in the past few years we have only rarely used fluconazole to treat maternal sore nipples. If at all. This is due to the fact that for all causes of sore nipples, other methods have worked well.
Candida albicans is learning to become resistant to fluconazole, and the dose we use has increased over the past few years until we have stopped using it virtually altogether.
Fluconazole in the milk
Fluconazole does appear in the milk, and this is as it should be, since the idea is to treat infection in the breasts and nipples. It is thus superior to ketoconazole, which gets into the milk in only tiny amounts. The baby will obviously get some, but this drug is now being promoted for use in babies for the treatment of simple thrush. There have been no complications in the baby reported from exposure to fluconazole in the breastmilk. Continue breastfeeding while taking fluconazole, even if you are told that you should stop.
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 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, 2021
Questions or concerns? Email Dr. Jack Newman (read the page carefully, and answer the listed questions).