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

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 (YEAST) INFECTIONS OF THE NIPPLE

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.

DIAGNOSIS OF CANDIDA INFECTIONS OF THE NIPPLES AND/OR DUCTS

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 TYPICAL SYMPTOMS OF A CANDIDA INFECTION OF THE NIPPLES ARE:

• Nipple pain that begins after a period of pain-free nursing. However, the most common cause of late onset nipple pain is not Candida albicans, but rather late onset decreased milk supply and flow. Late onset decreased milk supply and flow is common and occurs most frequently in mothers who begin with an abundant milk supply, but the milk supply, for some reason, has decreased. Please note that “decreased” does not mean “not enough milk”, but rather less than the mother had before.

• Late onset nipple pain due to Candida has never been proved to exist. And the symptoms mentioned after this point do not prove the pain is due to Candida albicans. We do not rule out the possibility of Candida, but point out that late onset decreased milk supply and flow is a more likely diagnosis.

• Burning nipple pain that continues throughout the feeding, sometimes continuing after the feeding is over, sometimes beginning in the middle of a feeding as baby is still drinking well.

• Pain in the breast that is “shooting” or “burning” in nature and which goes through to the mother’s back and shoulder. This pain is usually worse toward the end of the feeding, and worsens still more after the feeding is over. It also tends to be much worse at night. This pain may occur without any nipple pain.

TREATING CANDIDA INFECTIONS OF THE NIPPLES

The most important steps in treating sore nipples due to any cause are:

1. Help the baby to achieve the best latch possible. Almost all nipple pain is due to a less than adequate latch. There is no point in treating for Candida if the baby is not latched on well. See again these articles: asymmetric latch, latch quiz, tongue tie. These steps alone may result in the mother’s pain resolving without further treatment. However, learning a good latch after using a less than adequate latch for several days or even weeks may take repeated teaching of the technique.

2. The All Purpose Nipple Ointment (APNO) (see information sheet APNO).

3. Steps 1. and 2. should result in almost all mothers not longer having nipple or breast pain.

4. A word about topical gentian violet and topical grapefruit extract. Gentian violet is no longer available in Canada, based on one single article from 1985 which showed that if mice were fed enormous amounts of gentian violet every day for their entire lives, they had more liver cancers than if the mice were fed these enormous amounts for only have their lives. We really believe that it does not make sense to ban gentian violet on the basis of this one article. Gentian violet was a very good treatment for oral thrush in babies, but babies rarely seemed bothered by thrush. They breastfed normally and if they were older, they ate food without problem. The vast majority did not seem to be bothered. For adults with Candida infections, usually due to some sort of immune deficiency, other treatments are available.

5. As far as topical grapefruit seed extract is concerned, it may treat Candida very well, but we saw far too much misuse of this treatment. Too many mothers did not dilute the grapefruit seed extract, which caused severe “burns” of the areola. We think now treatment caused too many problems and furthermore is not necessary.

6. Even if the above treatment (improve the latch, including releasing tongue tie, the all purpose nipple ointment) does not help, fluconazole should not be used alone to treat sore nipples and should be added to treatment on the nipples, not used instead. We have not found nystatin to be particularly useful either in treatment of the baby’s mouth or in the treatment of the mother’s nipples. Clotrimazole cream alone is also not particularly effective in our opinion, but others obviously feel differently.

FLUCONAZOLE FOR BREAST PAIN OR VERY RESISTANT NIPPLE PAIN

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.

Side Effects

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.

Fluconazole

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).

Make an appointment at the Newman Breastfeeding Clinic.