Thrush and Breastfeeding - La Leche League GB

There are many causes of nipple and breast pain. Nipple thrush is one possible cause, although it is often wrongly or over-diagnosed before other possibilities have been investigated. A skilled breastfeeding supporter can help you rule out other possible causes before a thrush diagnosis is made.

What is thrush?

Thrush is a yeast infection, usually caused by the fungus Candida albicans. Thrush likes warm, dark and moist environments, and it might grow on your nipple.

Candida albicans is naturally present in our bodies and usually it causes us no harm; however, certain things can create an imbalance in the body and cause an overgrowth. These include:

Previous nipple damage.
If you have thrush affecting any other part of your body, or if another family member has a thrush infection.
If you or your baby have been treated with antibiotics or corticosteroids.
If you take the contraceptive pill.
Bottle or dummy use, especially in the early weeks after birth.
Anaemia or diabetes.
Exhaustion and stress.

Diagnosing thrush

Thrush is diagnosed by symptoms and/or by looking at mother and baby. Sometimes culture samples are taken. This is known as swabbing.

There are different views about swabbing. Some breastfeeding organisations recommend swabbing to confirm thrush¹. However, some studies say that swabbing is neither reliable nor accurate, as Candida can be part of the normal healthy skin surface. Although the Candida species can be easily singled out in the laboratory when present in milk, there is a lack of consistent rules for milk sample, collection, storage and analysis globally. ²

Swabbing is more complex than just ‘taking a test’. It does not always give a clear thrush diagnosis, or confirm if the pain is due to thrush or a bacterial infection. The roles of bacteria and yeast in relation to nipple and breast pain during breastfeeding remain unclear. It is also possible to have both Staph. and Candida on the nipples without any symptoms.

Thrush symptoms

There can be many causes of ‘thrush-like’ symptoms. Nipple and breast pain is likely to be caused by something OTHER THAN thrush if:

Breastfeeding has always been painful.
Your nipples are flattened, wedge-shaped or appear white after feeds.
Your baby has no symptoms.

Signs of thrush in the nursing parent may include:

A burning feeling in the nipples, especially after every feed.
Itchy nipples that may be sensitive to touch.
Flaking and/or shiny skin on the nipple or areola. Nipple skin and areola may be red on lighter skin and darker brown, purple or grey on darker skin. This can be more difficult to see on darker skin tones.
White patches/tiny blisters on the nipple or areola.
A loss of colour in the nipple or areola.
A nipple wound which is not healing despite appropriate management.
Nipple pain which:
- Gets worse during feeds and may continue after a feed.
- Begins suddenly after a period of pain-free breastfeeding.
- Happens on both sides.

According to research, thrush is more likely to be a cause of painful nursing if the following symptoms occur together:

Shiny nipple/areola with stabbing pain
Flaky nipple/areola and mammary pain.³

Pain may be felt deep in the breast; however, deep shooting pain between feeds, previously said to be a secondary infection in the milk ducts, is more likely to have a different cause.⁴

Signs of thrush in the baby include:

White patches on the cheeks, tongue, roof of mouth or gums. When wiped off they may look red or bleed.
Nappy rash.
Fussing during and between feeds due to pain.

A white coating on the tongue alone is not a sign of thrush as most nursing babies have a white, milky coating on their tongue (sometimes this may be as a result of poor tongue function). Nappy rash and fussiness may also have other causes.

Not Thrush? Alternative causes

Other conditions that can result in ‘thrush-like’ symptoms may include:

Bacterial infection

Bacterial and thrush infections of the nipple can have similar symptoms, such as burning pain and soreness. Staphylococcus aureus (Staph.) is the most common bacteria associated with breast infection. With a bacterial infection of the nipple there may be:

Yellow pus in the damaged area.
Yellow scabs or crusty areas on the nipple.⁵

It is possible for you to have both thrush and a bacterial infection.

Shallow latch

When the latch is shallow, the nipple is squashed, causing pain on the nipple and sometimes deeper within the breast. This may damage the nipple and increase the possibility of a bacterial infection. Even when thrush is the cause of sore nipples, a deeper latch can make it less painful.

You can read more about Positioning and Attachment here.

Skin conditions

Skin conditions, such as eczema or psoriasis, can affect the nipple area. Some people may also have sensitivities to nipple balms containing lanolin. If you have a history of skin allergies or a similar problem elsewhere on your body, discuss this with your GP. A dermatology referral is sometimes necessary.

You can read more about causes of nipple pain here.

Subacute Mastitis

Mastitis is inflammation of the breast. This may or may not be caused by a bacterial infection.

Often, the general term ‘mastitis’ is used to mean one type of breast inflammation. However, it may help to think of mastitis as being on a spectrum, with blocked ducts at one end and abscess at the other.

Different types of bacteria may be involved in breast inflammation. Some of these do not cause fever or flu-like symptoms, but you may still experience painful breastfeeding, needle-like burning pain and engorgement. Some researchers have suggested the term ‘subacute mastitis’ to describe inflammation of the breast without fever or flu-like symptoms. These researchers believe that the term ‘mammary candidiasis’ (thrush) should be avoided and replaced by ‘subacute mastitis’. ^6,7

You can read more about mastitis and treatment of mastitis here.

Vasospasm

Vasospasm is a sudden narrowing of the blood vessels. The main cause of nipple vasospasm is a shallow latch. When the nipple is squashed it may turn white or change shape. As blood flows back to the nipple, it causes pain on the nipple and deeper in the breast. Deep breast pain is sometimes called ‘Mammary Constriction Syndrome’. Tension and positioning may add to deep breast or muscle pain.

Vasospasm is also connected with the circulatory condition Raynaud’s Phenomenon. A history of Raynaud’s may increase the likelihood of it happening during breastfeeding. Symptoms may happen in response to cold and separately from breastfeeding.

For more information see Further Reading.

Thrush treatments

When thrush is diagnosed, it is recommended that both mother and baby are treated at the same time, even if one is symptom free, as they may pass a thrush infection back and forth between them. Breastfeeding should continue if thrush is diagnosed.

Medications for the nursing parent:

The most effective treatment for topical thrush is Miconazole (Daktarin) cream (2%), which should be applied to the nipple in small amounts after every feed. In mild cases, expect improvement within a couple of days. In more severe cases, it may take 3 to 5 days or longer. Sometimes, symptoms get worse before they get better. ⁸
If nipples are very inflamed, a mild steroid cream (hydrocortisone 1%) can be used to facilitate healing.
If symptoms do not improve, oral fluconazole may be required in addition to the above. A higher initial dose of 150-400mg is prescribed, followed by 100-200mg daily for at least 10 days. It may take a week or longer for the pain to disappear. ⁹
Mothers may also be prescribed nystatin (Nystan) cream or ointment, or clotrimazole (Canestan) cream. However, both are considered to be less effective than other options and clotrimazole is associated with allergic reactions. ¹⁰

Thrush can spread to other family members. Therefore, it may be necessary to treat partners and, if breastfeeding more than one child, the sibling.

Comfort options

Rinse nipples with clean water and let them air dry after each feeding.
Place something cold on your nipples before nursing. If cold or air drying increases the pain, it may be related to nipple vasospasm (see above).
Take mild over-the-counter pain medication.
In the short term, express milk and offer it to your baby by another means if feeding is too painful.

Medications for the baby:

- Miconazole (Daktarin) oral gel four times a day after feeds. Manufacturers recommend that this is not used in babies under 4 months due to risk of choking. Healthcare providers must ensure that the parent/carer is aware of how to apply the gel safely if prescribed under this age. ¹¹
- Nystatin (Nystatin) oral suspension may be prescribed, but this is considered less effective than miconazole gel.

Neither miconazole gel or nystatin suspension should be applied to the mother’s nipples.

Non-medical treatment options:

Practical, self-help measures you can take to combat thrush alongside medication include:

- - Frequent hand washing, particularly after nappy changes or using the toilet.
  - Having a separate towel for each person in the family, or at least for you and your baby.
  - Keeping nipples dry. Avoid breast pads, if possible, or throw away/change frequently.
  - Wearing 100% cotton bras and underwear.
  - Washing towels/clothing at 50 °C or above. A hot iron can also kill yeasts.
  - Washing and sterilising dummies, nipple shields, teats and toys frequently.
  - Replacing toothbrushes, toiletries and cosmetics.
  - Reducing sugar, yeast, dairy products and artificial sweeteners.
  - Rinsing nipples with vinegar in water or baking soda in water after every feed.
  - Switching to a non-antibacterial hand soap.
  - Taking herbal supplements and vitamins, such as grapefruit seed extract, garlic, B vitamins and zinc.
  - Anecdotally, some mothers find it helpful to take a probiotic, such as lactobacillus acidophilus.

If there is no improvement following prescription medications and self-care measures, then it may be worth considering if the original diagnosis of thrush is correct.

Expressing milk

Previously, parents were advised to avoid expressing and storing milk during a thrush infection to avoid possible re-infection, as freezing does not kill yeast. However, there is currently no evidence to suggest that this will happen.

If you are worried about using expressed/stored milk during a yeast infection, you can either use it while you and your baby are being treated for thrush, or you can warm the milk to 63 °C for 30 minutes to kill bacteria and yeast, before cooling and offering.

Current/ongoing research

Research has been carried out on both breastfeeding and non-breastfeeding, non-pregnant women in order to learn more about yeast infections of the nipple and reliable ways of confirming this.

There are different views about the presence of nipple thrush and how accurately it is diagnosed. One study suggests that the evidence supporting a link between nipple/breast pain and thrush is “non-scientific” and largely anecdotal, without the support of a proper microbiological analysis.¹²

Others believe that since thrush does not grow on normal skin, damage of the nipple and areola as a result of a shallow latch is the real problem and that, unless this is dealt with, nipple thrush will remain difficult to treat. ¹³

In summary

Candida albicans is naturally present in our bodies and finding an overgrowth can be difficult. Furthermore, the relationship between and the role of fungus and bacteria in relation to nipple/breast pain is unclear.

More research is needed to understand how common nipple thrush is and to find reliable ways of confirming this.

Further LLLGB reading

Blocked Ducts & Mastitis
Comfortable Breastfeeding
Nipple Pain – Why and What to do?
Positioning & Attachment
The Unhappy Breastfed Baby

References

1. The Breastfeeding Network Drugs in Breastmilk Information. Thrush and Breastfeeding, May 2020
(accessed 18th September 2022).
2. Jiménez E, Arroyo R, Cárdenas N, et al. Mammary candidiasis: A medical condition without scientific evidence? PLoS ONE, 2017; 12(7):
e0181071.
3. Mohrbacher, N. Breastfeeding Answers Made Simple. TX: Hale Publishing, 2012; 727.
4. Ibid., 728.
5. Ibid., 724.
6. Jiménez E, Arroyo R, Cárdenas N, et al. Mammary candidiasis: A medical condition without scientific evidence? PLoS ONE, 2017; 12(7):
e0181071.
7. Mohrbacher, N. Breastfeeding Answers Made Simple. TX: Hale Publishing, 2012; 755.
8. Ibid., 730.
9. Ibid.
10. The Breastfeeding Network Drugs in Breastmilk Information. Thrush and Breastfeeding, May 2020, (accessed 18th September 2022).
11. The Breastfeeding Network Drugs in Breastmilk Information. Miconazole Gel and the Breastfed baby with Oral Thrush (Candida), May 2020, (accessed 16th August 2022).
12. Jiménez E, Arroyo R, Cárdenas N, et al. Mammary candidiasis: A medical condition without scientific evidence? PLoS ONE, 2017; 12(7):
e0181071.
13. International Breastfeeding Centre. Candida Protocol, 2021, ibconline.ca/information-sheets/candida-protocol/ (accessed 18th September
2022).