A breastfeeding mother with a thrush infection of the nipple, areola and/or breast can experience pain in these areas both during and between feeds. If a baby’s mouth is infected it can be sore, making him fussy during feeds.
Women describe the pain of thrush as severe, even excruciating. They dread feeds, even though they want to nurse their babies, and have real worries about how they will continue breastfeeding. Without appropriate help and support, many mothers give up breastfeeding before they are ready. The good news is that appropriate treatment can protect mother and baby from stopping breastfeeding before they are ready.
Signs and Symptoms
Research about thrush and its treatment
Eliminating other possibilities
Treatment
Hygiene
Diet
Supplements and complementary therapies
Thrush medication
Topical medication for the mother
Medication for baby
Applying ointments or creams
Oral medications
When treatment doesn’t work as hoped
Eliminating thrush
Signs and symptoms
Symptoms of thrush in a baby
Your baby may have one or more of the following symptoms:
- White patches inside his cheeks or on his tongue or gums. These look like left over milk. When wiped off they leave red sore areas which may bleed.
- Your baby’s mouth may be uncomfortable or painful, making him fussy during and between feeds. He may slip on and off the breast and may make a clicking sound.
Symptoms of thrush in a mother
Having two or more of these symptoms makes it more likely that thrush is involved, especially if these include shiny or flaking skin:
- Burning nipple pain
- Flaking skin on the nipple or areola
- Shiny skin on the nipple or areola
- A loss of colour in the nipple or areola
- Painful breasts without tender spots or sore lumps
- Stabbing pains in the breasts behind the areola.
Thrush is also associated with previous nipple damage that had been healing. Itching of the nipples or burning pain are probably the most common symptoms of thrush of the nipple. Your nipples 
Nipple thrush is more likely when:
- A mother has thrush affecting any other part of her body – such as vaginal thrush.
- Any other family member has a candida infection, for example athlete’s foot, nappy rash or jock itch.
- Mother or baby has been treated with antibiotics or corticosteroids, or mother takes the contraceptive pill.
Thrush is also associated with:
Research about thrush and its treatment
Researchers have conflicting views on the diagnosis and treatment of thrush. This is not helped by the fact that thrush can be associated with bacterial infection. It has been suggested that thrush cannot spread in milk ducts. However, some practitioners believe thrush may enter milk ducts by tracking back from skin at the nipple, causing stabbing pains in the front of the breast.
Eliminating other possibilities
Try adjusting your nursing position and your baby’s latch-on before assuming pain is due to thrush. This is especially important if:
- Breastfeeding has always been painful.
- Your nipples are flattened, wedge-shaped or appear white after feeds.
An LLL Leader can help with this. Sudden onset of pain after a period of comfortable breastfeeding may suggest a thrush infection. Visiting your GP for a diagnosis is important as other skin diseases, including eczema, dermatitis, psoriasis, impetigo, herpes and bacterial infection can have similar symptoms to thrush. A mother may also experience breast pain for other reasons, e.g. engorgement, blocked ducts, mastitis, circulatory problems (Raynaud’s syndrome) or if her baby is sucking incorrectly.
Treatment
Source: United States Breastfeeding Committee
With appropriate treatment, many women and babies overcome thrush and continue their nursing relationship. There are practical, effective steps you can take to combat thrush alongside any medication you use. Thrush spreads easily and spores linger on anything they touch ready to infect the next contact. Therefore, a fourfold approach to treatment may be needed:
- Hygiene
- Diet
- Dietary supplements and complementary therapies
- Medication.
Hygiene
- Careful hand washing by all family members is essential, particularly after nappy changing or using the toilet. Wash your baby’s hands too.
- Keep a separate towel for each person in the family, or at least for you and your baby. Wash towels frequently at 60ºC. Or use paper towels for drying hands and dispose of them immediately.
- Keep your nipples as dry as possible between feeds and, ideally, avoid breast pads. If you use breast pads choose disposable ones and wrap and dispose of them immediately after use, or wash re-usable ones immediately at a high temperature.
- Wash anything that comes into contact with the affected area, immediately after use at a high temperature.
- Wear a clean cotton bra every day and wash all clothes in hot water, at least 50ºC if possible. Hang in the sun to dry or dry them at a hot temperature. A hot iron can also kill yeasts.
- Use sterilising fluid to regularly clean any items that could carry thrush: toys, pump equipment, bottles, teats, dummies. Or boil feeding and pump equipment for 20 minutes and replace teats and dummies weekly.
- Replace toothbrushes, toiletries and cosmetics as they may have become infected.
- Thrush cannot thrive in acidic conditions. Add 120 – 240ml (½ – 1 cup) distilled white vinegar to baths and in final rinses in washing machines.
Diet
When fighting any infection, eating a balanced diet and drinking enough water is a good idea. Limit sugar and other refined carbohydrates as they seem to make thrush symptoms worse. This can be a challenge as those with thrush often crave these foods. Many processed foods contain refined carbohydrates, so read food labels carefully. Note that fruits and juices contain sugar in the form of fruit sugar.
Some mothers have found that particular foods exacerbate their thrush and decide to limit them. These can include yeasty foods (such as bread, alcohol and mushrooms), dairy products or artificial sweeteners. If you decide to make major changes to your diet, you may find it helpful to consult a dietician.
Avoid giving your baby infant formula
Research has shown that bottle-fed babies are more likely to develop thrush.2 Although yeasts can grow in breastmilk, your breastmilk contains substances that help limit thrush growth. Formula, on the other hand, has high levels of added iron, which may encourage the growth of yeasts.
Avoid storing expressed milk
when you and your baby have a thrush infection. Freezing does not kill yeast cells so it’s possible to reinfect your baby with thrush in stored milk.
Supplements and complementary therapies
Thrush is more common in mothers who are run down or under stress. Sweetened and processed foods are low in nutrients. So try to eat a varied diet of vitamin and mineral rich foods instead. Although scientific evidence is lacking, some mothers decide to try the following alongside prescribed medication:
- Nutritional supplements from health food stores and chemists.
- Therapies from registered homeopaths or naturopaths.
Altering the relative acidity (pH) of your nipple skin may reduce itching. Rinse your nipples with:
- 5 – 10 ml (1 – 2 tsp) of distilled white vinegar in 160 ml (1/4 pint) of water four times a day
- Or 5 ml (1 tsp) of sodium bicarbonate in 240 ml (1 cup) of water once or twice a day Herbal products and essential oils should not be applied to your nipples, as it is not clear how safe they are for your baby.
| Nutritional supplement | Dosage |
|---|---|
| Lactobacillus acidophilus tablets | Follow dosage on the packet until you are free of symptoms for 2 weeks |
| Grapefruit seed extract | 250mg daily or 5 – 15 drops in 150 ml water 2 - 5 times daily |
| Garlic | 3 triple strength deodorized tablets, 3 times daily |
| Zinc acetate or zinc gluconate | 45mg daily |
| B vitamins | 100 mg of each daily (avoid nutritional yeast) |
Thrush medications
Prescribed medication
Certain strains of candida may be becoming resistant to commonly used medications so it’s important to be sure you definitely have thrush before using any medication. If your GP suspects thrush
Complete the course of medication
Even if symptoms improve earlier, certain medication needs to be used for a particular period of time to clear the infection. Follow the guidelines provided with the specific medication or ask your doctor or pharmacist for more detailed guidance.
Treat both mum and baby
Thrush spreads easily, so both you and your baby need simultaneous treatment to avoid reinfecting one another – even if one of you is symptom free. Research has shown that mothers often test positive for thrush before symptoms appear.
Topical medications for the mother
When deciding whether to use medications you will want to weigh the potential benefit against the possible side effects. Treatment will depend on whether there is any inflammation or an associated bacterial infection. You can discuss this with your GP and health care team. You may find it helpful to share this page with your doctor. Doctors may prescribe one of the following creams or ointments when thrush is diagnosed. See Applying creams or ointments for information on application and oral treatment.
| Name | Brand | Notes |
|---|---|---|
| NYSTATIN | Nystatin | Some strains of thrush are becoming resistant to nystatin. Use for at least 14 days. |
| CLOTRIMAZOLE | Canestan | Risk of contact dermatitis. Clotrimazole is less effective for topical infections of the breasts than miconazole |
| MICONAZOLE | Daktarin | |
| KETOCONAZOLE | Nizoral | |
| NYSTATIN Tri-adcortyl Contains a corticosteroid. Used occasionally for persistent with triamcinolone | Tri-adcortyl | Contains a corticosteroid. Used occasionally for persistent with triamcinolone eczema-like inflammation associated with a thrush infection. Ask your doctor about safe use while breastfeeding. |
Medications for baby
Treatments for thrush in a baby’s mouth are in the form of liquids or gels. To work effectively, they need to be applied to all the nooks and crannies in a baby’s mouth as directed by your doctor or pharmacist. Always wash your hands before and after application.
• MICONAZOLE (Daktarin Gel) is recommended as first-line treatment in children under two years.7 Due to risk of choking, manufacturers recommend it is not used for babies under 4 months of age and used only with care from 4 to 6 months. Divide each dose before applying and keep away from your baby’s throat to avoid choking. If applying using a finger, keep your fingernails short.
• NYSTATIN (Nystan) oral suspension is recommended as the second-line of treatment where miconazole is ineffective or causes side-effects. The easiest way to apply this is to pour the correct dose onto a measuring spoon and apply with a dropper or swab. Discard the swab after use. If the dropper has been in contact with your baby’s mouth, sterilise it before replacing in the bottle. Some strains of thrush are becoming resistant to nystatin.
Please note: Oral gel applied to your breast is unlikely to be effective; it has not been formulated for this use in this way, so will not have effective topical properties.
Applying ointments or creams
Unless your doctor states otherwise, creams (usually water-soluble) or ointments (usually oily) need to be applied after feeds several times a day for the recommended period of time and until you’ve been free of symptoms for at least two days. Take care to wash your hands before and after application. Wipe away any excess cream or ointment before nursing your baby. A water-soluble cream is more likely to have been absorbed by the skin. An oily ointment is best avoided as it may need removing with warm water and mild soap. Vigorous washing can cause further soreness.
• As you will be feeding your baby more often than you apply the medication, ask your doctor how often and how much to apply.
• You may find it helpful to use the cream after your baby nurses to sleep, especially if he is likely to sleep for a while.
• Resistant yeasts can replicate themselves every 30 minutes, so if thrush is persistent, ask your GP about applying the above medications in smaller more frequent doses while using the same amount in 24 hours.
• Be aware that symptoms may get worse as the thrush starts to die off, before you notice any improvement.
• Always taste a topical medication yourself as your baby will be tasting it. Some medications used for athletes foot (eg Timodine) are foul-tasting and should be avoided at all costs!
Oral treatments
Oral fluconazole (Diflucan) is usually only used when there is a definite diagnosis of thrush and topical treatments have been ineffective. A loading dose of 150–200mg followed by 100mg daily is required for up to 2 weeks. If things do not improve within this time, seek help for other causes. Although it is licensed to be given to babies in neonatal units, fluconazole is not licensed in the UK for use by breastfeeding mothers of babies under 6 months. It is only available for mothers of younger babies at the discretion of the GP.
When treatment doesn’t work as hoped
Sometimes it can take time to find an effective treatment for your infection. If symptoms don’t improve or get worse:
• Check for other sources of pain. An LLL Leader will be able to share information on other possible causes of nipple and breast pain.
• Check for possible sources of reinfection, especially if symptoms improved at the start of treatment. Treating any other candida infections in the family may help.
• Consider whether diet and hygiene need to be changed.
Let your doctor know if treatment was not effective or improved things only slightly:
• Another cream or ointment may be more effective if the diagnosis for thrush is certain.
• You and your doctor may need to investigate other possible causes of pain and skin changes.
• Other family members who have a candida infection may need treatment. In particular, if you have vaginal thrush, your partner may need treatment too.
If you are considering switching treatments, try the new preparation on just one side, while continuing on the other breast with the original treatment. You have two breasts so using them to experiment with treatments may help!
Eliminating thrush
It may take a little time and persistence to deal with a thrush infection and enjoy comfortable feeds once more. Sometimes it takes a little effort to find the right medication for your thrush. Many mothers have found using diet, hygiene, supplements and alternative therapies alongside any medication can make a great deal of difference and help prevent thrush returning.
Written by Sue Upstone and mothers of LLLGB
Further Reading
The Womanly Art of Breastfeeding. LLLI. London: Pinter & Martin, 2010.
Nipple pain
References
1 Francis-Morrill, J. Diagnostic value of signs and symptoms of mammary candidosis among lactating women. J Hum Lact 2004; 20(3): 288-94.
2 da Costa Zöllner, MSA et al. Candida spp. occurrence in oral cavities of breast feeding infants and in their mothers’ mouths and breasts. Pesqui Odontol Bras 2003;17(2): 151-5.
3 Francis Morrill, J et al. Risk factors for mammary candidosis among lactating women. JOGNN 2005; 34: 37-45.
4 Francis Morrill, J et al. Detecting Candida albicans in human milk. J Clin Microbiol 2003; 41(1): 475–478. 5. Wiener,
5 Diagnosis and management of Candida of the nipple and breast. J Midwifery Womens Health 2006; 51(2):125-8.
6 Chetwynd, EM et al. Fluconazole for postpartum candidal mastitis and infant thrush. J Hum Lact 2002; 18(2): 168-71.
7 http://www.nhs.uk/chq/Pages/2448.aspx
8 Brent, NB. Thrush in the breastfeeding dyad: results of a survey on diagnosis and treatment. Clin Pediatrics 2001; 40(9): 503-6.
9 Breastfeeding Answers Made Simple. Mohrbacher, N. Amarillo, Tx: Hale Publishing, 2010.
10 *Medications and Mothers’ Milk. Hale, TW. TX: Hale publishing, 2010
11 Moorhead, AM et al. A prospective study of fluconazole treatment for breast and nipple thrush. Breastfeeding Review 2011; 19(3): 25–29.
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Please note: Information is provided for educational purposes only. If you are concerned about your health, or that of your child, consult with your health care provider regarding the advisability of any opinions or recommendations with respect to your individual situation.
Copyright LLLGB 2016