The diagnosis and management of candida in the
breastfeeding dyad are difficult because diagnosis is most often based on
subjective signs and symptoms. Only one study has quantified signs and symptoms
with sensitivity, specificity, and positive predictive values. The participants
were examined for shiny skin of the nipple and questioned about four symptoms
of candida at the time of culture and then again at 9 weeks postpartum.
A complete history of pain, labor, delivery, and
breastfeeding is essential, including the use of antibiotics in labor, prior
history of cracked nipples, and the infant's use of pacifiers and bottles. Breastfeeding
mothers have often been misdiagnosed and treated for candida when Raynaud's
syndrome was the cause of nipple pain.
The pharmacologic
treatment of candida
of the nipple and ductal system is problematic because of a lack of clinical
trials. Several medications are used to treat candida of the nipples and
breast, but none have been studied for the effect on mammary candida. The most
common treatment for localized candida of the nipple is an antifungal, topical
medication such as Nystatin. The treatment plan often includes a topical
antibiotic ointment because nipple fissures can concurrently present with
candida of the nipples, and S. aureus is significantly associated
with nipple fissures.
Persistent cases of nipple yeast are frequently treated with
oral fluconazole, is not approved by the Food and Drug Administration for
mammary candidosis. In randomized controlled studies, the side effects from
fluconazole at the aforementioned doses were minimal. It is recommended that
breastfeeding continue while taking fluconazole. Consultation is recommended
before prescribing fluconazole to women who are on other medications.
Fluconazole
Fluconazole 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 after other first interventions to treat recurrent
Candida infections of the nipples, and if such a thing exists, Candida infections
of the breasts. If a mother has sore nipples, the nipples must be treated
aggressively first and then is fluconazole added if nipple treatment alone is
unsuccessful.
Candida infections of the nipples may occur any time while the mother is breastfeeding. Candida albicans likes warm, moist, dark areas. Many Candida infections would, perhaps, not have occurred if the mother had not had sore nipples and a breakdown of the skin of the nipples and areola. A positive culture from the nipple(s) does not prove your pain is due to Candida. Diagnosing the presence 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.
Candida infections of the nipples may occur any time while the mother is breastfeeding. Candida albicans likes warm, moist, dark areas. Many Candida infections would, perhaps, not have occurred if the mother had not had sore nipples and a breakdown of the skin of the nipples and areola. A positive culture from the nipple(s) does not prove your pain is due to Candida. Diagnosing the presence 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.
The typical
symptoms of a candida infection of the nipples are:
1. Nipple pain that begins after a period of pain-free
nursing. The nipple pain of candida may begin without an
interval of pain-free nursing, however.
2. 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.
3. Pain in the breast that is “shooting”
or “burning” in nature and which goes through to the mother’s back and
shoulder, may occur without any
nipple pain.
First approach to treating these
infections is to apply the All Purpose Nipple Ointment (APNO). Next, the mother
can add topical Grapefruit Seed Extract and Gentian Violet if the ointment
alone does not work. A good response to gentian violet confirms that the
mother’s nipple pain is caused by Candida since little else
will respond to gentian violet. It thus also justifies the use of fluconazole,
if needed. Even if the above treatment 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.
Fluconazole is an
antifungal agent that is taken systemically. Vomiting, diarrhea, abdominal
pain and skin rashes are the most common side effects.
Candida albicans is learning to become resistant to fluconazole, and the
dose has increased over the past few years. If you have nipple pain continue
with the “all purpose nipple ointment” while you are taking fluconazole.
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