Thrush Diagnosis and Treatment
By Mary Kay Smith, IBCLC
Occasionally, a breastfeeding mother will experience sore nipples after a period of pain-free nursing. If all other causes have been ruled out, such as improper positioning and inadequate latch-on, thrush should be considered.
What Is Thrush?
Thrush is a common yeast infection that affects the mucous membranes. Yeast is normally present in the body in harmless amounts, but an overgrowth can occur under a variety of circumstances. The organism thrives on the lactose in milk—be it human or bovine—and thrush can be a problem in a formula-fed baby as well.
A yeast infection in a premature or low-birth-weight infant can be life-threatening, as can a yeast infection in an individual whose immune system is impaired by other illness or infection. Luckily, for most people, thrush is not a serious condition and breastfeeding can and should continue.
What Are the Symptoms?
Symptoms in the mother that may cause thrush to be considered are itchy, “burning” nipples, “shooting” pains during or after a feeding, bright pink nipples extending into the areola (where baby’s mouth touches) or “flaky” nipple skin. Mother may also have symptoms of a vaginal yeast infection.
Signs of yeast infection in the breastfed infant may include a sudden onset of fussiness at the breast, including pulling off the breast during a feeding, gassiness or colic symptoms and, occasionally, slow weight gain. Baby may or may not have white spots or a film inside the mouth, on the gums or on the tongue.
The baby also may have a diaper rash with raised, patchy areas or a shiny appearance. Sometimes, the baby may refuse to nurse or pull off the breast repeatedly during a feeding. In rare cases, feedings may be interrupted by Baby’s discomfort, which could result in inadequate weight gain. However, it is possible for thrush to be present even without any visible symptoms on Mother or Baby.
How Is Thrush Acquired?
Mothers who are susceptible to vaginal yeast infections, have recently used antibiotics or have a history of diabetes (gestational or insulin-dependent) are more likely to harbor yeast in their bodies. A history of anemia, use of steroid medications such as those used to suppress preterm labor, use of antidepressant medications or the use of oral contraceptives can also contribute to the possible invasion of yeast.
Mothers who experienced a Cesarean delivery may not be aware that they were given antibiotics post-delivery to prevent infection. The physical state of pregnancy is such that yeast infections are common.
Physical factors that can contribute to yeast growth include a humid environment, maternal obesity or clothes that hold in moisture, such as wet bathing suits, panty hose, tight jeans or wet bras and nursing pads.
Routes of transmission to the baby include passage through the birth canal during delivery or transmission during feedings, especially in the presence of cracked or abraded nipples. In some cases, the mother’s sexual partner may harbor yeast and re-infect the mother. In this case, that person will need to be treated as well.
How Is Thrush Diagnosed and Treated?
Work with your medical provider to diagnose and treat thrush. Keep in mind that some physicians are skeptical of the theory of breast and nipple yeast and may need some more information before treating it.
Diagnosis of breast yeast by milk culture is not always reliable, as yeast is always present on the skin or in the milk in small amounts. The fact that lysozymes in human milk may destroy yeast organisms can further complicate the interpretation of milk cultures. There is research available that states that the presence of yeast in a urine culture can indicate that yeast overgrowth is present.
Treatment options should be based on the severity of pain in the mother and baby and involvement of other parts of the body. First line treatment measures usually include a topical antifungal to Mother’s nipples and Baby’s diaper area along with simultaneous treatment of the baby’s mouth with oral liquid antifungal medications, such as Nystatin.
Topical medications that can be applied to the nipple skin and diaper area such as Mycostatin cream and Lotrimin are now available over the counter. Others such as Nizoral (ketaconazole cream) or Lotrisone (clotrimazole betamethasone cream) may be available by prescription only.
Occasionally, mothers are advised to treat the nipple with the baby’s oral medication, but its high sucrose content may encourage rather than discourage yeast growth. Regular applications of medication are important, as yeast replicates quickly (in less than three hours). Both mother and baby should be treated after each feeding, as this is when the transfer of the yeast organism takes place.
There are strains of Nystatin-resistant yeast that require more “intensive” measures, including an oral antifungal medication. Diflucan (fluconazole) is one that is currently used in a single application dosage to treat vaginal yeast infections. To be effective against ductal yeast or systemic yeast, a dosage of at least 100 milligrams per day for 14 days is necessary. Most practitioners also use a loading dose (first dose) of 200 milligrams.
Some physicians feel that this medication should be contraindicated in breastfeeding women. However, new research shows that very little enters the milk and what does reach the baby is destroyed in the gastrointestinal tract.
What Herbal or Alternative Treatments Are Available?
Anecdotal information on the use of herbal and homeopathic remedies has shown them to be helpful when used both with and without conventional medical treatments. Women have reported relief from nipple pain with the use of topical application of calendula (tincture of marigold) or tea tree oil. A weak vinegar solution (1 tablespoon of white or cider vinegar to 1 cup of sterile water) can be used to rinse the nipples after each feeding. Oral antifungal treatments include Pau d’ Arco, acidophilus capsules or Echinacea capsules.
Gentian violet can be used to treat both Mother’s nipples and Baby’s mouth and diaper area. It is intended for short-term use only and misuse can cause painful mouth ulcers more painful than the thrush. It is effective; however, it stains clothing and skin. You definitely should not use it right before a special occasion where picture taking will occur!
Women who experience frequent yeast infections are often advised to cut down on their intake of sugary foods, wheat, cheeses and fermented food products. The addition of dietary supplements such as vitamin C, zinc and B complex vitamins may be helpful, as is adding garlic and yogurt with live cultures to the diet.
Above all, remember that Baby and Mother need to be treated simultaneously. If you continue to experience nipple pain after treatment, consider seeing your doctor to rule out a simultaneous bacterial infection or dermatitis of the nipple. Mastitis can be caused by long-term yeast infection. Sore nipples or breasts are the No. 1 reason why women stop breastfeeding, so getting quick and appropriate treatment is essential.
