Breastfeeding and Thrush
or
All that Burns is not Yeast
Summer
is here (although in our foggy part of the world, some days it feels
like a long cold winter) and this means a plethora of rashes, bug bites,
and minor injuries. For breastfeeding moms of new babies, it means a
lot of diaper rashes (both bacterial, and fungal), and *possible* nipple
thrush. Candida albicans loves warm, dark places- like the mouth, the
warm folds of skin covered by a diaper, and the damp inside of a
supportive bra. It is a part of our everyday human flora, held to
manageable numbers by competing microorganisms; the addition of a bit
more moisture, a more alkaline environment, and warmer weather are just
the resources yeast has been looking for to begin !world domination!
(starting with your nipples).
Because
breastfeeding involves both moms and babies- it is doubly hard to
treat. I will focus on Moms first, (because we tend to put ourselves
last).
Step 1:Look for the most obvious culprit of nipple pain- LATCH!
Many
books and online articles will leap immediately to yeast as a culprit
for burning nipple pain- I mean why not? that stuff is everywhere, and
in the warm-up phase, it is easy to treat over the counter with some
inexpensive cream. As a lactation consultant in practice for many
years, I have learned the hard way that most pain, burning or otherwise,
is usually caused by ~bad latch~. It is a sad, sad fact that no
amount of cream can cover. So the first stop for any burning pain is a
quick trip to a friendly lactation consultant to have a look at the
latch. Many stellar, comfortable, milk transferring, latches change
over time, as babies get bigger and bigger, they start looming over the
breast, tucking the chin to the chest to nurse, and not getting a wide
open mouth- ouch PINCHY!!
Step 2: Look for bacterial infection-
Yeast
is very hard to grow out in culture. The most comprehensive study of
burning pain and relation to nipple thrush actually implicated low level
BACTERIAL infection (meaning when we went hunting around- we found a
lot more bacterial causes). Most antifungals will also treat bacterial
(not as well, but will kill off some- often enough to let the body put
down the uprising). So If I see a crusty, goopy nipple with "white
stuff." It is usually bacterial in nature, and matching the cause with
the treatment means you get a faster, better solution to your nipple
pain.
Step 3: Ok- lets look for yeast-
Fungal
infections of the skin (because they are not a mucous membrane) usually
do not put out a lot of white stuff. Mostly what I see is BRIGHT
red/pink, and looks tight and shiny. Sometimes it looks dry and
cracked. Unfortunately, many other skin conditions also look like that:
Eczema on the nipples, contact dermatitis from soap, etc, etc etc. So
forays into yeast treatment are experimental. Ductal yeast (an
infection on the inside of the breast we cannot even see) usually feels
like glass under the skin- very painful latch- feels like tiny cuts
with glass shards, and then a very painful burning.
We came, we saw- now we want to conquer!
Try an over the counter antifungal-
Low
level yeast, or probable yeast (no one is ever quite sure) can be
treated with an over the counter vaginal yeast cream (clotrimazole,
miconazole, that little tube of external cream that came with your
vaginal yeast suppositories- it all works) Just put it on in a thin
layer after feeding or pumping. And now I am going to shock you.
*Don't wash it off* before your next nursing. A little bit of cream
will not hurt your baby in the slightest- while the friction, and soap
residue from washing your nipples compulsively every feed will definitely give you sore nipples.
Get rid of the warm, moist, alkaline environment-
Leave
the nipples open to air as much as possible. Wear a clean bra
everyday, put some vinegar in the rinse water to kill yeasty bits
hanging out there in the fabric. Ditch the disposable breast pads (they
have a plastic backing- holding in moisture- and they are very
alkaline). Try cotton ones, or my favorite WOOL (change them 3-4x per
day). If you like the idea of a vinegar rinse, I like a very dilute
vinegar and water mix in a spray bottle (one tablespoon of vinegar,
white or apple cider to one cup of water). Do not be tempted to make it
stronger- too much acidity will cause dryness, burning, and nipple
cracks- all signs of yeast. Sometimes we use coconut oil on the
nipples, reputed to be naturally antifungal and definitely supportive to
dry looking skin (no one has done the actual research, but it seems
like a good theory).
Check the baby's mouth-
Most
white tongue is actually milk tongue not yeast. Even low level oral
candida albicans usually requires no treatment, we just let it go. If
your nipples, and breastfeeding start to suffer, however, we often treat
the baby as well. When I first started at Noe Valley Pediatrics, the
oral Nystatin worked pretty well for most cases. We still use it, it
requires a trip into the office, so the Docs can have a look at the
mouth! Probiotics cant hurt, might help. For oral thrush, I like a
powdered probiotic, ¼ teaspoon, dampen a finger roll it around in the
powder, then put the finger in the babies mouth 1 time per day. Pro tip-
Can also be dusted on the nipples.
I did everything you told me, now where is my relief?
Sorry Moms- sometimes even if you did all that, we need to do more:-( Sad Story.
Oceans of potions-
All
Purpose Nipple Ointment (APNO)- When we are not quite sure, we tend to
throw this concoction at it. It is RX, is expensive (if not covered by
your insurance, most current plans DO, but the pharmacy may call you to
check) and needs to be compounded. The Walgreens near our office
stocks the stuff for us (bless them!) but otherwise it needs to be
filled at a compounding pharmacy (Like Four-Fifty Sutter downtown, or
The Rexall in the Sunset). It is an antibacterial, an antifungal, and
has a corticosteroid. We also use it for stubborn diaper rashes on
occasion, so some of you have tubes at home. Directions:
Thin layer after each nursing/pumping. *don't wash it off.* Follow-up
if it does not work in 7-10 days, don't just keep using it.
Gentian
violet- It is a purple, dye, clings well in tincture form to skin,
STAINS! This is sold over the counter at the 20th and Mission walgreens
in the "latino" section (that is what the Walgreens calls the section-
sometimes they will tell you they don't carry it at all- ask for the
latino section, and have a look- it is usually there- in spite of what
the staff says). Like many medicines, it can be toxic in large
quantities. In the level we are using it, probably non-harmful. It
does WORK reliably, as it treats both the nipple and the baby!!. New
and improved Directions: Applied one time a day!! I recommend at night. Strip down mom and baby. Put some aquaphor, or cream around, not in
the babies mouth to minimize staining. Open the tincture, put in a
clean q-tip, then put that q-tip inside the babies mouth and let them
suck on it. I find trying to paint the white parts is messier than just
the q-tip in the mouth. It coats well, and as a q-tip does not
actually hold very much tincture, they will not swallow much of anything
(usually just saliva). Throw that q-tip away, get out a new one, and
use it to paint your nipple and areola. (do not double dip the baby
q-tip, get your own clean one). Air dry the nipples. Now you have two
purple nipples, and a purple mouth baby. The baby will start off
looking like a member of Kiss, by the am, they will look like you are a
terrible parent, and are feeding your baby purple otter pops. By the
afternoon, they look slightly cyanotic. Then you will repeat for 5 days
THEN STOP. If there is no improvement in 3 days, please give us a
call. IF it is mostly better but not all clear at the five day mark you
can go to 7 days, THEN STOP. If in doubt, please call us! Weird
sores? STOP and call (has never happened on my watch, but before my
time, there was such a case).
Thanks to our model Shannon for showing off her purple mouth in the photo
Grapefruit seed extract GSE- (lifted, with permission, from Jack Newman) Use instead of vinegar and water spritz. Mix
very well 5- 10 drops in 30 ml (1 ounce) of water. Use cotton swab to
apply on both nipples and areolas after the feeding. Let dry a few
seconds, and then apply "all purpose nipple ointment". If also using
Gentian Violet, do not use GSE on that particular feed but use after all
other feeds. Use until pain is gone and then wean down slowly over the
period of at least a week. If pain is not significantly improving after
two to three days, increase the concentration by 5 drops per 30 ml
(ounce) of water. Can continue increasing concentration until 25 drops/
30 ml of water.
Diflucan-
This is for Mom for ductal yeast, (after we have ruled out other more
rare causes like Raynauds, and bad latch). We prefer you go through
your PCP or OB/GYN. The dosage is listed here because some HCP use the
one time vaginal yeast protocol (which does not work) Diflucan (generic
is just fine) 400mg loading dose on day 1, then 200 mg day 2-day 14
until you are PAIN FREE, can be repeated. We sometimes use this in
conjunction with gentian violet or nystatin for the baby.
For those moms who are yeasty people
Sometimes
women with stubborn yeast are just really, really good yeast growers.
They tend to get oral thrush, and vaginal thrush at the drop of a hat,
or with any antibiotics. You know who you are. I am one of this group;
It really, really sucks. For these folks, we go heavy hitting early
(gentian violet, and APNO and diflucan) and we also recommend some stuff
to cut down on yeast in your home environment. It is labor intensive,
so not every mom with a yeast problem needs to do these things! Use
your towel once, and only once. Wear a new nightgown or pajamas, sleep
bra etc every night, change your sheets every 5 days. Add vinegar to
every rinse of your laundry. Cut down on simple carbohydrates, and
sugars.
So that's it!
THRUSH, may you never have to do battle,
but if you do- Go prepared! Update 2023..The world health organization does not list gentian violet on their approved list of treatments.
