Friday, July 25, 2014

Nurse Charity blogs about thrush

Breastfeeding and Thrush
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! 

1 comment:

  1. Thank you for sharing. You have broadened my knowledge. Keep up the good work!

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