To provide effective diagnosis and treatment of thrush infections of the breasts and/or nipples during lactation, and to avoid unnecessary cessation of breastfeeding.

Effective diagnosis and treatment of nipple and breast thrush infections during lactation will be provided.

Thrush: A fungal infection caused by an overgrowth of the Candida albicans organism.

EBM: Expressed breast milk

Lactation consultants and midwives

Nurses working with breastfeeding mothers

Medical staff

Pharmacy staff

Thrush Infection

Thrush may affect the mother and/or the baby. Regardless, both mother and baby will need to be treated simultaneously to avoid repeated transfer of the infection between mother and baby, and to reduce the duration and severity of the infection.

Predisposing Factors

Sometimes there is no obvious reason for the development of thrush infections. However, the following factors may increase the chances of developing nipple and breast thrush infections during lactation:

• A history of vaginal thrush, particularly during late pregnancy.

• A history of long term or frequent antibiotic use / recent course of antibiotics, particularly during the perinatal period.

• Nipple damage.

• Maternal illness, stress, poor nutrition and vitamin deficiencies.

• Diabetes

• Thyroid or adrenal disorders.

• Systemic steroid use: eg prednisolone, hydrocortisone

• Wearing synthetic clothing

• Poorly controlled blood glucose levels in diabetes

• Baby with oral thrush

Symptoms

Symptoms may vary widely and may include some or all of the following:

Mother

• Burning, stinging nipple pain and itching

• Burning shooting breast pain radiating from the nipple back into the breast, sometimes into the back and down the arm, particularly during the 'let down' reflex. Sometimes a deep, aching breast pain

• Nipples may appear mildly inflamed, shiny, swollen or slightly flakey. Occasionally there may be traces of white in the folds. Often the nipples will appear normal.

• Nipple and breast pain may be felt during or after feeds, or may be continuous. Pain may range from mild to severe and may occur in one or both nipples/ breasts. Pain may be worse fifteen minutes after the feed.

• Persistent nipple pain/damage despite correct attachment.

• Delayed healing of nipple damage, without yellow crusting or exudate

• Sensitivity of nipples to touch.

Baby

• Mild oral thrush a white film adhering to the tongue, gums, buccal mucosa or roof of the mouth that doesn't remove easily with a cotton bud. (Often there will be maternal symptoms without obvious signs of oral thrush in the baby)

• Baby may pull on and off the breast due to oral discomfort if the infection is severe.

• Bright red nappy rash with red 'satellites' which may progress to small pustules. The skin on the buttocks may be inflamed, scaly or peeling.

Differential diagnoses

• Bacterial infection: if nipple damage is present. (Normally will present with exudate and crusting in addition to pain).

• Nipple vasospasm: if nipple pain is exacerbated by cold and/or nipples blanching.

• Nipple eczema/dermatitis: if significant itching and/or rash are present.

• Trauma from infant tongue-tie or other nipple trauma.

• Musculoskeletal pain radiating to breast and nipples

Inform the woman that she will need to be very diligent in following all the directions given to her in order to manage and treat the thrush and to prevent re-infection.

Management

Breast and nipple management

• Assess breastfeed to ensure correct positioning and attachment.

• Oral analgesia before feeds if required, e.g. paracetamol, ibuprofen. Avoid using analgesics containing codeine.

• Commence feeding on least affected side first.

• Express and feed EBM to baby by alternative means if pain severe. Consider alternating feeding with expressing.

• Air dry nipples after each feed.

• Change breast pads regularly.

• Air nipples in between feeds when possible, or wear breast shells.

• Avoid wearing a bra at night.

• Avoid synthetic bras and underwear in favour of cotton, this allows more air circulation.

• Avoid the use of silicone gel nipple pads.

General Management and Hygiene

• Emphasise importance of good handwashing

• Treat any other sites of fungal infection in the whole family

• Use of fresh bath towel daily.

• Wash nappies, towels, breast pads, bras and underwear in very hot water. Dry in sunlight if possible.

• Use clean bra every day.

• Drop dummies, teats, breastpump kits, shields and teething toys into boiling water and boil for ten minutes once a day. Air dry on a clean surface. Change dummies and teats regularly.

Treatment

Refer to CPG G0019 Appendix 1. Breast and nipple thrush prescription algorithm.

Provide mother with a copy of Appendix 2. Consumer Information handout: Breast and Nipple thrush treatment instructions.

Mother

Topical antifungal cream

• Apply miconazole cream to nipples and areola four times a day following a feed for 2 to 3 weeks and at least 1 week after symptoms have resolved.

• Cream does not have to be wiped off before the next feed unless the baby wants a top up very soon after application.

******* Note: Miconazole cream is preferred over miconazole gel as the gel may cause irritation and stinging for some women. However if the mother is already using miconazole gel without irritation she may continue to use this

Oral antifungal medication

• Fluconazole 150mg capsule every second day for (THREE DOSES) with one repeat prescription. This is a non-PBS funded medication.

• Review with Lactation Consultant after 1 week (phone or face to face consult). Complete second course of fluconazole if pain persists.

• Followed by nystatin 500,000 units per tablet / capsule, 2 tablets / capsules 3 times per day preferably with food for 7-10 days.

Unresolved Thrush

• If symptoms still persist after one week, fluconazole course may need to be repeated before commencing nystatin

• If symptoms persist after two weeks of treatment, consider fluconazole 150 mg daily for 10 days followed by course of nystatin as above (available only on private prescription)

• If breast pain does not respond to fluconazole reconsider the diagnosis or consider oral ketoconazole (as the infection may be caused by non-albicans Candida which may be resistant to fluconazole).

• If not resolving check for presence of underlying bacterial nipple infection, dermatitis, eczema, psoriasis or vasospasm of nipple.

• Consider gentian violet 0.5% aqueous paint - apply to nipples after breastfeeding twice a day for up to 7 days (made by compounding pharmacies).

Alternative nipple treatments

• Solution of bicarbonate of soda: one teaspoon bicarb to one cup of cooled boiled water. Keep in fridge and rinse nipples after each feed. Air dry then apply antifungal cream.

• Solution of vinegar: one tablespoon of vinegar to one cup of cooled boiled water. Rinse nipples after each feed, air dry, then apply antifungal cream.

There is no evidence that dietary changes can assist with management of breast and nipple thrush however many online sources encourage women to pursue dietary management. In view of this women who wish to pursue dietary management should be encouraged to maintain a healthy, well balanced diet. Dietary changes may include reducing the intake of the following foods:

• Refined sugars

• Alcohol

• Dried fruit and peanuts

• Cantaloupe (rock melon) and grapes

Baby

Oral antifungal medication - either miconazole gel OR nystatin oral drops can be used.

Safe use of miconazole oral gel:

• Warnings exist about a risk of infants less than 6 months of age choking on miconazole oral gel administered as a bolus by the supplied spoon. For this reason the manufacturer recommends that miconazole oral gel should not be used for infants under 6 months of age.

• If miconazole oral gel is to be used for an infant less than 6 months of age the parent or carer requires clear instructions from a healthcare professional regarding its safe use. Therefore, miconazole oral gel should be prescribed by a doctor and dispensed by a pharmacist, not bought over the counter for an infant less than 6 months of age.

• Instructions to the parent /carer must include the following:

• Apply orally, four times a day after feeds for 1 week then once a day for a further 1 week or longer until signs/symptoms resolve

  • Use the spoon supplied only to measure a 1/4 teaspoon dose.

  • The spoon supplied should NEVER be used to administer the gel into the infant's mouth.

  • Using a clean finger, remove the dose from the spoon and apply small amounts of gel to the inside of the baby's cheeks, roof of the mouth and over the tongue.

  • Appendix 2. BHS Consumer Information handout: Breast and nipple thrush treatment instructions include this information and should be provided to the parent whenever medication treatment for breast and nipple thrush is initiated.

Use of nystatin oral drops

• 1 mL (100,000 units) (half into each side of the mouth) orally four times a day (QID) after a feed.

• Continue for 2 days after symptoms have resolved.

If nappy rash is present, allow baby to go without a nappy where possible apply an antifungal cream e.g.

• Miconazole 2% applied BD and continued for at least one week after symptoms resolve, or

• Miconazole + zinc oxide (Daktozin) applied with every nappy change and continued for at least one week after symptoms resolve.

Follow-up

• Patient will need ongoing support from a Breastfeeding Service Lactation Consultant until symptoms resolve.