
Anne
Smith, BA, IBCLC, has been in the business of helping mothers
breastfed successfully for more than 20 years. Not only is Anne an
International Board Certified Lactation Consultant, but she is also
a certified La Leche League Leader and mother of six breastfed
children! And yes, she has experienced just about everything first
hand - cracked nipples, mastitis, engorgement, colic, slow weight
gain, jaundice...you name it.
Anne has gained a lot of experience in various areas of lactation
over the years. She has led group support meetings, taught
breastfeeding classes, trained breastfeeding peer counselors to work
with low-income mothers, worked one-on-one with mothers to solve
breastfeeding problems, held breastfeeding workshops for health
professionals, and taught OB, Pediatric and Family Practice
residents at Bowman Gray School of Medicine. Anne's
also runs Breastfeeding
Basics (www.breastfeedingbasics.com) a Web site where you can
find great breastfeeding information and products, including Medela
pumps and pump accessories. Anne also answers breastfeeding
questions online at Breastfeeding
Basics.


Are there alternatives to
treating a staph infection?
| NAME: |
Chris
|
| BABY'S NAME: |
Paul |
| BABY'S AGE: |
8 weeks
|
Anne
,
I was just diagnosed with a staph infection (culture done on my
nipples). This was after they first told me I had "intra-ductal
yeast" and took two doses of Diflucan. My main concern is
that my doctor wants me to take seven days of Bactrim, which of
course I will have to pump and dump and formula feed. I do not
want to do this plan of treatment. Do you have any suggestions?
Breastfeeding has been great. I'm afraid the baby will not
take the breast after the treatment. Thanks in advance for your
time.

Chris,
You do not have to "pump and dump" if you are taking
Bactrim. Dr. Thomas Hale says in Medications and Mother's
Milk that Bactrim is "secreted in breastmilk in small
amounts." There are no pediatric concerns reported via
milk, but it should be used with caution in weak or premature
newborns, babies with elevated bilirubin levels, and infants
with G6PD (an uncommon medical disorder).
Assuming that your little boy doesn't fit into any of these
categories, there should be no problem taking Bactrim for a
week. I am wondering why your doctor prescribed that particular
antibiotic for a staph infection. According to two pediatricians
that I consulted, Bactrim is not the first drug of choice for
staph. Antibiotics like cephalosporin and Augmentin are most
often used to treat staph infections in nursing mothers.
The majority of antibiotics are safe for nursing mothers to
take, since they enter milk in very small amounts, and most of
them are given directly to pediatric patients who receive a much
higher dose than they would in the breastmilk.
The "intra-ductal" yeast is a whole different issue.
Once the yeast has invaded your milk ducts, it is extremely
difficult to get rid of. The milk ducts provide a perfect
environment for yeast to grow - it thrives on moisture and
sugar, so breastmilk is a perfect culture medium for it. Dr.
Hale says that "because symptoms of ductal candidiasis are
sometimes slow to resolve, many clinicians now recommend 2-4
weeks of therapy. A minimum of 2-3 weeks is mandatory to clear
systemic infections."
Many health care providers are not aware that a single dose (or
even two doses) of Diflucan is not sufficient to clear up yeast
once it is in your milk ducts. The standard dose for a vaginal
yeast infection is one or two 150 mg tablets, and that almost
always takes care of the problem. Unfortunately, this treatment
doesn't even begin to clear up intra-ductal yeast in most
nursing mothers. One or two doses may make you feel better for a
couple of days, but then the infection usually comes back with a
vengeance. Getting rid of yeast can take weeks and weeks of
treatment, but if you don't treat it aggressively, it can hang
on for months and months. Make sure that your doctor understands
the difference between the treatment for a vaginal yeast
infection and that for an intra-ductal infection.
I consulted Dr. David Spencer on this one just to be sure.
He is
a board certified cosmetic surgeon (so he knows breasts), a
board certified dermatologist (so he knows skin problems), and a
board certified pediatrician (so he knows babies). I think he
plays the flute pretty well too. He's an amazing guy.
He has
had a special interest in breastfeeding problems (especially
mastitis and yeast) since his wife had trouble with yeast ten
years ago when she was nursing their son.
The dosage that Dr. Spencer recommends is a 400mg loading dose
on the first day, then 200 mgs a day for moms over 150 lbs, a
300 mg loading dose for mothers between 125-150 lbs, then 150 mg
a day after that, and a 200mg loading dose and 100mg a day for
the duration of therapy for mothers less than 125 lbs. His
standard treatment is 14 days minimum, but treatment may
continue for up to 6-8 weeks, depending on the mother's
response.


Tried nystatin and gentian
violet - still have thrush!
| NAME: |
Anne |
| BABY'S NAME: |
Mitchell |
| BABY'S AGE: |
9 weeks
|
|
BIRTH WEIGHT:
|
8lbs 7ozs
|
|
CURRENT WEIGHT:
|
12 lbs 8ozs |
During
an intense labor that resulted in a c-section, I was given
antibiotics intravenously. Weeks later my son had a mild case of
thrush on his tongue, and I was experiencing an occasional
burning sensation in my nipple that shot up through the ducts.
We both were treated with nystatin for 2 weeks. It didn't seem
to help the thrush, and last week we saw our pediatrician and
she put us on gentian violet. I swabbed his mouth once a day for
3 days. I also put the treatment on my nipples.
Today is day 4 and he still has a small bit of white on his
tongue and my nipples are still feeling occasional pain. I am
avoiding a lot of sugar, am taking acidophilus supplements
daily, boil everything, and have not had a vaginal yeast
infection throughout this whole ordeal. I am getting frustrated.
I guess my question is...what next?

Anne,
Coping with yeast infections has got to be one of the most
frustrating situations a nursing mother ever has to deal with.
I
think it's worse than sore nipples, engorgement, and mastitis
all put together, because all of those problems are temporary,
but yeast can linger and make your life miserable for months and
months if you don't treat it aggressively. Many mothers wean
due to the pain and stress caused by yeast infections, which is
especially unfortunate since once you have yeast on your nipples
or in your milk ducts, it doesn't go away just because you
stop nursing. I have worked with moms who gave up and weaned
their babies, and then were still in so much pain a month or
more later that they couldn't pick up their babies without
discomfort.
One of the problems in treating yeast is that some nasty strains
have developed over the past few years and are becoming
resistant to the old standard treatments. It's very similar to
the strains of penicillin resistant bacteria that have become
such a concern to everyone in recent years. For the first 20
years that I worked with nursing mothers, yeast (or thrush) was
a minor nuisance. The baby's mouth had some white patches, the
mom's nipples stung a little, the baby had a diaper rash, you
treated the problem with nystatin ointment or drops for a week
or two, and it went away. Over the past few years, however,
yeast has become a huge problem instead of a minor nuisance.
More and more mothers are developing infections, (possibly due
to increase in c-sections and general overuse of antibiotics),
the infections are more painful and more likely to enter the
milk ducts, and the old standard "nystatin" doesn't
work very well anymore. Dr. Hale reports in Medications and
Mother's Milk that "due to the emergence of
resistance to other antifungals, particularly nystatin, the use
of fluconazole (Diflucan) is increasing". For babies with
oral thrush, the cure rate is 46% for patients treated with
nystatin, versus 86% for babies treated with Diflucan. Since one
of the key factors associated with getting rid of yeast and
making sure it stays gone is treating both mother and baby, then
it makes sense that if you are treating your baby for weeks and
weeks with something that works less than 50% of the time, you
may have a very hard time getting rid of the yeast completely.
I personally feel that if the nystatin is going to work, you
will know it within a few days of treatment. If you're not
seeing rapid improvement during that time, then I would ask your
doctor for another anti-fungal treatment, like Diflucan.
Diflucan is available in tablet form for mothers, and in a
pediatric suspension for babies. No complications from exposure
to Diflucan exposure in breastmilk have been found, and Dr. Hale
states that it's use in pediatric patients is increasing, with
90% of practitioners using it. All the things you are doing, like reducing sugar intake,
boiling anything that touches the baby's mouth, and taking
acidophilus are great, but are probably not enough to clear up
the problem without effective medications. I would ask your
doctor about what your other options are if the nystatin hasn't
gotten rid of the yeast after weeks of treatment.
By the way, the fact that you haven't had a vaginal yeast
infection isn't surprising. Yeast hardly ever shows up neatly
in all places at once. It would be a lot easier to diagnose if
the baby had a white tongue and a diaper rash at the same time
mom had a vaginal yeast infection, burning nipples, and sharp
pain inside her breast. The fact is that it usually shows up one
place, then maybe weeks later in another, and maybe not at all
in some areas. I personally wish that yeast would make your
breasts turn bright green or something equally dramatic just so
we could be sure the problem was yeast. It's sometimes awfully
hard to tell, because so many of the symptoms (like diaper rash,
nipple soreness, and gassiness) can be caused by other things.


Taking Terazole for thrush –
how should I wash my breasts before each feeding?
| NAME: |
Georgia |
| BABY'S NAME: |
Sam |
| BABY'S AGE: |
3.5 months
|
|
BIRTH WEIGHT:
|
8lbs 1oz
|
|
CURRENT WEIGHT: |
15 lbs |
My
son and I have thrush (we've had it for about 6 weeks but,
embarrassed biology major that I am, I did not realize what it
was till I described my 'blocked nipple duct' and white patches
in my son's mouth to a breastfeeding friend, who recognized it
as thrush). So, now we have the Nystatin suspension (he's
learning how to spit it out instead of swallow it) and my OB/GYN
prescribed Terazole for my nipples. He told me that I need to
wash it off "really well" before I feed the baby, and
that as a general practice I ought to be washing my breasts both
before and after feeding the baby. I was a bit surprised by
this, since everything I have read says, "Just use water!
No soap!" etc. So I have compromised by vigorously
scrubbing my nipples with a warm wet washcloth to remove the
antifungal cream. Your opinion/advice?
Also, if I need to boil everything connected with my milk
supply (such as all parts of breast pump, nipples for bottles,
etc.), should I also put all his toys (which also ALL go into
his mouth lately) through the washer/dishwasher? And, more
importantly, should I discard all the frozen breast milk that
might be affected? Or will freezing kill the yeast? (I used to
prepare yeast cells [for experiments] that were stored at -80
deg C after freezing in liquid nitrogen, so I'm not hopeful that
my lowly home freezer can kill Candida in the milk.) No one
seems to have addressed this point in the reading I've been
doing.
Thanks.

Georgia,
I'm so sorry that you had to go through weeks and weeks of
discomfort and/or pain before figuring out what the problem was.
That is one of the biggest problems with diagnosing yeast.
The
only definitive cultures for yeast are not difficult to perform,
but can only be done in certain specific labs under very
specific conditions. Most OB's offices are not equipped to do
these tests, and only some dermatologists offices. Because of
the difficulty of coming up with a positive culture, most health
providers base the diagnosis on clinical symptoms. The problem
is that the primary and most troubling symptom in the mother is
severe nipple pain, and many mothers expect soreness as part of
the breastfeeding process, especially if they are first-time
mothers and don't have anything to compare the pain to. Moms
can come up with all kinds of excuses about why their nipples
suddenly become sore: "He has such a strong suck...I must
have sensitive skin...she's teething...etc." The bottom
line is that breastfeeding a baby should not hurt,
especially after the first couple of weeks, and if it does,
there is a problem that needs to be addressed quickly before it
turns into a much bigger problem (like intra-ductal yeast).
In my previous answer, I talked about why nystatin may not be
clearing up your yeast. If it seems to be working, by all means
stick with it (your baby may be in the lucky 46th
percent), but if it doesn't work in a few days, I'd ask the
pediatrician about prescribing something else.
The Terazol is an antifungal agent that can be very effective,
but it does not need to be washed off before feedings at all. I
consulted Dr. David Spencer (cosmetic surgeon, dermatologist,
and pediatrician) and he assured me that none of the topical
antifungals (like Nizoral, nystatin, miconazole,clotrimazole, or
Terazol) need to be removed before nursing. He said that they
are absorbed very quickly, in about 10-15 minutes, and the
amount the baby would receive while nursing would be
insignificant.
I can't imagine why any doctor who has read any breastfeeding
literature in the past 25 years would recommend that you wash
your nipples before and after nursing. The next time your doctor
suggests something that just doesn't sound right to you, ask
him (respectfully) to back up his advice with some written
references. It would be interesting to see what he comes up
with. I suspect that he would be hard pressed to come up with
any research to support "vigorously scrubbing your nipples
with a wet washcloth." Ouch! Just the idea of scrubbing
yeasty nipples with anything is painful to think about.
Please don't do that anymore, unless your doctor comes up with
some convincing proof that it is necessary - and if he does,
please let me know. I'd love to see it.
I think that boiling everything that touches the baby's mouth,
running it through the dishwasher, or microwaving it for 5
minutes, is a good idea, even though it is a huge pain. I don't
think that those measures alone will make a huge difference, but
it's a good idea if you can do them. However, it's much more
important to treat the yeast aggressively than to be really
compulsive about boiling everything.
The question about whether freezing kills the yeast is the
subject of much debate. The answer depends on whom you ask.
For
years, we were told that freezing didn't kill the yeast
spores, and that you could use milk that you expressed during
treatment (which usually lasts for weeks), but that you should
not freeze milk expressed during that time because you could
re-introduce the fungus and start the whole horrible process
over again if you offered the milk months later. Recently, some
experts have questioned whether this is a valid concern. In his
new book Dr. Jack Newman's Guide to Breastfeeding, Dr.
Newman says: " Throwing away frozen milk collected while
the mother has her problem with yeast seems to me a terrible
waste. Although freezing the milk does not kill the yeast, it is
likely, given the antifungal factors in breastmilk, that the
fungus will remain in a form (deactivated) that does not cause
problems." Dr. Spencer (the cosmetic
surgeon/dermatologist/pediatrician) agreed. He said that the
likelihood of reintroducing the yeast was miniscule, especially
if the baby was not a newborn.
Since the information is conflicting, here is what I recommend:
I would not throw any "liquid gold" away. I would mark
it clearly with the date and the fact that it was
"yeasty" at the time you froze it. I would save it for
a time when you really needed it, and during that time period,
your baby will be getting older and less susceptible to the
yeast if you do reintroduce it.. Maybe you'll never need it,
but if you do, it's probably fine to use.

 What does thrush look like on
Mom?
| NAME: |
Rhea |
| BABY'S NAME: |
Nicholas |
| BABY'S AGE: |
2 months
|
|
BIRTH WEIGHT:
|
8lbs 14 1/2 oz |
|
CURRENT WEIGHT:
|
over 10lbs |
What
exactly do you look for with thrush? I know what it looks like
in a baby's mouth, but not on me. Please help me with this.

Rhea,
One of the problems in diagnosing thrush is that it can present
in so many different ways. The mother's nipples can be
exquisitely painful, yet look completely normal. They can also
have tiny blisters or white patches, or be flaky, itchy, or
shiny. The most common symptom is severe nipple pain, which
often occurs after a period of pain free nursing. If the nipples
look different at all, they will usually be pink or reddish.
If
the yeast has been untreated for a long period of time, the
nipple tissue can break down and cause cracks and fissures.
Mothers with yeasty nipples will usually describe pain that
persists all the way through the feeding, as opposed to easing
off after the initial latch and let-down. The pain often occurs
between feedings as well, especially immediately after feedings.
The pain may radiate into the mother's back, armpit, or
shoulder. This usually indicates that the yeast has reached the
milk ducts. The pain from an improper latch is usually described
as "sharp" or "stabbing." When a mother has
a yeast infection, she usually describes the pain as
"burning" or "stinging." I have heard the
most graphic descriptions of pain from yeast infections: mothers
have told me everything from "It feels like a piece of
glass inside my nipple" to "It feels like someone is
holding a blowtorch to my breast" to (this one is my
favorite) "I'd rather go through labor than be in this
much pain." When mothers describe this kind of pain -
the
kind that makes you curl your toes and break out in a cold sweat
- I tend to take them very seriously and suspect a yeast
infection. It is unfortunate that yeast often doesn't make the
nipples look nearly as bad as they feel, because many mothers
have had to deal with the frustration of having their doctor
look at their nipples and say "Hmmm. They don't look that
bad to me. Put tea bags on them and call me back in a couple of
weeks if they aren't better." Arrgggghhhhhh!!!!!!


Recovering from thrush, but
nipples still red
| NAME: |
Melanie |
| BABY'S NAME: |
Madeline |
| BABY'S AGE: |
4 months
|
|
BIRTH WEIGHT:
|
5lb 11oz
|
|
CURRENT WEIGHT:
|
11lbs |
Hi
Anne,
We battled thrush for several months. I did the vinegar rinse on
nipples, bleach and vinegar on the bras etc., went topless, did
nystatin, did diflucan, cut out sugar, boiled everything, ate
yogurt and took acidipholus tablets and then gentian violet.
The
pain resurfaced two times and went away with gentian violet.
I
use gentian violet about once a day now on my nipples or every
other day just to make sure. My nipples are still red - is this
normal? Can I start to freeze my breastmilk?

Melanie,
It sounds like you tried really hard to tame the yeast monster.
I once had one of my nursing moms tell me that she wanted to
form a "Yeast Survivors's Group," just for women who
had fought yeast and finally won. It can be a long, drawn-out
battle. Mothers who have been fortunate enough to never have
yeast just don't know how lucky they are to be able to nurse
their babies without clenching their teeth and taking deep
breaths. You have to be really committed to nursing to hang in
there after everything you've been through, but trust me, it's
worth it.
The fact that your nipples are still red and you are having
periodic episodes of pain indicates to me that you never really
got rid of the yeast in the first place. The nystatin often isn't
very effective, and the Diflucan only works if you take it for
long enough (and most doctors don't prescribe it for long
enough to be effective). The problem with gentian violet is that
it can be very irritating and drying to the skin, especially if
used over a long period of time. That's one of the reasons
that most practitioners recommend using it for no more than a
week, and optimally only for about three days. The question of
whether gentian violet is toxic when used for a long period of
time has not been answered, but chances are that it won't hurt
to keep using it, especially if your skin doesn't seem to be
irritated from it. It would probably be better to treat the
yeast with a more effective treatment, such as Nizoral cream on
your nipples, or a longer course of Diflucan if you weren't
given a full course the first time around. If you do continue
using the gentian violet, I would consider diluting it half and
half if you are using the standard 1% solution. That would
reduce the risk of irritation or ulceration somewhat.
As far as freezing the milk during a yeast infection, check out
my answer to Georgia (question #3).


Are there alternative
treatments for thrush
other than nystatin?
| NAME: |
Angela |
| BABY'S NAME: |
Katelin |
| BABY'S AGE: |
8 weeks
|
|
BIRTH WEIGHT:
|
7lbs 3oz
|
|
CURRENT WEIGHT:
|
9lbs |
Is
there an alternate medication or treatment for thrush other than
nystatin? How about Diflucan?

Angela,
I think I've pretty much covered the question of how effective
nystatin is (or isn't) in the previous answers. I can give
you a little more information about the Diflucan, though.
Diflucan is effective against a wide variety of fungal strains
(yes, there are many varieties - that's why one antifungal
treatment will work and another not do a darn thing against a
particular strain, and since it is so difficult to culture the
yeast and tell exactly which strain you're dealing with, the
treatment is often hit or miss). Dr. Hale reports that "Of
the antifungals, Diflucan is very well tolerated. In
adults, side effects are usually minimal and include GI symptoms
such as vomiting, nausea, diarrhea, and abdominal pain.
Pediatric complications from oral ingestion include the same symptoms.
No
complications from exposure to breastmilk have been found."
The safety profile for fluconazole (Diflucan) is very similar to
that of nystatin. At this time, there is no other medication
that I know of that is as effective in treating yeast
(especially if it has reached the milk ducts) as Diflucan.
There are numerous alternative treatments for yeast infections.
These include acidophilus (moms can take it three times daily,
and babies can take acidophilus or "baby bifidus" in
liquid form, or on a finger dipped in the powder), a mixture of
vinegar and water (1 Tablespoon to 1/4 cup in a cup of water)
applied to the nipples several times a day, olive oil applied
after feedings, zinc (45 mg daily), garlic tablets (triple
strength deodorized tablets - take 3 tablets 3 times daily),
Caprylic acid (2-3 capsules 3-4 times daily for 2 weeks), and
Lecithin (two 250 mg capsules taken 3 times a day).
These are just some of the alternative therapies for treatment
of yeast. For more information about alternative therapies, I
recommend Chris Hafner-Eaton's excellent article Good News
for Breastfeeding Moms: Treating and Preventing Thrush in
the March/April issue of Mothering Magazine (#99).


Is this thrush again?
| NAME: |
Dawn |
| BABY'S NAME: |
Ian |
| BABY'S AGE: |
9 months
|
|
BIRTH WEIGHT:
|
8lbs 15oz
|
|
CURRENT WEIGHT:
|
20lbs 14oz |
We
had thrush for the first time a couple of weeks ago that I
thought had gone away. We have it again, or at least I think
that it is thrush again. His mouth has the white spots; my
nipples are sore and burn after feeding. I have noticed that
there are white little spots surrounding my nipples. I have been
treating both of us for thrush for three days now, but my
condition is not improving. Is this thrush, or do we need to see
our doctors for another diagnosis?

Dawn,
You
probably still have thrush. It usually takes several weeks of
treating thrush aggressively and consistently in order to get
rid of it completely. It certainly sounds like you still have
many of the classic symptoms.
You didn't say how you are treating the thrush, but if the
treatment is working, you should see some improvement after a
few days. If there is no improvement at all, or if the symptoms
are getting worse, you need to think about a different or more
aggressive treatment. You might want to try the gentian violet
and a different antifungal cream. One key to treating yeast is
to find the antifungal agent that works for you, against your
particular strain of yeast. The other key is to treat your baby
at the same time, and make sure that the treatment is working
for him as well. I don't see any point in a doctor phoning in
five refills of the nystatin week after week. If one treatment
isn't working, try something else until you hit on the
combination that works for you and your baby.
Going to your doctor probably won't do much good at this
point. Since it is very difficult to culture for yeast, your
doctor will go by the same things you're going by: the
symptoms. He or she can't see anything that you can't see
for yourself. You're probably better off at this point in
trying some of the over the counter treatments like gentian
violet or clotrimazole and giving them a chance to work, then
consulting your doctor about the possibility of prescribing a
stronger prescription medication like Diflucan if the symptoms
get worse instead of better, or if the yeast seems to have moved
into your ducts.


Should I use nystatin to
prevent thrush?
| NAME: |
Linda |
| BABY'S NAME: |
Sara |
| BABY'S AGE: |
12 months
|
|
BIRTH WEIGHT: |
7lbs 11ozs
|
|
CURRENT WEIGHT:
|
21lbs |
My
daughter is on prophylactic antibiotics for reflux, and I'm
paranoid about her getting thrush. Another daughter got it and
gave it to me before. Should I use nystatin all the time just in
case, or should I wait for symptoms? She has thrush on her
bottom at the moment and I keep checking her mouth for it, but
it's quite hard to see.

Linda,
I consulted Dr. Spencer on this one, and he felt that it would
not be a good idea to use nystatin on a daily basis to prevent
yeast. While nystatin is exceptionally safe, it may cause side
effects such as gas, nausea, or fatigue. Since nystatin isn't
all that effective anymore, I recommend its use only when a
mother has symptoms and the baby doesn't. In that situation,
it may act as a preventive. If the baby does develop symptoms of
oral thrush while on the nystatin treatment, I would ask the
doctor to prescribe an alternative, more effective medication
like Diflucan pediatric oral suspension.
You might also want to consider using acidophilus as a
preventive. Dip your finger in the powder and let the baby suck
or lick it off, or swab his mouth with acidophilus diluted in
breastmilk. Some health food stores offer "baby bifidus,"
especially formulated for infants or very young children.
I don't blame you for being paranoid. Anyone who has
experienced yeast while nursing has every right to be paranoid,
and will go to great lengths to avoid going through that
experience again. Just remember that some mothers and babies
never trade yeast back and forth, while others just can't seem
to get rid of it. I think that the best approach is to watch
diligently for early symptoms, and nip them in the bud before
they develop into a big problem.

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