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?
	Tried nystatin and gentian violet - still have thrush!
	Taking Terazole - how should I wash breasts before a feeding?
	What does thrush look like on Mom?
	Recovering from thrush, but nipples still red
	Are there alternative treatments for thrush other than nystatin?
	Is this thrush again?
	Should I use nystatin to prevent thrush?

Are there alternatives to treating a staph infection?

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!

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?

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 46^th 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?

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

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?

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?

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?

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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