Thrush (Candida Albicans Infection)

by Dr. Ruth Lawrence

Candidiasis is a fungal infection usually due to candida albicans species.  The fungus has been identified at many sites in the healthy individual but rarely causes disease except during pregnancy, lactation, and in the newly born or the immuno compromised individual.  Common sites for this infection in the mother are the vagina and the breast in the lactating woman and the mouth and diaper area in the neonate.  A study by Amir and colleagues reported cultures of 125 women who were lactating and 31 non-lactators.  Nineteen percent of those with breast pain grew the fungus on the nipple and in the milk.  Only 3% were positive in the pain-free group and none in the non-lactating group.  Staphylococcal aureus was cultured in 34% of the pain group, in 5% of the pain free lactating women, and in none of the non-lactators.  These data confirm the statement that not all burning breast pain is due to thrush.  The infant may actually harbor candida without any mouth or perineal lesions.

The classic description of thrush of the breast is burning pain - mothers often describe it as feeling like being stabbed with a hot poker when their infant suckles.  The nipples themselves may not appear unusual.  Occasionally, they are described to have a pink hue.  Others describe a red or purple hue.  Vesicles, papules, or pustules are not thrush, although they usually represent significant disease.

Thrush in the neonate is manifest by white caseous coating on the inner surfaces of the cheeks and on the surface of the tongue.  Although it looks like curdled milk, it cannot be scraped off. In severe cases, suckling is painful for the infant.  A candida diaper rash is perineal, spreading from the anus anteriorly including the creases.  In contrast, a contact dermatitis excludes the creases.

Confirming the diagnosis can be done by culturing the nipple/areolar area, the milk and the infant's oral cavity.  The diagnosis requires more than one symptom or sign: if a mother has burning pain on feeding, there should be evidence of thrush infection in the neonate's mouth or perineum, a history of maternal vaginal thrush or recent maternal treatment with antibiotics.  Positive cultures would confirm the diagnosis.

If treatment is undertaken, both mother and infant should be treated simultaneously.  The course of disease often begins with asymptomatic vaginal colonization which seeds the infant during delivery through the vagina.  The infant in turn infects the nipple and areola.  The mother may be infected by her partner, and this should always be investigated especially if the infection is resistant to the first round of treatment or recurs.

Treatment for the mother should include local ointment applied to the nipple and areola after feedings as well as systemic antifungal treatment such as fluconazole.  Treatment should extend at least ten days even if symptoms clear.  The mother should dry her nipples after a feeding as moisture encourages fungal growth. Nystatin ointment or Myconazole cream works best.

Treatment for the infant should begin with rinsing the mouth after a feeding.  A few mouthfuls of water by medicine cup remove the milk from the mouth, which encourages the growth of the fungus.  Then Nystatin can be applied with a disposable swab directly on the oral lesions.  Diaper rash is treated with Nystatin ointment. It should be applied after each feed for three days, then alternate feeds for a full ten days of treatment.

Should Nystatin fail to cure confirmed thrush, Myconazole cream can be used. Many feel that Miconazole gel applied to oral mucous membranes and perineum is the treatment of choice for the infant.  If the newer antifungals fail, a reassessment of the diagnosis is appropriate since only one third of cases of burning nipple pain actually grow candida, a third grow staphylococcus and a third have no significant growth. Geniten violet, a purple dye, has been used for decades prior to antibiotics and may be effective.  It is applied to the lesions and turns everything purple.  Geniten must be applied fresh daily to effect a cure.

It is important to recognize that the mother must change her disposable breast pads frequently and be treated for vaginal infection if necessary.  Decreasing sugar in the diet and colonizing the body with lactobacillus by consuming unpasteurized yogurt or taking acidophilus capsules are supplement treatments effective in resistant cases.

Anything that goes in the infant's mouth such as a pacifier, bottle, or teething ring must also be sterilized daily or discarded.  Children who use pacifiers have a greater frequency of relapse than non-pacifier users.  A study of healthy infants, both breast and bottle fed, revealed 48% positive equally in both groups in both breast and bottle.  Only pacifier had a significant influence increasing the rate of positives.

Systemic medication with Fluconazole is indicated when local treatment has been in effect or there is recurrence.  Simultaneous treatment of mother and infant is essential.