Candida (yeast) infections of the nipple and ducts
Candida infections of the nipples may occur any time while the mother is breastfeeding. Candida albicans likes warm, moist, dark areas. It lives normally on us, and 90% of babies are colonised by it within a few hours of birth. It only becomes a problem under certain circumstances. Candida infections of the skin or mucous membranes are more likely to occur when there is a breakdown in the integrity of the skin or mucous membrane—another reason why a good latch is very important from the very first day. Many Candida infections would, perhaps, not have occurred, if the mother had not had sore nipples and a breakdown of the skin of the nipples and areola. The oozing of serum which occurs often in cracked nipples turns Candida albicans from its harmless form to a disease causing form.

The widespread use of antibiotics also encourages the overgrowth of Candida albicans. Many pregnant women, women in labour, and new mothers, as well as their babies receive antibiotics, sometimes with very little justification.

Diagnosis of Candida infections of the nipples and/or ducts
There is no good test which helps makes the diagnosis. A positive culture from the nipple(s) proves little. Neither does a negative culture. The best way to make a diagnosis is by history.

The presence or absence of a Candida infection in the baby is not helpful. A baby may have thrush all over his mouth, but the mother have no pain. A mother may have the classic symptoms of a Candida infection of the nipples, and the baby have no thrush or diaper rash.

The typical symptoms of a Candida infection of the nipples are:

• Nipple pain which begins after a period of pain free nursing. Though there are a few other causes of nipple pain which begin later, Candida infection is definitely the most common. The nipple pain of Candida may begin without an interval of pain free nursing, however.

• Burning nipple pain which continues throughout the feeding, sometimes continuing after the feeding is over.

• Pain in the breast which is "shooting" or "burning" in nature and which goes through to the mother’s back and shoulder. This pain is usually worse toward the end of the feeding, and worsens still more after the feeding is over. It also tends to be much worse at night. This pain may occur without any nipple pain.

• Pain, as above, which is made much better with the use of gentian violet.

Treating Candida Infections
Our first approach to treating these infections is gentian violet (handout #6 Using Gentian Violet) plus all purpose nipple ointment (handout #24 Treatments for Problems). This approach is safe, works rapidly, and almost always, though there seems to have been a decrease in the effectiveness of gentian violet over the past few years. For this reason, I now use a combination. A good response to gentian violet confirms that the mother’s nipple pain is caused by Candida since little else will respond to gentian violet. It thus also justifies the use of fluconazole, if needed.

Fluconazole
Fluconazole is an antifungal agent which is taken systemically (taken by mouth or intravenously). It is fungistatic, which means that it stops fungi (such as Candida albicans) from multiplying, but does not actually kill them. This accounts for the fact that sometimes it takes several days to have an effect.

Side Effects
Fluconazole is generally well tolerated, but there is no such thing as a drug which never has side effects. Concern about liver injury is exaggerated, since this complication seems quite rare, and usually occurs in people who are taking other medications as well, and who have taken fluconazole for months or longer, and who have immune deficiencies. But it is a possibility that needs to be kept in mind and if it does occur, it can be very serious. Vomiting, diarrhea, abdominal pain and skin rashes are the most common side effects. These are not usually severe, and only occasionally is it necessary to stop the medication because of these side effects. Allergic reactions are possible but uncommon. Call immediately if you have any concerns.

Fluconazole in the milk
Fluconazole does appear in the milk, and this is as it should be, since the idea is to treat infection in the ducts and nipples. It is thus superior to ketoconazole, which gets into the milk in only tiny amounts. The baby will obviously get some, but this drug is now being promoted for use in babies for the treatment of simple thrush. There have been no complications in the baby reported from exposure to fluconazole in the breastmilk. Continue breastfeeding while taking fluconazole, though you may be told you cannot.

Dose of fluconazole
Candida albicans is learning to become resistant to fluconazole, and the dose we use has increased over the past few years. Only a few years ago, 100 mg daily for 10 days cured 90% of women of their symptoms. We have now found this to be inadequate. For resistant cases, a newer antifungal agent, itraconazole, can be used, though it may not be the answer either, as it does not have a very powerful effect against Candida. Your prescription will be for fluconazole 400 mg as a first dose, followed by 100 mg twice daily for at least two weeks. If you have nipple pain continue with the "all purpose nipple ointment" while you are taking fluconazole. We like the mother to be symptom free for at least a week before stopping the medication. This seems, on the basis of our experience, a fairly good guarantee against relapse. However, this means that although most mothers require only the usual two weeks, some need longer treatment. Occasionally it may take up to a week for the pain to even start going away. Call if there is no relief in seven days.

It is sometimes useful to treat the baby as well. The dose for the baby would be 6 mg/kg as a first dose, followed by 3 mg/kg/day as one dose for the same period of time as the mother.

Jack Newman, MD, FRCPC is a pediatrician, a graduate of the University of Toronto medical school. He started the first hospital-based breastfeeding clinic in Canada in 1984. He has been a consultant with UNICEF for the Baby Friendly Hospital Initiative in Africa. Dr. Newman has practiced as a physician in Canada, New Zealand, and South Africa.

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