As you read the post title, some of you are saying, “what the heck is that?” while some of you are groaning in remembered agony.  For the uninitiated – you know yeast infections?  Well, you can get one in your nipples when you’re breastfeeding.  And they hurt like hell.

A “yeast infection” is caused by candida albicans, a fungus. Yeast used in making alcohol and bread is saccharomyces cerevisiae, which is in the same taxonomic family as candida, but is a different genus and species.  It has no role in yeast infections.

Candida is normally present on our skin, it’s just when it grows out of control that it becomes a yeast infection.  That also means that it’s difficult to diagnose – a culture isn’t going to reveal whether it’s just “some” yeast or “too much.”  So diagnosis is usually done by looking at the mom’s symptoms and history. Predisposing Factors include recent use of antibiotics, hormonal changes during pregnancy, and nipple trauma.

For the mother, the most noticeable symptom of nipple yeast is pain.  Pain that makes you writhe, makes you dread nursing.  Mothers with bad cases describe it as having their nipples rubbed with broken glass.  It’s often accompanied by itching or burning, and it stays the same or gets worse as a nursing session goes on.  If it hurts when the baby latches on, but gets better once he’s on there, it’s not likely to be yeast.

Other symptoms can include dry, peeling, flaking, red or shiny skin, blebs, recurrent mastitis, or yeast infection in another part of the body.

In the baby, symptoms of candidiasis include white patches in mouth, a pearly look to saliva and insides of lips, excess gas,  fussiness, refusal to nurse, and clicking during nursing.   The baby may have a raised red diaper rash with outlying red bumps.  Most importantly, the baby may have no symptoms.  This is something many doctors seem ignorant of.  A mom says she suspects yeast, the doctor looks in the baby’s mouth and doesn’t see white patches, and says it’s not yeast.  A lot of the time, the only evidence of a yeast infection is the mother’s pain, and some doctors won’t take that seriously. Another mistake many doctors make is treating only one half of the nursing dyad.  The standard of care is to treat mother and baby whenever one shows symptoms of candidiasis.  Otherwise, one is constantly passing a new load of yeast to the other, despite treatment.

So what are doctors going to prescribe for this treatment? Basically, there’s Nystatin, azole creams, fluconazole, and All Purpose Nipple Ointment.

Nystatin is the traditional treatment for babies with candida overgrown in their mouths.  Unfortunately, it now has relatively poor effectiveness, due to the evolution of resistant candida.  According to the experts, “Use should be limited to never-treated cases of thrush.” (Riordan & Wambach, Breastfeeding and Human Lactation, 4th Ed.)  Possible side effects include skin irritation, diarrhea, nausea or vomiting,and  stomach pain.Azole creams miconazole and clotrimazole can be found labeled as athlete’s foot and jock itch remedies at the drug store (there are other drugs used for athletes foot and jock itch that aren’t necessarily safe for nursing – it’s important to read labels!).  They can also be used on a mother’s nipples, and according to Jack Newman, M.D., they don’t have to be washed or wiped off before nursing as long as they’re applied sparingly after a feeding.  Possible side effects are burning, redness, skin rash, blistering or other skin irritation.

Fluconazole is a systemic drug, taken orally. Newman recommends 400mg loading dose, followed by 100 mg twice daily until mother is pain-free for a full week, and this regimen can be really effective, especially when other treatments haven’t worked.  This can be used along with topical treatments, and has been used in newborns and premature infants in the hospital, though I’m not sure if pediatricians will prescribe it generally.  It has little transfer into mother’s milk.  Possible side effects include acid or sour stomach, belching, change in taste or bad, unusual, or unpleasant (after) taste, heartburn, indigestion, stomach discomfort or upset.

All Purpose Nipple Ointment is an invention of Jack Newman’s.  It combines antifungal, antibiotic, and corticosteroid drugs into one cream, to kill yeast and opportunistic bacteria while reducing inflammation (and thus pain).  It needs to be prepared by a compounding pharmacy, and it can’t be used in a baby’s mouth, but it can be well worth the effort for a suffering mom.  The formula is Mupirocin 2% ointment (15 grams) + Betamethasone 0.1% ointment (15 grams) + Miconazole powder to make final concentration 2%.  There have been no clinical trials for efficacy or toxicity, and under some circumstances, corticosteroid element may favor yeast growth.

Next time: Alternative treatments for candidiasis