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Nipple Yeast, Part 2 – Alternative Treatments and What’s in Them

OK, this is what you’ve been waiting for – “natural” and alternative remedies for candidiasis! (Part 1 is background and doctor-style remedies.)

First up, gentian violet.  This is renowned for its quick-acting slaughter of all things fungal, and it’s often recommended in crunchy circles.  Whereas most yeast treatments take at least two weeks, this takes about three days.  The one big drawback is that this stuff is seriously PURPLE and stains everything it touches. (That’s my daughter with a purple mouth, purple thumb, and slightly purple pajamas thanks to GV.)

Want to guess where gentian violet comes from?  Nope, it’s not extracted from organically grown violets.  Nor from gentian flowers.  It’s an extract of coal tar.  It was first used as a dye, but then users noticed when they used it for gram staining microscope slides, it killed all the wee beasties they were trying to look at.  (And yes, I find it a bit hilarious that there are people who decry mineral oil use on the skin, but who happily slather the insides of their infants’ mouths with extract of coal tar.)

The other potential risks of gentian violet are mouth ulcers and a possible increased risk of cancer.  But that’s based on a study of ingestion of large amounts by mice.  Honestly, if I had it to do again, I would still use gentian violet for nipple yeast.

Next big natural cure: grapefruit seed extract (GSE).  Again, this seems to be a pretty powerful antimicrobial agent.  There is research showing that its efficacy is comparable to that of bleach in killing microorganisms.  And because it’s derived from grapefruit, a lot of moms feel more comfortable using it on their nipples and in their infants’ mouths.  But that’s where we need to back up the truck – the reason this stuff is so powerful is that it is either contaminated with or nearly chemically identical to well-known antimicrobial chemicals Triclosan, benzethonium chloride, and benzalkonium chloride.  The latter are often referred to simply as BAC.  One study found some commercial GSE preparations contained Triclosan.  The others typically find the spectrometry is pinging for BAC.

The main manufacturer of GSE, Nutriteam, Inc., maintains that their product is not contaminated with BAC.  They say their GSE is just similar to BAC, so it confuses the spectrometer.  And well, I kind of believe them.  My conclusion is that their product isn’t contaminated.  It’s just that it is for all intents and purposes BAC.  I don’t know how BAC is typically manufactured, but I suspect you can make it using grapefruit as a raw material.  And Nutriteam themselves call GSE a “quaternary compound” (just like BAC is), and describe a manufacturing process that sounds pretty industrial and non-crunchy.  It sounds like they’re doing pretty typical chemical synthesis to me.  And they wind up with a substance that tests and works just like BAC, only they call it a dietary supplement so they don’t really have to comply with any regulations, and they slap a label on it that makes it sound like something natural, not a “chemical” or gods forbid, a “toxin.”

Now, BAC isn’t actually evil, necessarily.  It’s used as a preservative in cosmetics and in anti-bacterial wipes.  Hell, if you’ve ever given a urine sample, you have probably smeared BAC all over your naughty bits.  And since many people have used GSE without ill effects (beyond a bitter taste and the possibility of dry, peely skin), I wouldn’t be averse to using it myself if I ever got nipple yeast again.  I really don’t like that the manufacturers are getting away with fooling people, but look at my previous yeast post – it feels like rubbing your nipples with broken glass.  For me, I’d hold my nose and use GSE since it makes that go away – quickly, for both me and my nursling, without having to get a prescription and explain to the doctor why Nystatin doesn’t work and how much Fluconazole you really need to prescribe, and so on.  But I do think moms deserve to know the real story before they decide whether to use it.

So there you go, two wildly popular crunchy alternative yeast treatments, that aren’t really that crunchy.  But I’d still use them!

Nipple Yeast – Part 1 of 2

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