Good News for Breastfeeding Moms

Treating and Preventing Thrush

By Chris Hafner-Eaton

A common cause of breastfeeding failure, and one that often goes undiagnosed, is yeast overgrowth, also known as thrush or candidiasis. Leading to intense nipple soreness and breast pain, thrush can be caused by several factors. However, with proper management, thrush need not undermine breastfeeding.
To identify underlying causes of pain, consider your history of pregnancy, labor, delivery, and nursing. Mothers who received antibiotic therapy for B-strep prophilaxis may experience thrush. Other possible causes include: any procedure that has required antibiotics such as C-section or tubal ligation after delivery; the use of corticosteroids such as terbutaline to delay labor or asthma medications, or prednisone for allergic reactions; any other immune suppression (such as being HIV positive); long-term use of histamine-blockers; or a condition of diabetes.
Yeast infections may also be triggered by damp, rainy weather or exposure to other funguses and molds, including household and garden molds. There is any indication that dietary yeast may also be a trigger, a potential problem for women who frequently bake yeast breads. Yeasts love dark, moist, warm places, thrive in sweet environments, and multiply very rapidly. These factors account for why diabetics as well as pregnant and lactating women are all prime candidates for yeast overgrowth. The added factor of immunosuppression of the body's natural balancing agents (such as broad-spectrum antibiotics or corticosteroids taken within the past few months, or even years if repeatedly used) may allow yeast to proliferate unchecked.
Mothers describe the classic symptoms of breast yeast in various ways: severe pain without nipple trauma; sharp, shooting pains radiating from nipples that may extend to the chest wall or back; nipples that may be red, flaky, itchy, shiny, or burning (these are all relative signs, so consider what is normal for you); small, white, hard blisters on the nipple (this may also be due to a blocked duct); and sometimes white fuzzy patches in the folds of the nipple.
When nursing mothers describe an ice pick or glass sensation inside their breast, or pain that persists beyond latch on, yeast overgrowth in the milk ducts may be the cause. In the instance of thrush, babies may pull off the breast, refuse to latch on, or make clicking sounds. Other less clear clues for the mother range from cravings of sugars and breads to extreme fatigue.
At low levels, however, thrush may not have visible signs. Nursing may have been going well, and all of a sudden it hurts or the baby pulls off the breast (sometimes making that clicking or popping sound). In most cases, if latch on has been assessed and/or corrected, the offending agent is Candida albicans, but there are several other somewhat rare strains of Candida, and not all produce the fluffy patches of cotton that typically indicate a yeast infection. Fungal overgrowth, such as aspergillus and others, are less likely causes of nipple and breast pain, but practitioners should be aware of them.

It is possible, in some cases, to have either yeast/fungal mastitis or bacterial mastitis coupled with yeast. Symptoms of bacterial mastitis (fever over 102o F, flu-like symptoms, red streaks on the breast, hot spots on the breast, etc.) require immediate medical attention, followed by lots of rest (including nursing lying down, if possible). Yeast, combined with bacteria is likely to require a course of antibiotics and other medication.
Treating Thrush
Over-the-counter and self-help approaches to yeast management can be quite effective, particularly if they are part of a comprehensive, holistic approach, and if the problem hasn't become chronic. Along with the common recommendations of changing breast pads at each feeding, going braless (this can be a major help), and topical treatments, dealing with the underlying health status of mother and baby-and sometimes the entire family--is essential. Regardless of the type of treatment-prescription, naturopathic, homeopathic, or other--mothers need to address certain issues such as hygiene, diet, and even laundry. In a nursing relationship, it is imperative that both mother and the baby be treated, even if only one is symptomatic; many times father and siblings require lower-level treatment as well. In cosleeping arrangements, all members who sleep in close contact with each other should be treated. Yeast infections can be challenging because treatment must be continued for two weeks after symptoms subside.
Personal hygiene matters in yeast control. While antibacterial soaps are promoted for new parents, they may contribute to yeast overgrowth by killing 'good' bacteria. Still, it is important to wash your hands with warm water and soap after diaper changes and using the bathroom. In addition, short-term switching to paper towels as a drying method (single use only) can help stop the spread. Temporary use of disposable diapers may help, too. Family members should use a spray bottle of vinegar solution (1/4 cup white distilled vinegar to 1 cup of water) to spray any areas on their bodies that stay or get moist (pubic areas, armpits, under breasts and under any folds of skin). This routine should be followed at least twice a day by those who are not symptomatic and four times a day by those who display symptoms, and continued for two weeks beyond the time that anyone shows symptoms. Bath towels should not be shared, and ideally should only be used once. If laundering after each use seems extreme, then they must be allowed to thoroughly dry after every use. Additionally, items such as toothbrushes and makeup can also harbor yeast spores. Every family member should get a new toothbrush once the anti-yeast regimen is begun, and then again when all symptoms disappear. No cornstarch powders or deodorants should be used, as they are a food source for yeast.
Extra housework is relished neither by new mothers nor anyone else, but it is necessary, to clear up chronic cases of thrush. Sources of mold-wet windowsills, damp laundry hampers, and moist bathtubs (especially the kind with jets) need to be cleaned with either a 10-percent bleach solution or white distilled vinegar in water. Floors, baseboards, and walls may all be cleaned by the same method. Laundry should be sanitized by washing in the hottest possible water and then adding a cup of white distilled vinegar to the final rinse. Because it would take a gallon of bleach in a standard washer to kill yeast spores (which would shred your clothing), boiling clothing and other items of close contact (such as underwear and sheets) for five minutes is suggested. Microwaving on the high setting for five minutes will also kill yeast spores; freezing, however, will not. Cloth diapers, whether from a service or your own, should also be sanitized in the same way, as should toys and any items babies gum or chew on. The latter may be put in the dishwasher if your water is hot enough (over 130degree F) and you add vinegar to the rinse.
Yeasts are extremely persistent in the right environment, but there are a number of medical and naturopathic treatments available for mothers experiencing thrush. If you choose to use a prescribed pharmaceutical whose effects are unknown (check with the your local La Leche League Leader), remember that you may be able to pump and discard your milk instead of permanently weaning. However, most pharmaceuticals associated with yeast treatment do not require weaning.

Natural Remedies for Thrush
The following is a brief overview of how to utilize natural remedies in the case of breast yeast. Use up to three capsules of acidophilus (Lactobacillus acidophilus) three times daily. Babies may be treated with acidophilus diluted in breastmilk swabbed in their mouths, or you can dip a finger in the powder and let the baby suck. The intent of acidophilus treatment is to rebalance your body, so don't expect instant results. Sometimes lactobacilli need a bit of help getting hold in the intestines, and some practitioners recommend FOS (fructo-oligo-saccharides) to enhance colonization.
Apply 1/2 cup white distilled vinegar in 1 cup water topically to the breast.
If this is too strong, you can use a dilution as weak as 1 tablespoon in 1 cup water. Allow to air dry, and do not wash it off before nursing unless baby protests.
This must be done at least four times a day and continued for two weeks after all symptoms are gone. Taking baths with vinegar in the water will allow the treatment of more than one source at a time. White distilled vinegar must be used because the distillation process destroys any active fungus spores. Arguments about the logic of using vinegar (which is fermented) abound, but yeast cannot survive in the pH environment that is created by fermentation and the temperature needed to distill the vinegar. If they catch the overgrowth early, many mothers have found that vinegar treatment works quite well when used with oral acidophilus taken three times a day to rebalance the intestines.
Apply olive oil topically to breasts after each feeding. Olive oil contains linoleic acids, which are antifungal and may cut off the yeast's oxygen supply.
Make a paste of baking soda in water and swab the baby�s mouth after each feeding (if baby always falls asleep, then do it whenever possible, but at least four times a day). This also alters the pH of the environment (more toward the alkali side, in this instance), making it inhospitable to yeasts. Practice caution with baking soda because if swallowed in quantity it can dangerously disrupt the electrolyte balance. Apply potassium sorbate topically-1 tablespoon dissolved in 1 quart of warm water. A strong immune system booster that may be lacking in the mother's and baby's intestines if they have had antibiotics is nonyeast-based vitamin B complex.
Another immune system booster is zinc; take 45 mg per day.
Take vitamin C up to the point where loose stools occur, then reduce the dosage a bit. Since vitamin C is water soluble, it must be consumed throughout the day. Echinacea capsules or tincture can be taken simultaneously to boost the immune system.
Although increasing dietary garlic may be useful, clinically effective doses are easier to get if you take triple-strength deodorized garlic tablets (three tablets, three times daily for two weeks or more). The liquid, cold-pressed, aged garlic is thought to be most potent. Kyolic is the brand about which the most conclusive research has been published.  Note: ginger and cinnamon reportedly also have antifungal properties, but their use is infrequently reported and primarily unstudied.
Caprylic acid, when taken orally, has strong antifungal properties; take two to three capsules three to four times per day for two weeks (or 1 gram at meals).
Citrus seed oil is a strong, but natural, antifungal, antibacterial, and antiviral substance. It may be used topically, but must be diluted before use on the breast or on any mucous membrane. Try 10 drops in a cup of water swallowed at once, twice daily.
The Australian antiseptic tea tree oil is thought to have antifungal properties; a few drops may be added to bathwater or diluted and applied to the breast. The bath method may also be used with vinegar, and has the added benefit of helping clear the sinuses.
Take either 1 to 2 grams dried barberry (Berberis vulgaris) bark or 1 - teaspoons (4 to 6 ml) of tincture (1:5), or 250 to 500 mg of powdered extract, three times a day.
Although very bitter, golden seal (Hydrastis candadensis) is very effective at clearing yeast from the body. Consume either 1 to 2 grams dried bark or 1 - teaspoons (4 to 6 ml) of tincture (1:5), or 250 to 500 mg of powdered extract, three times a day.
Caution: The rapid yeast die-off can cause intestinal gas.
Pau d'arco (Tabebuia impetiginosa) is an antifungal tincture with a long history of use in developing countries; take 20 to 30 drops four times a day (warning: it tastes horrible).
Maitake tea is an antifungal tea that also helps to rebalance the intestines; drink the strongly brewed tea throughout the day for two weeks (4 to 6 cups a day).
Soak plantain seeds (Plantango major) overnight in warm water and apply the resultant gel topically.
One of the oldest antifungal antiseptics available (preceding topical iodine) is gentian violet, which is very effective although extremely messy, staining everything it touches. Gentian violet should only be used for a maximum of two to three days (two treatments per day) by coating the nipple, areola, and surrounding breast tissue (plus the underside of the breast) with the liquid on a cotton ball. The long-term toxicity of this treatment is still being debated, but short-term treatment appears to cause no ill effects. Nursing babies will get a purple mouth, which will disappear in a few days. You might want to wear clothing that is dark or can be thrown away or bleached.
Lecithin can be taken orally. Take two 250 mg gel capsules, three times per day, or the equivalent in lecithin granules sprinkled on foods.
Deep massage of any plugged ducts with arnica oil as a lubricant supplements this treatment. Massage while the baby nurses, taking advantage of gravity.
The over-the-counter anti-inflammatory ibuprofen might be appropriate for both pain relief and reducing ductile inflammation.
Some practitioners have prescribed over-the-counter vaginal yeast creams with miconozole or clotrimazole be applied to the breast. While these may be effective and the active ingredients are compatible with nursing, there may be other ingredients not appropriate for babies to consume; therefore, this approach is not recommended unless extreme caution is used. As always, watch your baby carefully.

Pharmaceutical Remedies for Thrush
The first line of defense that is usually prescribed for yeast is Nystatin (cream or suspension), an exceptionally safe pharmaceutical that acts by disrupting the necessary enzymes yeasts need to reproduce, but doesn't cross cell membranes. However, the drug may cause side effects such as nausea, gas, and fatigue as the yeast dies off. Nystatin must be scrupulously applied after every nursing, since yeast multiplies rapidly.  Some researchers question the effectiveness of Nystatin suspension because it is mixed in a sucrose base (in which yeast thrives); instead, they recommend using Nystatin powder mixed in water or other liquids (breast milk for babies).

If Nystatin is not effective initially, or the yeast becomes chronic or invades the ducts of the breast, other methods are available. Mycelex troches are often prescribed for the nursing pair. These tablets are crushed, mixed with breast milk, and applied to the thrush. Older babies may like chewing on the troches. The active ingredient in these is miconazole, which is also the ingredient in many over-the-counter vaginal yeast medications. If
applied to the breast, the drug will be taken into the baby's mouth, as would any topical substance that is not washed off. (See above.)
As a third line of defense in the topical war against yeast, some practitioners may resort to Nizoral 2 percent cream for the breast and diaper areas (ketoconazole is the active ingredient). Nizoral is also available for internal use, although the effects of it have not been studied on infants. Nizoral tablets are a potent chemical whose side effects should be weighed against its possible benefits.
Lastly, a new and now commonly prescribed vaginal yeast medication, Diflucan (fluconazole), is being used to treat breast yeast. One dosage is utilized in vaginal yeast cases, but experience has demonstrated that in the case of breast yeast many more doses are required to fully clear the growth. Diflucan has few side effects, is taken once per day, and is quite effective if given for a long enough period (usually two to four weeks) while the baby's mouth is simultaneously treated with another anti-yeast treatment. Sporonax is another drug that is available, but not very much is known about how it affects the nursing relationship, so you might want to think about asking for an alternative.
For more information on this topic, write to Dr. Hafner-Eaton for a list of articles at drmom@ or 1807 NW Beca, Corvallis, OR 97330.
Chris Hafner-Eaton carries a PhD in health services research and policy analysis and an MPH in behavioral sciences and health education (UCLA).
She is a certified health education specialist and international board-certified lactation consultant. She is the full-time homeschooling mother of three boys (9, 4, and 1), retired accredited La Leche League Leader, organic medicinal herb gardener, and part-time professor of women's health, lifetime wellness, and nutrition. She and her husband and children make their home in Corvallis, Oregon, along with cats, ferrets, fish, and turtles.

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