Treatment of Mucocutaneous Candidal

Infection in the Breastfeeding Mother and

Child
Katie Reynolds, MD, Betsy Ayers, IBCLC, and John Werdel, MD
Abstract
Candidal infections of the breastfeeding mother and infant are commonly encountered in clinical
practice, but can be increasingly difficult to treat successfully. Mothers may complain of severe
pain, but sometimes physical examination of the breasts is entirely normal. Diagnosis should be
based on assessment of risk factors, history, and examination of the mother and infant. Both
mother and infant must be treated, even if only one is symptomatic. There is increasing fungal
resistance to Nystatin; most experts now recommend other topical preparations as first-line
maternal treatment (including miconazole, clotrimazole, mupirocin, and Gentian Violet). Options
for treatment of the infant are more limited, including topical nystatin or Gentian Violet, and
systemic fluconazole. Lack of response within three to four days of treatment should prompt
reassessment and consideration of alternate topical therapy of systemic treatment. Treatment
should be continued at least one week after resolution of symptoms, and environmental control
of yeast overgrowth is essential.
Background
The importance of breastfeeding for mothers' and infants' long-term health is recognized by the
American Academy of Family Practice
3
, the American Academy of Pediatrics
4
, and the
American College of Obstetrics and Gynecology
5
. These organizations, along with the World
Health Organization6, recommend six months of exclusive breastfeeding, and at least one to two
years of breastfeeding combined with other foods. In an effort to promote these goals, physicians
must become knowledgeable about management of breastfeeding concerns and their treatment.
Nipple pain (often a result of Candidal infection
1
) has been shown to be one of the major causes
of premature weaning
2
. Although research into treatment options is expanding, at present we
have little evidence-based information, and none of the above-referenced organizations provide
consensus recommendations on management of this common problem. The following
information and recommendations are based on a review of the current literature, incorporating
expert opinion where controlled trials are not available. It is critical to treat both mother and
infant, even if one is asymptomatic; coordination between care providers will be necessary if
more than one physician is involved with the dyad.
Diagnosis
Symptoms of Candidal involvement of the nipple can be quite variable, and the differential
diagnosis is extensive. Mothers often complain of pain that is severe, generally sudden in onset
(often after weeks or months of successful nursing), burning or shooting, and occurs during and
between feedings.
7
The mother's nipple may appear entirely normal despite ongoing infection;
conversely, the infected infant does not always have clinically evident thrush. Presentation of
symptomatic nipple involvement may include puffiness, scaling, flaking, weeping, dark pink or
shiny red or purple coloration, erythema, striae radiating from the nipple, satellite lesions, or
vesicular rash.
2
Symptoms in the infant can include feeding difficulty
2
(either refusing to nurse
or pulling off the breast repeatedly while still appearing hungry), fussiness and possibly
increased gassiness
7
, and may be associated with a Candidal diaper rash. On examination, the
involved infant generally has white patchy plaques on the oral mucosa, and background
erythema, but again there may be no significant findings.
Assessment of maternal risk factors for candidal infection may be useful in making the diagnosis
when clinical presentation is atypical. These risk factors include history of antibiotics during
labor
8
, vaginal yeast infection, history of gestational diabetes or ongoing maternal
hyperglycemia, antibiotic or corticosteroid use (in mother or infant), nipple trauma (as from
incorrect latch), and pacifier use.
9

Treatment of the Mother Topical Therapy
A recent survey of physician members of the Academy of Breastfeeding Medicine demonstrated
that most lactation experts begin treatment with a topical antifungal.
2
For this purpose, ointments
are preferred, as they provide a better moisture barrier and are less likely to sting.
10
These
ointments are applied sparingly to the nipple and areola after each feeding, or at least 3-4 times
daily. Traditionally, nystatin has been used as first-line treatment for this purpose; however,
recent studies show that there is increasing resistance of C. albicans, up to 40-45% of strains
tested.11 As a result, some experts recommend that this no longer be used as initial therapy.
10,13

Other topical antifungals include miconazole (Monistat, Micatin); this preparation has the
advantage of very poor bioavailability in the infant
10
, and therefore need not be wiped off prior
to the next feeding. Clotrimazole (Lotrimin, Mycelex) may also be effective, but may be a
topical irritant and thus worsen maternal pain and inflammation. There is also systemic
absorption of clotrimazole by the infant, and this can result in elevated liver enzymes, and
wiping off the product prior to nursing is recommended.
10
Mupirocin ointment has recently been
shown to be efficacious, as it has both antifungal and antibacterial activity.
8
There is no
significant absorption from topical use
10
, and it is ideal for nipples with severe cracking or
trauma which may also have bacterial superinfection.
With topical antifungal preparations, improvement is typically seen in 24 to 48 hours, and
symptom exacerbation in the first day of treatment is not uncommon. If a patient is not
improving after three to four days of treatment, a different topical preparation can be tried. Most
sources recommend treating for one to several weeks after symptom resolution.
2

Gentian violet is a traditional antifungal and antibacterial agent that remains efficacious. It is
available without a prescription in a 1% solution, and should be diluted to 0.25-0.5%. It is used
once daily for no longer than 3 to 4 days, and can damage mucus membranes if overused
(uncommon).
10
Patients often experience relief within hours of the first treatment and require
only a single treatment, with complete resolution of pain by day three. The solution is swabbed
onto mother's nipple and areola and onto the child's oral mucosa; alternatively, the child may
simply be allowed to breastfeed after topical application to the nipple and areola. Caution is
required in the use of this product, as it temporarily stains skin (duration approximately 2 days)
and permanently stains all other surfaces with which it comes into contact.
Many lactation experts also recommend bathing the nipples with vinegar solution, to help reduce
fungal overgrowth. One tablespoon of white vinegar is added to 1 cup water, and applied
directly. The solution must be made fresh daily to avoid contamination.
12

Treatment of the Mother Systemic Therapy
Failure of topical therapy generally indicates the need for systemic treatment; this is commonly
due to deeper ductal candidiasis. Fluconazole (Diflucan) is generally administered at 200-400 mg
PO on the first day of treatment, followed by 100-200 mg PO qd. At this dose, infants receive
less than 6% of the usual pediatric dose.10 Two to four weeks of therapy is recommended,
7,8,10

with some practitioners extending treatment to six weeks. The clinical cure rate for fluconazole
is 86%, compared with 46% for nystatin; however, cost is substantially higher (see Appendix A).
If pain continues despite systemic treatment, the practitioner should consider altering
management. Although Candida albicans remains the most common species to cause human
infection, less common strains including C. krusei, C. glabrata, and C. dubliniensis are often
resistant to fluconazole, and require treatment with ketoconazole.8 Alternatively, pain may be
persistent due to non-fungal etiology, including vasospasm, bacterial superinfection, contact
dermatitis, or rarely Paget's disease of the nipple. If patients report white discoloration of the
nipple associated with the pain (suggestive of vasospasm), they should be instructed to keep the
nipples warm and cover after feeds; magnesium and calcium supplements may also be helpful,
and occasionally oral nifedipine.
8
If there is suspicion of bacterial superinfection, treat with
topical (mupirocin) or oral agents. Visible breaks in the skin may reasonably be assumed to be
secondary to bacterial involvement.
13
Severely inflamed nipples may have a component of
contact dermatitis, and may benefit from moderate strength corticosteroids in addition to
antibiotics.
10,13

Treatment of the Mother Pain Management
Pain from nipple candidiasis is often severe (8-10 on the pain scale), so prompt treatment is
critical for the successful continuation of breastfeeding.
2
Shorter, more frequent nursings may be
more comfortable. Cool packs prior to feedings are recommended, and nipples should be air-
dried after each nursing (unless the patient also experiences nipple vasospasm). If pain is too
severe for direct nursing, milk can be expressed and fed via bottle or cup to the infant. Breast
shells between feedings may be helpful when nipples are extremely sensitive to touch (caution:
NOT nipple shields).
9
Ibuprofen can be recommended for analgesia; narcotics are rarely
indicated.
Treatment of the Child
First-line treatment of the child by most lactation experts still consists of nystatin solution,
2

despite the above-referenced increasing resistance. Parents should use a cotton swab to rub into
all surfaces of the child's mouth, gums, cheeks, under the tongue, and the roof of the mouth. The
manufacturer recommends four times daily, but some physicians will treat more often (half dose,
eight times daily), due to yeast's ability to grow rapidly. Gentian violet may also be used as
described above; again, overuse can potentially result in damage to mucus membranes. Other
topical antifungal preparations are not available in pediatric form.
Fluconazole may be used for treatment failures, and is increasingly used as first-line treatment.
The usual dose is 6 mg/kg PO on first day, followed by 3 mg/kg/day for 2 to 4 weeks, or at least
one week after resolution of symptoms. Although not yet approved by the FDA for use in
pediatric patients, a recent survey indicated that 90% of practitioners use it.
10

Treatment of the Environment
Many treatment failures and recurrences are due to incomplete eradication of yeast from the
environment, or from treatment of only one member of the mother-child pair. Patients should be
educated that pumped milk can contain yeast, even if frozen, and may recontaminate the infant's
mouth if used at a later time. It should be labeled "yeast" and used immediately, or saved for
emergency use only. Good handwashing is important, and all equipment (pacifiers, bottles,
rubber nipples, breast shells, and pump kit parts) should be boiled daily and washed after each
use with hot soapy water. Nursing pads may form a reservoir for yeast growth, and should either
be avoided during treatment or washed in 10% bleach solution. All clothing, towels, and diapers
should be washed in the hottest possible water and dried in sunlight if possible. Mothers should
use a clean towel after each shower or bath.
Complementary therapies are gaining popularity in this as in most other ailments. Acidophilus
supplements, either via yogurt with active cultures or in capsules (40 million to one billion units
tid) may reduce yeast colonization, and should be used daily for two weeks after symptoms are
gone. Other preparations that may discourage yeast growth include grapefruit seed extract (250
mg tid), garlic (3 triple-strength deodorized tablets tid), zinc (45 mg qd), and B complex vitamins
(one qd).
14

Summary
Candidal infection of the maternal nipple and infant's oral mucosa can seriously impair the
chances of successful long-term breastfeeding. Symptoms are often severe, but clinically
apparent signs of maternal involvement may be subtle, and diagnosis requires a high index of
suspicion. The most important principal of treatment is recognition that both mother and infant
require treatment, even if only one has clinically apparent involvement. Although Nystatin has
been the mainstay of therapy, there is now significant resistance and higher chance of treatment
failure with this regimen. Treatment for mother and infant may incorporate topical or systemic
antifungal therapy, and often needs to be continued for up to four weeks, particularly when there
is deeper ductal involvement. Failure of topical therapy generally indicates the need for a
different topical preparation or a change to systemic therapy; failure of systemic therapy should
prompt consideration of resistant Candida species or alternative diagnoses. Finally, eradication
of fungal organisms from the environment is essential to successful therapy.
References
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