My nipples are sore with a sensation of burning and itching. It sounds like thrush, but I can't see anything white in my baby's mouth. What could be wrong?

It is very possible to have a thrush (candida) outbreak in a mom and have the baby be asypmtomatic. What you describe sounds like a classic case of candida on your breasts. If you get help right away, it is possible that you can clear it up easily. Left untreated, the baby is likely to become symptomatic and the thrush resistant to treatment. Itching and burning are generally reported as are pain or tenderness during and after nursing. The nipples and areola may appear dry and/or pink/red with or without a rash. Left untreated, yeast overgrowth can also result in milk supply problems.

Here are the standard treatment recommendations. The baby's mouth and diaper area, and the mother's nipples, areola and vaginal area are prime sites for candida infection, and generally speaking, all should be treated simultaneously to prevent reinfection. Treatment should continue for TWO WEEKS AFTER ALL SYMPTOMS ARE GONE.

1. Antifungal cream (Clotrimazole, Lotrimin, Mycelex) for the nipples and areola applied before and after each feeding. If the doctor is willing to prescribe Fluconazole (trade name: Diflucan) at the start, this is usually extremely effective, and will take care of any vaginal yeast overgrowth present.
2. Most pediatricians prescribe Nystatin for the baby. Yeast cells begin reproducing after one hour, so the typical recommendation of 3 or 4 applications a day by some doctors often doesn't resolve the yeast as quickly as possible. If you cut the doseage recommendation in half and double the application, you can administer it after every feeding (6-8 times a day). The medication should be put into a small medicine cup from the dropper that comes with the medication (putting the dropper in the baby's mouth can just extend the infection), and then swabbed in baby's mouth on a clean q-tip, clean finger, or gauze pad. Wash hands after application, and throw away used q-tips and gauze pads. Antifungal cream can be applied to yeast overgrowth in diaper area. It is extremely important to treat both mom and baby even if one is asymptomatic so that reinfection does not occur. Because research has shown that Nystatin may only be effective in the treatment of thrush 40% of the time, many doctors who are breastfeeding knowledgeable are beginning to use Fluconazole (Diflucan) for the treatment of thrush in babies as well. Fluconazole has also been used successfully in NICUs for the treatment of thrush and is cleared for use in the neonate.
3. In cases of systemic or ductal candida, some breastfeeding friendly doctors are willing to prescribe a loading dose of Diflucan the first day--400 mg, with 200 mg following for the next 28 days (as recommended in: Hale, Medications and Mother's Milk, p. 267).
4. If you prefer a more natural approach to resolving the thrush right from the start, you can try using Gentian Violet (GV). GV is a strong topical antifungal that will penetrate several layers of skin just as the thrush does. GV is usually easy to obtain from any pharmacy or Wal Mart--just call ahead to be sure that it is available. Use a clean q-tip for each areola/nipple and for the baby's mouth. When applying, wait until after a feeding, and coat each areola and nipple and allow to air dry. While some advise moms to apply the GV and then allow the baby to nurse (the idea is that this allows the baby's mouth to be coated more easily), I have had some moms report that the baby swallows the GV instead of being well coated. Coat all mucosal areas in the baby's mouth, including his tongue. Only reapply the GV when the stain is gone (usually means once or possibly twice daily), using for a total of three days. For a severe case that isn't appearing to resolve, a fourth day is okay, but after that, you must wait three days before going through another treatment round if it hasn't completely cleared up. GV is a very strong topical antifungal and can cause a layer or more of skin to peel, so it is very important to only reapply once the stain is gone, and to use for no longer than 3 days (except as noted above). If you have any yeast overgrowth vaginally, the GV cannot be used internally to treat it, but buying an over-the-counter cream is very easy now-a-days (generic Lotrimin is easy to find). One added note: GV is very messy and can cause permanent stains to clothing, so you may want to put away your favorite items of clothing while you are using it!
Other recommendations:
-Wash hands regularly, and dry on a paper towel.
-Wear 100% cotton underwear and bras that can be boiled in plain water for 5-10 min.
-Boil all items that come in contact with the breast such as breast pads, breast pump, and the baby's mouth (pacifier, bottle nipples, toys, etc.). The use of disposable pads is not recommended as they may just trap moisture (which yeast thrives on).
-Because yeast can be spread among family members (causing reinfection) condoms should be used during intercourse until 14 days past the time symptoms are gone (or abstain). Husband may need to be treated with topical cream as well.
-Expose nipples to direct sunlight for a few min. twice daily. (I know this one is hard, but if you have a good window that you could lie down under this is great).
-Cut all sugars and sweetners from your diet until 2 weeks past symptoms are gone (yeast thrives on sugar)
-You can also use a vinegar/water rinse (1TBSP vinegar to 1 cup water) on the breasts and diaper area before applying antifungal creams. Vinegar doesn't kill yeast, but does create an environment that is not hospitable for growth.
You can use all of these treatments, but many find they have the best long-term results if they recolonize the good bacteria in their body (by the way, most yeast overgrowths are related to antibiotic use in mom or baby because the good bacteria in the gut is also killed off). The easiest way to do this is by taking acidophilus or acidophilus bifidus in capsule form. You can buy it in the refrigerated section of a health food store, and take a few capsules daily. The same type of "good" bacteria is found in yogurt with live cultures, but most yogurt contains either sugar or artificial sweetners, and yeast thrives on sugar. Many moms are comfortable moistening a finger and dipping it into the powder of an opened capsule and allowing the baby to suck the acidolphilus off the finger (once a day), but others just hope the baby gets enough through the breastmilk. As with many ingestible substances, the amount that comes through in the breastmilk is not as concentrated as the baby could ingest. This part of the treatment depends on your own comfort level with a "natural" approach to health care.

Dr. Jack Newman's handout on the use of Gentian Violet

Using Gentian Violet

Gentian violet (1% solution in water) is an excellent treatment for Candida albicans. Candida albicans is a yeast which may cause an infection of skin and/or mucous membranes in both children and adults. In small children, this yeast may cause white patches in the mouth (thrush), or diaper rash. When the nursing mother has a yeast infection of the nipple, she may experience severe nipple pain, as well as deep breast pain.

Nipple pain caused by Candida albicans

The pain caused by a yeast infection is generally different from the pain caused by poor positioning and/or ineffective suckling. The pain caused by a yeast infection:

1. is often burning in nature, rather than the sharp, stabbing or pinching pain associated with other causes. Burning pain may be due to other causes, however, and pain due to a yeast infection does not necessarily burn.
2. frequently lasts throughout the feeding, and occasionally continues after the feeding has ended. This is in contrast to the pain due to other causes which usually hurts most as feeding begins, and
3. gradually improves as the baby nurses.
4. may radiate into the mother's armpit or into her back.
5. may cause no change in appearance of the mother's nipples or areolas, though there may be redness, or some scaling, or the skin of the areola may be smooth and shiny.
6. not uncommonly will begin after a period of pain free nursing. This characteristic alone is reason enough to try treatment for yeast. However, milk blisters on the nipple also may cause nipple pain after a period of pain free nursing.
7. may be associated with recent use of antibiotics by the baby or mother, but not necessarily.
8. may be quite severe, may or may not be itchy. may occur only in the breast. This pain is often described as "shooting", or "burning" in nature, and is often worse after the feeding is over. It is often said to be worse at night. At the same time, the breast appears or feels normal. This is not mastitis and there is no reason to treat with antibiotics. On the contrary, antibiotics may make the problem worse.

Please Note:
a. The baby does not have to have thrush in his mouth.
b.A yeast infection of the nipple may be combined with other causes of soreness.

Using Gentian Violet

We believe that gentian violet is the best treatment of nipple soreness due to Candida albicans for the breastfeeding mother. This is because it works almost always, and relief is rapid. It is messy, and will stain clothing, but not skin. The baby's lips will turn purple, but the purple will disappear after a few days. Gentian violet is available without prescription but is not available at all pharmacies. Call around before going out to get it.

1. About 10 ml (two teaspoons) of gentian violet is more than enough for an entire treatment.
2. Many mothers prefer doing the treatment just before bed so that they can keep their nipples exposed and not worry about staining their clothing. The baby should be undressed to his diaper, and the mother should be uncovered from the waist up. Gentian violet is messy.
3. Dip an ear swab (Q-tip) into the gentian violet.
4. Put the purple end of the ear swab into the baby's mouth and let him suck on the swab for a few seconds. The gentian violet usually spreads around the mouth quickly. If it does not, paint the inside of the mouth to cover as much of the inside of the cheeks and tongue as possible.
5. Put the baby to the breast. In this way, both the baby's mouth and your nipple are treated.
6. If, at the end of the feeding, you have a baby with a purple mouth, and two purple nipples, there is nothing more to do. If only one nipple is purple, paint the other one with the ear swab and the gentian violet. In this way, the treatment is finished in one go.
7. Repeat the treatment each day for three or four days.
8. There is often some relief within hours of the first treatment, and the pain is usually gone or virtually gone by the third day. If it is not, it is unlikely that Candida was the problem, though it seems Candida albicans is starting to show some resistance to gentian violet, as it is to other antifungal agents. Of course there may be more than one cause of nipple pain, but after three days the contribution to your pain caused by Candida albicans should be gone. Do not continue the gentian violet if no relief occurs after 3-4 days of treatment. Instead, get more information.
9. All artificial nipples that the baby uses should be boiled daily during the treatment, or well covered with gentian violet. Consider stopping artificial nipples.
10. There is no need to treat just because the baby has thrush in his mouth. The reason to treat is the mother's and/or the baby's discomfort. Babies, however, do not commonly seem to be bothered by thrush.
11. Uncommonly, babies who are treated with gentian violet develop sores in the mouth which may cause them to reject the breast. If this occurs, or if the baby is irritable while nursing, stop the gentian violet immediately, and contact the clinic. The sores clear up within 24 hours and the baby returns to feeding.

If the infection recurs, treatment can be repeated as above. But if the infection recurs a third time, a source of reinfection should be sought out. The source may be the mother who may be a carrier for the yeast (but may have no sign of infection elsewhere), or from artificial nipples the baby puts in his mouth. Treatment of the mother (usually with a medication other than gentian violet) at the same time as treatment is repeated for the nipples will usually eliminate reinfection. Contact the clinic.

Questions? (416) 813-5757 (option 3)

Handout #6. Using Gentian Violet Revised January 1998. Written by Jack Newman MD, FRCPC. This handout may be copied and distributed without further permission, on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated.