Thrush while breastfeeding: how to deal with it

When we think of thrush, we usually think of a vaginal infection, or perhaps oral thrush in baby’s mouth. But for breastfeeding women, thrush can take on another unwelcome form: nipple thrush. The bad news is that it’s quite common, and there’s a fair chance you’ll get it at least once. The good news is that everything you need to know about treating nipple thrush is right here.

What causes thrush?

Thrush is caused by a yeast called Candida albicans. It lives in your gut, and it can travel to all sorts of other places and cause infections, including your vagina, your nipples and your baby’s mouth. What makes thrush so hard to kill is that it forms spores (think of them as seeds of the Candida yeast) and these spores can hang around for a very long time. This means that once either you or your baby have thrush, the yeast is probably living on both of you as well as on anything that baby puts in his mouth (e.g. bottles, dummies) and your bras. Remember this when we start to talk about treating thrush.

Symptoms of thrush

Nipple thrush

The hallmark sign of thrush is nipple pain, especially during and after breastfeeds. If you suddenly develop nipple pain after a period of pain-free breastfeeding, thrush is often the prime suspect. Some women describe a burning pain, while others describe it as a stabbing pain, like needles poking into the nipple. Unlike with vaginal thrush, itching is not typical. Your nipple may also look unusually bright pink if you have white skin; on black skin, the nipple usually turns a lighter, slightly more pink colour than the areola. You will not typically see white spots the way you would with oral thrush.

If you have nipple thrush, there will usually (but not always) be signs of thrush infection in baby too. So if baby has obvious signs of thrush, you can be pretty sure that the nipple pain that you’re experiencing is thrush. However, keep in mind that it’s possible to have thrush on your nipples even when baby is showing no signs of infection whatsoever.

Thrush in baby

In babies, thrush usually infects one of two places: the mouth or the gut (and from there, the bum). If your baby has thrush in his mouth, you will notice white spots in the mouth that you cannot rub off with a washcloth (a white coating that you can rub off is not a problem; it’s probably just milk residue). A baby with oral thrush will often be fussy at the breast, since it is quite painful.

Thrush infection in the gut will usually show up as a particularly bad nappy rash, with or without red bumps on the skin. If you are struggling with a nappy rash that just won’t go away, there’s a chance it may be thrush.

Risk factors for getting thrush

There’s one major risk factor for developing thrush: ANTIBIOTICS! (If you’re a female, you probably know this already). Any time when either you or baby need to take antibiotics, there’s a risk that you both will develop thrush. This is because the antibiotics kills off a lot of the good bacteria in your gut. Those good bacteria usually make sure that there’s no room for Candida to get out of control, kind of like your gut’s police force – but with the good guys killed off by the antibiotics, the bad guys quickly get out of control. Once you have a Candida overgrowth in your gut, it can easily spread to all other areas via your hands. So this presents us with two important things to do whenever you or baby are on antibiotics:

1. Take a good probiotic (the live ones that live in the fridge are the best).
2. Wash your hands very, very well after using the toilet and changing baby’s diaper.

If you already have vaginal thrush, there’s a good chance that it can spread to your nipples, especially if the skin is already damaged. Again, good hand hygiene is essential. If you suffer from recurring vaginal thrush, it could even be that your sexual partner is harbouring the infection and keeps passing it back to you – so a course of treatment may be in order for him, too.

Using bottles and dummies are also associated with thrush, simply because the spores of Candida can stubbornly keep living on them long after the infection is over. If you’ve battled with thrush once, either replace everything or heat sterilize it very thoroughly.

Treatment for thrush

Before we start talking about the treatment for thrush, there’s one very important thing you must remember: you always need to treat both mom and baby. It doesn’t matter if only one of you has symptoms; you’ll both be carrying the spores. So if you only treat one or the other, you’ll keep passing the infection back and forth.

There are a few different angles of attack for treating thrush, so we’ll discuss them all here:

Medical treatment

Thrush is an infection, and it needs to be killed, so you will have to use some form of medication. Luckily there’s a lot of good stuff available over the counter.

Nystatin is the most commonly prescribed treatment for oral thrush – if you ask for medicine for thrush at the pharmacy, that’s usually what you’ll get. It’s a medicine that you give to baby, and you can also rub it inside baby’s mouth and on your nipples. Nystatin can work quite well for mild cases of thrush, but we’re seeing more and more cases of Candida that is resistant to nystatin. So if you use nystatin and do not see much improvement, go on to the next one.

Miconazole ointment is a very effective treatment for thrush, and usually my first choice of treatment. It’s a gel-like ointment that you apply to the lesions in baby’s mouth and your nipples. I’ve found it to be a lot more effective than nystatin, and it is much rarer to find Candida with resistance to miconazole. However, doctors and pharmacists are often reluctant to give it to young babies; in that case you may want to give nystatin to the baby and use the miconazole for your nipples. If you apply it directly after a feed, it will be absorbed by the time baby feeds again, so there’s no need to wash it off before feeding.

Important: any topical ointment should be continued for at least two days after all the symptoms are gone, to ensure that all lingering traces of infection are eliminated. It took me several rounds of recurring thrush to learn this lesson, so please spare yourself the agony and just do it! Be warned that it takes a day or two for symptoms to start improving, so don’t expect immediate relief (in fact, sometimes it gets worse before it gets better).

If neither of these treatments work, you may be dealing with a particularly stubborn infection – in that case you may want to check out Dr Jack Newman’s protocol, which you can find here. It describes, among other things, how to use Gentian violet and systemic fluconazole, which you will need to speak to your doctor about.

Non-medical treatments

Apart from medications, there are a number of other things that you can do to help you get rid of a thrush infection:

• Take a good probiotic supplement: 1 billion CFU of acidophilus daily is recommended (for baby, use a formulation specifically for infants). I prefer the type probiotics that live in the fridge, since there’s a better chance that all of it will still be alive by the time you drink it.
• A probiotic skin spray may be useful for eliminating the infection on your nipples or if baby has a thrush nappy rash.
• Cut out sugar and refined carbs from your diet until the infection is over (or forever, if you can – it can only be good for you). Thrush loves sugar, so if you’re eating a lot of it you’re feeding the Candida that lives in your gut.
• Garlic is known to have antifungal properties. Use it copiously in your food, or just swallow a whole clove or two like a pill every day. If you find that garlic upsets your stomach (or you just don’t care for garlic breath), you can also get garlic extract in pill form. Just don’t do what I once did and apply fresh garlic to your nipples – it burns like fire!
• If you struggle with recurring vaginal thrush, consider using a special vaginal wash instead of soap for your daily wash. And don’t douche – ever.

You can also help your nipples to heal by doing the following things:

• Apply coconut oil to your nipples after every feed when you’re not using your medicated cream (usually it’s a good idea to alternate between coconut oil and medicated ointment, since you’re not supposed to apply that stuff ten times a day). Not only will the coconut oil soothe your tender skin, it also has antifungal properties to help fight the infection. Coconut oil is safe for baby to ingest, so there’s no need to wash it off before feeds.
• Keep the nipples dry: let them air-dry after feeds, and replace wet breast pads immediately. Candida thrives in a moist environment.
• Expose the nipples to the sun for a few minutes twice a day.

Stop the infection from spreading

You will need to eliminate the Candida spores that are living all over your stuff now, otherwise the infection will just keep recurring. A good rule of thumb is that anything that was in contact with baby’s mouth or your nipples should be considered infected, and needs to be sterilized (if you also had vaginal thrush, you can include your panties too). Heat is the best way to kill candida spores:

• Wash bras, underwear and cloth breast pads in very hot water and/or bleach to kill spores. You can also iron your undies to help kill the yeast spores.
• If your baby uses a pacifier or bottles, sterilize them by boiling for 5-10 minutes or use a microwave steam sterilizer. Don’t use a sterilizing solution – I don’t care what the package says, Candida can live in those solutions. You will need to sterilize these things after every use for as long as you are treating the thrush and after you have both recovered.
• If you are using cloth nappies and your baby had a thrush-related bum rash, you will need to strip your nappies (but then, if you’re using cloth, you probably know this already!)
• If vaginal thrush is part of your problem, you may want to use condoms during sex for a while to prevent cross-infection to and from your sexual partner.

When “thrush” isn’t thrush

On a last note, I need to warn you that sometimes what looks like thrush isn’t really thrush. Specifically, vasospasms can have symptoms that are confusingly similar to thrush. Other skin infections (such as Staphylococcus aureus) and various forms of dermatitis can also give you similar symptoms. So if you have been treating thrush with no success, it may be worth looking into those other causes. Your doctor may be able to do a swab of your skin for culturing to determine whether there is an infection, and a good lactation consultant can help you sift through the other possible causes.

In summary

Thrush can be a truly annoying visitor, but if you take action quickly and treat it aggressively, it should be gone before too long. And always remember that an ounce of prevention is better than a pound of cure, so take those probiotics!

Have you ever had nipple thrush? What treatments worked for you? Share in the comments so that we can all learn!