Thrush

by Dr Jenny Boyd, General Practitioner

I saw the GP with mastitis twice, thrush on my nipples and in babies mouth & got brilliant care, prompt & appropriate support, advice & treatment. I was supported more by my GP than my Health Visitor, she had advised just to switch to formula. I carried on feeding my little boy until 2 ½ years

SG, Mother

Thrush can sometimes cause breast and nipple pain in breastfeeding mothers. It should be a diagnosis of exclusion however after other causes have been ruled out, in particular positioning and attachment (see our webpage on ‘Pain when Breastfeeding‘). It is important to consider and recognise the symptoms as thrush can be extremely painful and can lead to a mother deciding to stop breastfeeding prematurely. With recognition and prompt treatment the infection can be dealt with and breastfeeding is more likely to continue.


Signs of Thrush in Baby

  • White spots on tongue, gums, tongue or inside cheeks that cannot be wiped away with a clean cloth
  • Unsettled during a feed
  • White film on lips
  • Persistent nappy rash

Signs of Thrush in the Mother

  • Pain starting after a period of pain free feeding
  • Both breasts affected
  • Pain can vary from dagger like deep breast pain to acute nipple pain and itch
  • Pain starting towards the end of a feed or after feeds lasting up to an hour
  • Reddening of nipple and pale areola

You would Not expect to See

  • Pyrexia
  • Red or inflamed areas on the breast
  • Pain on attachment alone
  • Misshapen nipples after a feed

Investigations

Local guidelines may vary with regards to investigation of breast thrush.

  • Ideally swabs should be taken from both the mother’s nipples and the baby’s mouth (charcoal swab to bacteriology)

Management

  • Consider referral to breastfeeding specialist to ensure optimal positioning and attachment
  • Baby
    • Miconazole gel four times daily. It is important that the parent/carer is made aware of how to apply the gel safely, applying gently and carefully, using small amounts at a time on a clean finger, until all surfaces of the mouth are covered.  Information can be found here
  • Mother
    • Topical miconazole cream applied to nipples sparingly after every feed
    • If not responding to topical treatment prescribe fluconazole 150-200mg as a loading dose followed by fluconazole 50 – 100mg twice daily for two weeks
    • If the nipples are very red and inflamed a mild steroid cream may also be used
    • Bear in mind the mother may have both thrush and bacterial infection and may need to be treated for both
  • Remember general measures eg handwashing, wash nursing bras at high temp, change breast pads often

There are some concerns about the potential for accumulation of fluconazole in very young or preterm babies; prescribers should carefully consider the individual circumstances in such conditions and further information is available from the Breastfeeding Network and UKDILAS.  When thrush is suspected in dyads under 6 weeks of age, particular thought should be given to whether the diagnosis is correct, particularly whether problems with attachment and positioning may be a factor, and referral for specialist infant feeding assessment may be considered.

When treating mother and baby topically it is critical to ensure that miconazole oral gel is not applied to the mother’s nipples– the treatment for the mother is miconazole cream.


Further Information

National Infant Feeding Network (NIFN) Statement: Thrush December 2014

The Breastfeeding Network: Thrush and Breastfeeding

The Breastfeeding Network: Miconazole Gel and the Breastfed Baby with Oral Thrush (candida) October 2014

NICE CKS Breastfeeding Problems: Management Revised January 2017 – See the sections on ‘Ductal Infection’ and ‘Nipple Damage’ which cover candida infections.

NICE CKS Breastfeeding Problems: Oral Fluconazole

NICE CKS Breastfeeding Problems: Miconazole Oral Gel 

NHS Choices: Breastfeeding and Thrush


References

  1. Jones W, Breward S.  Thrush and Breastfeeding Community Practitioner 2010; 83(10):42-3.
  2. Brent N. Thrush in the Breastfeeding Dyad: Results of a Survey on Diagnosis and Treatment. Clinical Pediatrics. 2001;40(9):503-506.
  3. Chetwynd E, Ives T, Payne P, Edens-Bartholomew N. Fluconazole for Postpartum Candidal Mastitis and Infant Thrush. Journal of Human Lactation. 2002;18(2):168-171.

Published April 2017, Updated October 3rd 2017