Grapefruit Seed Extract for Treatment of Thrush

Grapefruit seed extract can also be used for treating Candida as well. It can be used directly on the nipples and/or orally. If used directly on the nipples, it should be diluted (5 to 15 drops, occasionally up to 25 drops, in 30 ml or 1 ounce of water), applied on the nipples with a Q-tip or cotton ball, allowed to dry, and then covered, sparingly, with the all purpose nipple ointment. By mouth, grapefruit seed extract can be taken as a pill, 250 mg three times a day.

Grapefruit seed extract (ACTIVE INGREDIENT MUST BE “CITRICIDAL”) should be used in conjunction with the All purpose nipple ointment. Apply the diluted liquid grapefruit seed extract on the nipples, and then follow with the ointment (always after the feeding).

Apply solution directly on the nipples. It does not need to be refrigerated. It may be covered and used until solution is finished.

• Mix very well five to 10 drops in 30 ml (1 ounce) of water (preferably, but not necessarily, distilled).
• Use cotton swab or Q-tip to apply on both nipples and areolas after the feeding.
• Let dry a few seconds, then apply “all purpose nipple ointment”.
• If using Gentian violet, do not use GSE on that particular feed but use after all other feeds.
• Should be used in conjunction with oral GSE, either tablets, capsules, or liquid extract (see above)
• Use until pain is gone and then wean down slowly over the period of at least a week.
• If pain is not significantly improving after two to three days, increase the dose by 5 drops per 30 ml (ounce) of water. Can continue increasing until 25 drops per 30 ml of water.
• If flaking, drying, or whiteness appears on the skin, substitute vitamin E oil or pure olive oil for APNO 1-3x/day.
• Laundry can be treated as well: add 15-20 drops in the rinse cycle of all wash loads

If not using Gentian Violet, it may be helpful to treat baby with acidophilus by rolling a wet finger in acidophilus powder (break open a capsule), and let baby suck on the finger right before a feeding. Use 2x first day, 2x second day only. Mother may want to ingest Acidophilus as well, 3x/day for 1-2 weeks.

Handout #3b. Treatments for Sore Nipples and Sore Breasts. January 2005. 
Written by Jack Newman, MD, FRCPC © 2005.

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

Using Gentian Violet

Gentian violet (1% solution in water) is still an excellent treatment forCandida Albicans, though we don’t suggest mothers use it alone forCandida Albicans (thrush, yeast) because it tends to dry out the nipple and areola. Furthermore, it does not seem to work as well as it used to.Candida albicans is a fungus that may cause an infection of skin and/or mucous membranes (inside of mouth, for example) in both children and adults. In small children, this yeast is a frequent cause of white patches in the mouth (thrush), or diaper rash. When the nursing mother has a Candidal infection of the nipple, she may experience severe nipple pain, as well as deep breast pain. Please note: Gentian violet 1% in water also contains alcohol (10% by volume), but the amount of alcohol in the tiny amount of gentian violet you use is of no concern. Apparently some pharmacists are now dissolving it in glycerin, thus avoiding the use of alcohol, but if gentian violet is used as directed baby will get vanishingly small amounts.

Nipple pain caused by Candida albicans

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

• Is often burning in nature, rather than the sharp, stabbing or pinching pain associated with other causes (such as a poor latch). Burning pain may be due to other causes, however, and pain due to a Candida infection does not necessarily burn.
• Frequently lasts throughout the feeding, and occasionally continues after the feeding has ended. This is in contrast to the pain due to other causes that usually hurts most when the baby latches on, and gradually improves as the baby sucks (unless nipple damage is very severe, in which case the pain may continue throughout the feeding).
• May radiate into the mother’s armpit or into her back. This does not mean that the Candida actually is inside the breast or in the ducts. Pain that is felt in a place where there is no cause of the pain, but due to pain elsewhere in the body is called ‘referred pain’. An example is pain in the neck which is actually due to heartburn which may also be felt at the lower end of the breast bone.
• 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 and the nipple may crack.
• Not uncommonly will begin after a period of pain free nursing. This characteristic alone is reason enough to try treatment for Candida. However, milk blisters on the nipple also may cause nipple pain after a period of pain free nursing as may eczema or other skin condition. Also, if the mother’s milk supply diminishes, the mother may start having pain later on since babies tend to slip down on the breast when the flow is slow. Another possibility is a new pregnancy, which in itself can cause sore nipples and since the milk production decreases during pregnancy may cause soreness also for that reason.
• May be associated with recent use of antibiotics by the baby or mother, but not necessarily.
• May be quite severe, may or may not be itchy.
• May occur in one breast or nipple only.
• 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 since mastitis is associated with a large painful lump in the breast; therefore, 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 Candida infection of the nipple may be combined with other causes of soreness.

Using Gentian Violet

We believe that gentian violet (combined with “all purpose nipple ointment”, see the information sheet Candida protocol - Toronto) is a good treatment of nipple soreness due to Candida Albicans for the breastfeeding mother. This is because it often works even when used alone (though we don’t recommend this, see first paragraph), and relief is rapid. It is messy, and will stain clothing (actually, it will usually wash out eventually or may be removed from clothing with rubbing alcohol), 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. If you are in the US: gentian violet seems to be sold commonly as a 2% solution rather than a 1% solution. This is too strong a concentration and probably accounts for the mouth ulcers that some babies get after being treated with it. The pharmacist should dilute it for you. It’s easy to do on your own: just add an equal amount of water to the gentian violet 2% and you have gentian violet 1%.

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. Your baby will be less purple if, before you apply gentian violet, you rub some olive oil into the baby’s cheeks and around his mouth.
4. Dip a clean ear swab (Q-tip) into the gentian violet.
5. Paint one of your nipples and the areola and let dry for a few seconds.
6. Put the baby to the breast. In this way, both the baby’s mouth and your nipple are treated.
7. When baby is finished on that side, touch up the gentian violet on the nipple if necessary, place a breast pad over top, and cover up that side.
8. Repeat for the other side
9. 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.
10. A cotton pad can then be used to wipe the excess gentian violet from baby’s face
11. Repeat the treatment each day for at least three or four days t see if it is working and then continue for the rest of the week if it is seen to be working (see the Candida protocol - Toronto information sheet for how long to use gentian violet).
12. 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 seemsCandida Albicans is starting to show some resistance to gentian violet, as it already has 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. However, if your pain is virtually gone after three or four days, but not completely, you can use gentian violet a few more days if necessary.
13. All artificial nipples that the baby uses should be boiled daily during the treatment, or well covered with gentian violet, or rinsed in a solution with grapefruit seed extract. Consider stopping artificial nipples. Artificial nipples can interfere with the way the baby latches on and may contribute to your pain.
14. 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, only very occasionally seem to be bothered by thrush.
15. Uncommonly, babies who are treated with gentian violet develop sores in the mouth that 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.
16. It is advisable that a mother with a recurring infection take probiotics orally for a few weeks and or grapefruit seed extract orally for at least 2 weeks. In this case, the baby should probably be treated with probiotics as well (see the Candida protocol - Toronto information sheet).

If the infection recurs, treatment can be repeated as above. But if the infection recurs a third time, a source of re-infection 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. See the Candida Protocol information sheet.

Gentian Violet, Revised 2009 
Written and Revised by Jack Newman, MD, FRCPC 1995-2005 
Revised by Edith Kernerman, IBCLC, and Jack Newman, MD, FRCPC © 2009

Flucanazole (diflucan)

Fluconazole (Diflucan™) is a synthetic antifungal agent that can be used for the treatment of Candida albicans and other fungal infections. For the breastfeeding mother in particular, it can be used after other first interventions to treat recurrent Candida infections of the nipples, and, if such a thing exists, as I believe it does, Candida infections of the breasts. If a mother has sore nipples, the nipples must be treated aggressively first and then is fluconazole (Diflucan) added if nipple treatment alone is unsuccessful.

Candida (yeast) infections of the nipple and ducts

Candida infections of the nipples may occur any time while the mother is breastfeeding. Candida albicans likes warm, moist, dark areas. It normally lives on our skin and other areas, and 90% of babies are colonized by it within a few hours of birth. It, like many other germs that live on us normally, only becomes a problem under certain circumstances.

Candida infections of the skin or mucous membranes are more likely to occur when there is a breakdown in the integrity of the skin or mucous membrane—one of the reasons why a good latch is very important from the very first day. Many Candida infections would, perhaps, not have occurred if the mother had not had sore nipples and a breakdown of the skin of the nipples and areola. The oozing of liquid that occurs often from cracked nipples encourages Candida albicans to change from its harmless form to an invasive form.

The widespread use of antibiotics also encourages the overgrowth of Candida albicans. Many pregnant women, women in labour, and new mothers, as well as their babies receive antibiotics, sometimes with very little justification.

Diagnosis of Candida infections of the nipples and/or ducts

There is no good test which helps makes the diagnosis. A positive culture from the nipple(s) does not prove your pain is due to Candida. Neither does a negative culture mean your pain is not due to Candida. The best way to make a diagnosis is by getting a good history.

Diagnosing the presence or absence of a Candida infection in the baby is not helpful. A baby may have thrush all over his mouth, but the mother may have no pain. A mother may have the classic symptoms of a Candidainfection of the nipples, and the baby may have no thrush or diaper rash.

The Typical Symptoms of a Candida Infection of The Nipples Are:

• Nipple pain that begins after a period of pain-free nursing. Though there are a few other causes of nipple pain that begin later, Candidainfection is definitely the most common. The nipple pain of Candidamay begin without an interval of pain-free nursing, however.
• Burning nipple pain that continues throughout the feeding, sometimes continuing after the feeding is over, sometimes beginning in the middle of a feeding as baby is still drinking well.
• Pain in the breast that is “shooting” or “burning” in nature and which goes through to the mother’s back and shoulder. This pain is usually worse toward the end of the feeding, and worsens still moreafter the feeding is over. It also tends to be much worse at night. This pain may occur without any nipple pain.

Treating Candida Infections of the Nipples

Our first approach to treating these infections is to apply the All Purpose Nipple Ointment (APNO) (see information sheet All purpose nipple ointment). Next, the mother can add topical Grapefruit Seed Extract and/or Gentian Violet (information sheets Gentian violet and Candida protocol - Toronto) if the ointment alone does not work. This approach is safe, works rapidly, and almost always, though there seems to have been a decrease in the effectiveness of gentian violet over the past few years. For this reason, we now use the combination of the ointment and the gentian violet as well as the grapefruit seed extract. A good response to gentian violet confirms that the mother’s nipple pain is caused by Candida since little else will respond to gentian violet. It thus also justifies the use of fluconazole, if needed. Even if the above treatment does not help, fluconazole should not be used alone to treat sore nipples and should be added to treatment on the nipples, not used instead. I have not found nystatin to be particularly useful either in treatment of the baby’s mouth or in the treatment of the mother’s nipples. Clotrimazole cream alone is also not particularly effective in my opinion, but others obviously feel differently.

Fluconazole for Breast Pain or Very Resistant Nipple Pain

Fluconazole is an antifungal agent that is taken systemically (by mouth or intravenously). It stops fungi (such as Candida albicans) from multiplying, but does not actually kill them. This accounts for the fact that sometimes it takes several days to have an effect. Fluconazole powder is also available and can be mixed with the all purpose nipple ointment instead of miconazole powder.

Fluconazole tends to work best when used in conjunction with probiotics and oral grapefruit seed extract.

Side Effects

Fluconazole is generally well tolerated, but there is no such thing as a drug that never has side effects. Concern about liver injury is exaggerated, since this complication seems quite rare, usually occurs in people who are taking other medications as well, and who have taken fluconazole for months or longer, and who have immune deficiencies. But it is a possibility that needs to be kept in mind and if it does occur, it can be serious.

Vomiting, diarrhea, abdominal pain and skin rashes are the most common side effects. These are not usually severe, and only occasionally is it necessary to stop the medication because of these side effects. Allergic reactions are possible but uncommon. Call or email immediately if you have any concerns.

Fluconazole in the milk

Fluconazole does appear in the milk, and this is as it should be, since the idea is to treat infection in the breasts and nipples. It is thus superior to ketoconazole, which gets into the milk in only tiny amounts. The baby will obviously get some, but this drug is now being promoted for use in babies for the treatment of simple thrush. There have been no complications in the baby reported from exposure to fluconazole in the breastmilk. Continue breastfeeding while taking fluconazole, even if you are told that you should stop.

Dose of fluconazole

Candida albicans is learning to become resistant to fluconazole, and the dose we use has increased over the past few years. Only a few years ago, 100 mg daily for 10 days cured 90% of women of their symptoms. We have now found this to be inadequate. For resistant cases, a newer antifungal agent, itraconazole, can be used, though it may not be the answer either as it does not have a very powerful effect against Candida.

Your prescription will be for fluconazole 400 mg as a first dose, followed by 100 mg twice daily until you are pain free for a full week, which usually means at least two weeks. This seems, on the basis of our experience, a fairly good guarantee against relapse. If you have nipple pain continue with the “all purpose nipple ointment” (± gentian violet and grapefruit seed extract) while you are taking fluconazole. However, this means that although most mothers require only the usual two weeks, some need longer treatment. Occasionally it may take up to seven to ten days for the pain to even start going away. Call if there is no relief in seven days. If there is no relief in 10 days, none at all, it is very unlikely fluconazole is going to be of any help. For very resistant cases we have used 100 mg 3x/day for 1 week.

It is sometimes useful to treat the baby as well. The dose for the baby would be 6 mg/kg as a first dose, followed by 3 mg/kg/day as one dose for the same period of time as the mother. Preferable is to treat the baby first with probiotics by mouth (see Information Sheet Candida Protocol). This is easy to do and fairly inexpensive. A small amount of probiotic powder placed on mother’s wet finger so baby will suck on it for a few seconds before a feeding 2x/day for 4-7 days is often adequate treatment for the baby with thrush.

Note: Some mothers may find the two week prescription costly. Generic fluconazole is generally more affordable.

Written and Revised by Jack Newman, MD, FRCPC, © 2009
Revised by Edith Kernerman, IBCLC, © 2009