Nipple pain caused by Candida albicans

By Carole Dobrich RN, IBCLC, from Dr. Jack Newman’s candida protocol (with permission) & Dr. Jay Gordon’s web site

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

The pain caused by a Candidal infection:

• 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 Candidal 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, which usually hurts most as feeding begins, and gradually improves as the baby nurses.
• may radiate into the mother’s armpit or into her back.
• 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.
• 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.
• 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 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:

1. The baby does not have to have thrush in his mouth.
2. A Candidal infection of the nipple may be combined with other causes of soreness.
3. Treat both mother and baby, even if only one has symptoms.

Step one: start with Gentian violet

Once a day for 4 to 7 days. If pain is gone after 4 days, stop gentian violet.

If better, but not gone after four days, continue for 7 days. Stop after 7 days no matter what.

If not better at all at 4 days, stop the gentian violet, continue with the ointment as below and call your doctor.

Gentian violet is available without prescription but is not available at all pharmacies, so call your pharmacy to confirm they have it before going out to get it. You may need to call several pharmacies to find one that has it.

Using Gentian Violet:

It is messy, and will stain clothing (it will wash out), but will not stain skin. The baby’s lips will turn purple, but the purple will disappear after a few days.

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 a clean 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 as described above *.
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 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 3 or 4 days, but not completely, you can use gentian violet a few more days if necessary.
9. All artificial nipples that the baby uses should be boiled in a large pot with 3 - 4 tblspns of vinegar 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 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. Treatments 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 re-infection. Contact the clinic.

Step two: add All purpose nipple ointment (APNO) as below:

• Mupirocin 2% ointment (15 grams)
• Betamethasone 0.1% ointment (15 grams)
• To which is added miconazole powder so that the final concentration is 2% miconazole. This combination gives a total volume of just more than 30 grams. Clotrimazole powder to a final concentration of 2% may be substituted if miconazole powder is unavailable, but both exist (the pharmacist may have to order it in, but compounding pharmacies almost always have it on hand). I believe clotrimazole is not as good as miconazole. Using powder gives a better concentration of antifungal agent (miconazole or clotrimazole) and the concentrations of the mupirocin and betamethasone remain higher. Sometimes we will add ibuprofen powder to a final concentration of 2%.

The pharmacist mixes it all together and it is applied sparingly after each feeding except the feeding when the mother uses gentian violet. Do not wash or wipe it off, even if the pharmacist asks you to. This ointment can be used for any cause of nipple soreness. Use the ointment until pain free and then decrease frequency over a week or two until stopped.

GSE (2 - 5 drops to 1 - 2 oz water) can be applied to mum’s nipples after nursing and then APNO applied.

Step three: add Grapefruit seed extract

250 mg three times a day orally (taken by the mother), seems to work well in many cases. It can be used instead of fluconazole or in addition to fluconazole in resistant cases.

Grapefruit Seed Extract

Here is the site of the company recommended by Dr Jay Gordon: nutriteam.com

It has a lot of information about GSE - here is their dosing info: 
Recommended Dosage for NutriBiotic Liquid Concentrate 
These recommendations are for NutriBiotic Original GSE. Those using Citricidal Professional Strength liquid concentrate should divide these recommended dosages by three (or multiply by 1/3).

Internal Use Note: Never use full strength, may cause irritation.

Orally. Suggested Use: 5 to 15 drops mixed in 5 ounces of water or juice, 2 to 5 times daily, with or without meals. (Or, take one-two NutriBiotic CapsulesPlus® or one-two NutriBiotic® tablets (125 mg each) 1 to 5 times daily).

Children (under 10 years): 1 to 6 drops mixed in 5 ounces juice, 2 to 3 times daily. Do not use full strength in mouth. Some people think the liquid extract is more effective.

Dr Gordon only uses it topically, as he describes on his website: drjaygordon.com

Step four:

If pain continues or reoccurs and it is reasonably sure the problem is Candida, add Fluconazole (Diflucan) 400 mg (loading dosage), then 100 mg twice daily for at least 2 weeks, until the mother is pain free for a week. The nipple ointment should be continued and the gentian violet can be repeated. If fluconazole is too expensive, ketoconazole 400 mg loading, then 200 mg twice daily for same period of time. If Candida resistant, itraconazole, same dose and time period as fluconazole, though Candida actually is less sensitive to itraconazole, generally, than it is to fluconazole. Fluconazole should not be used as a first line treatment or if nystatin alone does not work (which it usually doesn't).

Step five:

For deep breast pain, ibuprofen 400 mg every four hours may be used until definitive treatment is working (maximum daily dose is 2400 mg/day).

At any time A supplement of high dose acidophilus 1 cap 2 - 3 times daily or BioK 1/2 a pot daily can be added while using the above treatment.

For Baby

Gentian Violet as above and GSE (2 - 5 drops to 1 - 2 oz water) can be used in baby’s mouth prior to nursing. It is best to avoid the possibility of baby associating the bitter taste with nursing. High dose acidophilus powder can be used 1 - 2 times daily on baby’s tongue. Open a capsule or use 1/8 teaspoon of powder, wet finger and dab in powder & let baby suck on your finger. Repeat until all the powder is gone. Baby dose of fluconazole is 6mg/kg loading, then 3mg/kg/day as a single dose.

May be copied and distributed without further permission

Treatments for Problems

Cabbage leaves for engorgement

Severe engorgement about the third or fourth day after the baby is born can usually be prevented by getting the baby latched on well and drinking well from the very beginning. (See Starting out right and The importance of skin-to-skin contact, as well as Increase intake of breastmilk. See also Breastfeeding videos for videos to help use the Protocol). If you do become engorged, please understand that engorgement diminishes within 1 or 2 days even without any treatment. Continue to breastfeed the baby, making sure he gets on well and nurses well. However, if you should get engorged to the point of severe discomfort or if the baby is not able to take the breast, cabbage leaves seem to help decrease the engorgement more rapidly than ice packs or other treatments. If you are unable to get the baby latched on, start cabbage leaves, start expressing your milk and give the expressed milk to the baby by spoon, cup, finger feeding or eyedropper and get help quickly.

1. Use green cabbage.
2. Crush the cabbage leaves with a rolling pin if the leaves do not accommodate to the shape of your breast.
3. Wrap the cabbage leaves around the breast and leave on for about 20 minutes. Twice daily is enough. It is usual to use the cabbage leaf treatment two or three times or less. Some will say to use the cabbage leaves after each feeding and leave them on until they wilt. Others are concerned that such frequent use will decrease the milk supply.
4. Stop using as soon as engorgement is beginning to diminish and you are becoming more comfortable.
5. You can use acetaminophen (Tylenol(tm), others) with or without codeine, ibuprofen, or other medication for pain relief. As with almost all medications, there is no reason to stop breastfeeding when taking analgesics.
6. Ice packs also can be helpful.
7. If you are one of the women who gets a large lump in the armpit about 3 or 4 days after the baby’s birth, you can use cabbage leaves in that area as well.

Handout #24. Miscellaneous treatments. 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.

Breastfeeding in Public

By Elizabeth Pantley, Author of Gentle Baby Care

In many parts of the world, the sight of a nursing mother is an ordinary aspect of daily life. In our society, however, some people are still uncomfortable seeing a mother breastfeed in public. Slowly but surely, though, people are coming to see breastfeeding as the natural, normal way of feeding a baby that it is. And thanks to public education campaigns, people are becoming more knowledgeable about the many benefits of breastfeeding.

Your legal right to breastfeed

Society has conditioned many people to view breasts only from a sexual standpoint and not as a body part with a crucial biological function - to feed a baby. Breastfeeding is the natural default for baby feeding - not bottlefeeding - yet no one harangues a woman who is feeding her baby from a bottle in a public place. If anyone even suggests that you shouldn't be feeding your baby in public, be aware that you are well within your rights. Keep in mind that it’s the onlooker’s problem, not yours.

From a legal perspective, you have a right to breastfeed your baby in public anywhere in the United States. Some states have gone so far as to implement specific legislation to that effect to protect the rights of both babies and their mothers; these states have set out legal consequences for violations, too. As of this writing, 17 states have passed laws that say you can breastfeed your baby in any public or private location; thirteen more exempt breastfeeding from public indecency laws. This may lead you to believe that the act is legal only in those states with legislation. The fact is, you have a legal right to breastfeed your baby in public even without a specific law. Don't be shy about letting an impolite person know this. For more information about the legal aspects of breastfeeding in public, check out the website of Elizabeth N. Baldwin, an attorney who specializes in this issue.

In Canada, the Human Rights Code protects women from discrimination on the basis of sex. Breastfeeding in public is not specifically labeled as a protected activity; however, many people are lobbying to explicitly include breastfeeding under this human rights code.

What about breastfeeding when in foreign countries? It’s best to respect the customs native to the country you are visiting. Even if you think you should breastfeed wherever you please, it’s important to understand and adhere to local customs. If you don't see other women breastfeeding their babies, then ask around. Talk to a woman with young children, ask a health professional, or do a little research. Once you know what is typically acceptable, then you can proceed confidently without risk of offending anyone, breaking a law, or embarrassing yourself.

Getting comfortable breastfeeding in public

Although you have the right to feed your baby in public, there is still the issue of your feelings about doing so. Each woman has her own comfort level. Most women want to find the right balance of pride and modesty - not overly exposing themselves, while feeling comfortable knowing that people are aware that they are breastfeeding. You'll probably need some practice with the particulars, simply because breastfeeding is a function that involves a private part of your anatomy that is normally not exposed in public. Wanting to be discreet doesn't mean that you are embarrassed or ashamed to feed your baby; it simply means that you don't want to cause yourself or others social discomfort.

The biggest issue for most new mothers is learning how to get settled with your baby modestly. Even a new mother who is breastfeeding with ease at home may fumble and struggle when she perceives that she has an audience; her tension then causes her impatient baby to cry. That only deepens the feeling that all eyes are on her. The reality is that most people are paying attention to their own activities and their own private conversations, by and large ignorant of what’s happening with other people. Once you become adept breastfeeding discreetly, you'll be able to comfortably nurse your baby anywhere. All it takes is a little practice.

PARENT TIP

“Always remember that what you are doing is necessary, beautiful, and miraculous. Breastfeed your baby with pride.”

Deborah, mother to Peter (five), Jeremy (three), and Claire (one)

Tips for breastfeeding in public

• Give yourself permission to feel comfortable about nursing your baby in public. Feeding your baby is a natural, normal part of mothering, whether you are at home or out in public.
• Dress for breastfeeding. Wear a shirt or sweater that can be lifted up or unbuttoned from the bottom. When you lift from the bottom, the top portion of your shirt helps cover you from the top, and your baby covers you from the bottom. Whatever portion of your breast is shown while feeding your baby is certainly much less than is shown in the typical television show, magazine or at your local beach or public swimming pool.
• Try a nursing cover-up or a breastfeeding garment with a built-in flap. Many are so beautifully made that even under the most careful scrutiny, they don't look like nursing clothes. Most stores that sell maternity clothing also sell nursing apparel. Even if you don't use these at home, they may help you feel more comfortable when in public.
• Bring along a small baby blanket. Some babies are fine with having a blanket thrown over your shoulder and over their heads, but many are very good at pulling such a blanket off. A good alternative is to bring the blanket up from below, and tent it around your baby, to cover you as you settle your little one to the breast. The blanket can be loosely placed to create privacy, or even removed once you're settled.
• Use your sling as a nursing cover-up. Baby slings are wonderful for nursing your baby on the go because they hold your baby perfectly in the nursing position while providing extra fabric for a screen. Some brands have a "tail" at the end that doubles as an extra blanket to keep the baby from trying to peek out while nursing.
• Feed your baby at the first sign of hunger, because hungry babies aren't quietly patient! If you wait until your baby is crying to be fed, then you may become nervous; your baby may move about and make the latch-on difficult. Instead, if you nurse him promptly, you can be more relaxed about getting him settled.
• Remember that the alternative to public breastfeeding is usually public crying. Whether you're in a restaurant, at church, or on an airplane, people typically would prefer that you feed your baby than let him cry, fuss or otherwise disrupt the peace. I remember once attending a live play with a very antsy two-year-old: my son, David. When I finally settled him on my lap to breastfeed, the gentleman sitting beside me actually said, “Thank you!”

For more information

La Leche League International

INFACT Canada

The World Alliance for Breastfeeding Action

This article is an excerpt from Gentle Baby Care by Elizabeth Pantley. (McGraw-Hill, 2003)