IS THRUSH CAUSING MY SORE NIPPLES?
Common reasons for ongoing nipple pain
Approaches to try to help resolve painful nipples or breasts
If you still suspect thrush
Do I need to stop nursing or discard my milk?
Resources for additional information
Is thrush causing my sore nipples? Perhaps you recently had a baby and you have sore nipples. Perhaps your baby is a few months old and you suddenly are experiencing an uncomfortable latch. The internet, other parents, or your healthcare provider may suggest thrush as a diagnosis. But is this the most likely cause of this pain? Finding the source of discomfort is an important step in treatment.
In the past, persistent nipple pain was often attributed to thrush, a fungal infection caused by Candida albicans. The connection is controversial. Yeast is common on our bodies and recent research disputes that yeast plays a role in breast and nipple pain. (Jimenez)
Thrush on the nipple or breast was often assumed if nipple pain was combined with recent antibiotic use, predisposition to candida infections, existing nipple injury, yeast infection in the baby, latch or shooting pain in the breast. However, all of these symptoms can be associated with other conditions. It is always wise to consult your healthcare provider for a full diagnosis and consider all explanations.
COMMON REASONS FOR ONGOING NIPPLE PAIN
Common reasons for ongoing nipple pain may include:
- Latch and positioning challenges: this is the most common cause of nipple pain
- Hyperlactation (overproduction of milk)
- Mammary dysbiosis (also known as subacute mastitis)
- Nipple bleb
Everyday factors that may contribute to a painful or irritating skin reaction on the nipple include:
- An allergic reaction to something baby ate or touched,
- Wearing a new bra that has a different fit or is made from a material that might cause irritation,
- Sensitivity to a nursing pad,
- Reaction to an ointment used in treatment.
APPROACHES TO TRY TO HELP RESOLVE PAINFUL NIPPLES OR BREASTS
Approaches to try to help resolve painful nipples or breasts:
- Focus on latch. Research suggests that nipple pain is more likely to be caused by a shallow latch and related challenges (such as vasospasm) than by thrush.
- If pumping, check that your pump flange and nipple tunnel fit comfortably. If too much of your areola is pulled into the tunnel during pumping it can cause rubbing and soreness. If the tunnel is too tight it can inhibit milk flow. Your nipple should not rub against the flange; allow for space on all sides. Flange size varies between different makes and models. Many are available in a choice of sizes. Manufacturers usually provide a sizing guide. You may need a different size for each breast.
- Soothe your tissue by using warm or cold compresses and gentle touches. Ask your medical provider about pain management.
- Offer your baby short, frequent feedings, beginning on the least painful breast.
- Don’t make your job harder than it needs to be. While there are lots of suggestions online for changing your diet and introducing extra cleaning steps, these may not be necessary. Focus on good basic hygiene measures and hand washing.
- Sometimes nursing may seem too uncomfortable. You can express milk either through pumping or hand expression to maintain milk production. This will also help you avoid engorgement. Expressed breastmilk (see Pumping Milk) can be offered to your baby in a small cup or in a bottle.
- Cracked nipples may suggest that your baby’s latch is not deep enough. Seek information from an LLL Leader, an International Board Certified Lactation Consultant or other lactation specialist to address this and improve comfort.
- Bacterial infections are thought to be more common than thrush or may occur at the same time. They require a different treatment regime. The Academy of Breastfeeding Medicine suggests that with persistent pain, having a milk culture done may be revealing (see page 6 of their document) Persistent Pain with Breastfeeding.
- Nipple vasospasm is a painful condition related to a brief interruption to normal blood flow. It may be experienced as shooting deep breast pains following nursing or exposure to cold, for instance in the freezer section of the grocery store. It is often confused with thrush symptoms. Talk to your healthcare provider or a lactation consultant (IBCLC) about this possibility. You can find support from an LLL Leader via our ‘Get Help’ page.
- Consider stopping all creams/substances applied to your nipple. Many of the interventions that are suggested for thrush can be drying or irritating to the skin of the nipple, possibly creating an allergic reaction and another cause of discomfort. If you find that a prescribed cream is causing stinging or is not helping, ask your doctor whether it should be continued. Some people may react to their baby’s oral treatment as well, so consider applying it after nursing.
- To explore whether the cause of symptoms is related to a different skin condition, speak with your doctor or ask about a referral to a dermatologist supportive of breastfeeding. It may be helpful to explore whether the symptoms are related to a different skin condition. This resource provides a helpful overview of skin conditions often confused with thrush, please note that it includes clinical photos of breast and nipple infection and injury.
- There is a section on treatment for other causes of sore nipples in this post about sore nipples.
DO I NEED TO STOP NURSING OR DISCARD MY MILK?
Recent research suggests that thrush in a baby’s mouth does not automatically mean it will be passed along to you through breastfeeding therefore continued breastfeeding is not a concern. See more information in the following National Center for Biotechnology Information’s article (see discussion section, last line, 7th paragraph) and this article in the Physician Guide to Breastfeeding.
According to the Academy of Breastfeeding Medicine and several other sources, there is no need to discard milk that was pumped during a presumed thrush infection. You can read this in the upper left of page 393, #10: “If a mother has breast or nipple pain from a bacterial or yeast infection, there is no evidence that her stored expressed milk needs to be discarded.”
IF YOU STILL SUSPECT THRUSH
Sometimes the treatments you’ve been offered may resolve the issues. Consult with your primary healthcare provider and your baby’s physician, as both you and your baby will often be treated.
Physicians prescribe a variety of treatment options when they diagnose thrush. Anti-fungal ointments with other ingredients are common (Newman, 2017). Nystatin, miconazole and fluconazole may be prescribed for either you or your baby (Berens et al, 2016). Different people react better to different medicines, so you may have to try more than one. Check with your healthcare professional about the medications listed and other options.
New research suggests that several commonly used treatments may not be effective for the mother and may actually cause increased discomfort. (See ABM Protocol #36). This is especially the case with gentian violet (less than 0.5% aqueous solution). This treatment has been used historically as a treatment of thrush. However, it has recently been identified as a cause for concern. (Wambach and Spencer, 2021). Both the World Health Organization (WHO) and Health Canada advise against its use. There has also been a suggestion that fluconazole may also worsen symptoms of vasospasm. (Nipple Vasospasm Patient Handout 2019. Herzl Family Practice Centre, Goldfarb Breastfeeding Clinic).
If your symptoms persist after you have tried these interventions, you may not have thrush. It is important to get back in touch with your healthcare provider.
You might want to have medical tests done to rule out other conditions including anemia and diabetes.
Attend a La Leche League Group meeting in your area for additional information and support.
Updated January 2023 by Cindy Garrison, LLL Leader, BS, IBCLC
RESOURCES FOR ADDITIONAL INFORMATION
La Leche League Articles
LLLGB: Positioning & Attachment
LLLI: Medications – A Quick Guide For Parents
LLLI: Pain – General
LLLI: Persistent Pain When Breastfeeding
LLLI: Sore Nipples
LLLGB: Nipple Pain
LLLI: Cleaning and Sanitizing Pumping Accessories
Berens, P., Eglash, A., Malloy, M., et al, ABM Clinical Protocol #26: Persistent Pain with Breastfeeding, Breastfeeding Medicine, 2016, https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/26-persistent-pain-protocol-english.pdf (accessed 30 January 2023)
Herzl Family Practice Centre, Goldfarb Breastfeeding Clinic, Nipple vasospasm Patient handout, Jewish General Hospital, 2019, https://cdn.ciussscentreouest.ca/documents/hgj/pfrc/Breastfeeding_clinic/Vasospasm_px_handout_2019.pdf?1561062105 (accessed 30 January 2023)
- Amir L. et al., Does candida and/or staphylococcus play a role in nipple and breast pain in lactation? A cohort study in Melbourne Australia, BMJ Open, https://bmjopen.bmj.com/content/3/3/e002351(accessed 30 January 2023)
- Berens P et al., Academy of Breastfeeding Medicine, Protocol #26, Persistent Pain with Breastfeeding, Breastfeeding Medicine, 2016, https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/26-persistent-pain-protocol-english.pdf (accessed 30 January 2023)
- Barrett ME, Heller MM, Fullerton Stone H, et al. Dermatoses of the breast in lactation, Dermatol Ther, 26:331–336, 2013,
https://pubmed.ncbi.nlm.nih.gov/23914890/ (accessed 30 January 2023)
- Betts RC, Johnson HM, English A, Mitchell KB, It’s Not Yeast, Breastfeeding Medicine, 2021, https://www.liebertpub.com/doi/abs/10.1089/bfm.2020.0160 (accessed 30 January 2023)
- Douglas P., Overdiagnosis and overtreatment of nipple and breast candidiasis: A review of the relationship between diagnoses of mammary candidiasis and Candida albicans in breastfeeding women, Women’s Health, Vol 17:1-10
https://pubmed.ncbi.nlm.nih.gov/34269140/ (accessed 30 January 2023)
- Eglash A et al., Academy of Breastfeeding Medicine, Protocol #8: Human Milk Storage Information for Home Use
for Full-Term Infants, Breastfeeding Medicine, 2017, https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/8-human-milk-storage-protocol-english.pdf (accessed 30 January 2023)
- Garrison CP, Nipple Vasospasms, Raynaud’s Syndrome and Nifedipine, Journal of Human Lactation, https://journals.sagepub.com/doi/abs/10.1177/089033402237913 (accessed 30 January 2023)
- Hale TW, Medications and Mothers’ Milk, 18th ed., NY, Springer Publishing, 2019
- Jimenez et al. Mammary candidiasis: A medical condition without scientific evidence? PLoS ONE, 12(7): e0181071, 2017, https://eadn-wc01-5994650.nxedge.io/wp-content/uploads/2021/08/JimenezetalCandidiasnotcauseofpain.pdf (accessed 30 January 2023)
- Mayo Clinic Staff, Yeast infection (vaginal), Mayo Clinic, 2015, http://www.mayoclinic.org/diseases-conditions/yeast-infection/basics/definition/CON-20035129?p=1 (accessed 30 January 2023)
- Mitchell, K. B., Johnson, H. M., Rodríguez, J. M., Eglash, A., Scherzinger, C., Zakarija-Grkovic, I., … & Academy of Breastfeeding Medicine, Clinical Protocol# 36: The Mastitis Spectrum, Breastfeeding Medicine, 17(5), 360-376, 2022, https://www.bfmed.org/assets/ABM%20Protocol%20%2336.pdf (accessed 30 January 2023)
- Mohrbacher N., Breastfeeding Answers: a Guide for Helping Families, Arlington Heights, IL, 2020
- Newman, J., Candida Protocol, International Breastfeeding Centre, 2017 https://ibconline.ca/information-sheets/candida-protocol/ (accessed 30 January 2023)
- Wambach K and Spencer B., Breastfeeding and Human Lactation 6th ed., Burlington, MA, 2021
- Wilson-Clay B and Hoover K., The Breastfeeding Atlas, 7th ed. Manchaca, TX, 2022
BioSpace: Warning of potential cancer risk associated with gentian violet
Ask Lenore: Candida or thrush of the nipple and breast
Ask Lenore: Nipple Vasospasm
Centers for Disease Control & Prevention: Fungal Diseases
International Breastfeeding Centre: Candida Protocol
International Breastfeeding Centre: Vasospasm