Breastfeeding: Candida Protocol

by Jack Newman, MD, FRCPC

Whatever the cause of sore nipples in your case, it is important to get the best latch possible when you have sore nipples. Even if the cause of sore nipples is Candida (yeast, thrush), improving the latch can decrease the pain. With the "ideal" latch, the baby covers more of the areola (brown or darker part of the breast) with his lower lip than the upper lip. Note also that the baby's nose does not touch the breast. Of course, it is not always easy to change the latch of the baby older than 3 or 4 months, but it is worth a try. Also see our videos showing how to latch on a baby. For a fuller description of how to get the baby to latch on well, see also the hand-out When Latching.

Diagnosing Candida albicans (yeast)
An infection due to Candida albicans can be difficult to diagnose and mothers should not attempt to do so on their own. The pain due to Candida albicans is often confused with pain due to poor latching and/or pain due to vasospasm/Raynaud’s phenomenon. Furthermore, more than one cause of sore nipples may be the source of your pain. A good practitioner will help you to differentiate between these conditions.

For Nipple Pain: Treatment applied to the nipple(s)

APNO (All Purpose Nipple Ointment) is a compounded ointment mixed from the following ingredients:

• 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 (not as good as miconazole in our opinion, as it often causes irritation) or fluconazole powder to a final concentration of 2% may be substituted for miconazole powder if miconazole powder is unavailable, but both exist (the pharmacist may have to order it in, but many compounding pharmacies almost always have it on hand). Using powder gives a better concentration of antifungal agent (miconazole or clotrimazole) and the concentrations of the mupirocin and betamethasone remain higher.
• We no longer use nystatin ointment in our recipe and haven't for over 10 years.
• Sometimes adding ibuprofen powder so that the final concentration of ibuprofen is 2% helps when the regular ointment does not. We do not prescribe this one routinely because it is even more difficult to get it made up and it is more expensive because of the extra ingredient. Furthermore, if the regular APNO works, as it usually does, then adding an extra ingredient is wasteful.

To find a compounding pharmacy near you in Canada and the US, go to http://www.iacprx.org">International Association of Compounding Pharmacists. Then click "For Patients, Pet Owners" in the red box on the left side of the page, then click "Finding a Compounding Pharmacist Near You." You will need to sign in. Canadians: make sure that you leave a space between the two sets of 3 letters in the postal code: M2K 2E1, not M2K2E1.

The ointment is applied sparingly after each feeding (except the feeding if/when the mother uses gentian violet). "Sparingly" means that the nipple and areola will shine but you won’t be able to see the ointment. Do not wash or wipe it off, even if the pharmacist asks you to. The APNO can be used for any cause of nipple soreness ("all purpose nipple ointments"), not just for Candida (yeast, thrush). Use the ointment until you are pain free for a few days and then decrease frequency over a few days until stopped. If you are not having less pain after 3 or 4 days of use, or if you need to be using it for longer than two or three weeks to keep pain free, get good help or advice but do not stop using the APNO.

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