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.

If Not Getting Better...Add:

  • Gentian violet (see the information sheet Using Gentian Violet). Actually, the gentian violet can be used along with the APNO from the very first, but it should not be used alone as it is drying and often does not work when used alone.

    Use once a day for four to seven days. If pain is gone after four days, stop gentian violet. If better, but not gone after four days, continue for seven days. Stop after 7 days no matter what, not because it's dangerous, but if the gentian violet hasn't helped in 7 days, it probably won't. If not better at all after four days of use, stop the gentian violet, continue with the ointment as above and seek good help.

    Gentian violet comes as a 1% solution in water. It also usually dissolved in 10% alcohol, as gentian violet is not soluble in pure water. This amount of alcohol is negligible, as the baby will only get a drop of gentian violet at each treatment. Apparently some pharmacists will dissolve it in glycerine instead of alcohol, if you wish.

    Attention US residents: 2% gentian violet, which seems to be the usual concentration found in the US, should not be used. The pharmacist should dilute it to 1% for you.

    And/or:

  • Grapefruit Seed Extract (GSE), active ingredient must be "citricidal," should be followed by, and used in conjunction with, the APNO (All Purpose Nipple Ointment). Apply diluted solution directly on the nipples. It does not need to be refrigerated. It may be covered and used until solution is finished.

Using GSE:

  • Mix very well 5-10 drops in 30 ml (1 ounce) of water.
  • Use cotton swab to apply on both nipples and areolas after the feeding.
  • Let dry a few seconds, and then apply "all purpose nipple ointment."
  • If also using Gentian Violet, do not use GSE on that particular feed but use after all other feeds.
  • 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 concentration by 5 drops per 30 ml (ounce) of water. Can continue increasing concentration until 25 drops/ 30 ml of water.
  • If you start to get flaking, drying, or whiteness appears on the skin, substitute pure olive oil for APNO 1-3x/day after each feeding and decrease the concentration of the GSE drops. If the flaking does not get better, stop the GSE drops.
  • Laundry can be treated as well: add 15-20 drops in the rinse cycle of all wash loads.
  • GSE may be used in conjunction with oral GSE and Probiotics

    If you are not getting better and/or you have pain in the breast as well that is not responding to treatment of the nipples alone:

    Add:

  • Oral GSE: Grapefruit seed extract (not grape seed extract). The active ingredient must be "citricidal." Use tablets or capsules, 250 mg (usually 2 tablets of 125 mg each) three or four times a day orally (taken by the mother). If preferred the liquid extract can be taken orally, 10 drops in water three times per day (though this is not as effective as the pills and the taste is quite bitter). Oral GSE can be used before trying fluconazole, instead of fluconazole, or in addition to fluconazole in resistant cases.

    And/or

  • Probiotics: Acidophilus with bifidus (with FOS (fructo-oligosaccharides) is okay). The mother should take 1-2 capsules (strength of 10 billion cells) 2-3x/day. The probiotics should be taken at least 1 hour apart from oral GSE. Baby should be treated with Probiotics 2x/day for approximately 7 days (Mother may wet her finger and roll it in probiotic powder (break open a capsule), and let baby suck on mother's finger right before a feeding).

    If Still Not Getting Better at All…

    Add:

  • Fluconazole: (see the information sheet Fluconazole) If pain continues and it is likely the problem is Candida, or at least reasonably likely, add fluconazole 400 mg loading, then 100 mg twice daily for at least two weeks, until the mother is pain free for a week. The course of treatment with fluconazole is not two weeks. The nipple ointment should be continued and the gentian violet can be repeated.

    Fluconazole should not be used as a first line treatment, especially if you have sore nipples. If used, fluconazole should be added to above topical and oral treatments, not used alone. Fluconazole takes three or four days to start working, though occasionally, in some situations, it has taken 10 days to even start working. If you have had no relief at all with 10 days of fluconazole, it is very unlikely it will work, and you should stop taking it.

Other Medications: 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).

Questions? Get Dr. Jack Newman's book The Ultimate Breastfeeding Book of Answers.

Jack NewmanJack Newman graduated from the University of Toronto medical school as a pediatrician in 1970. He started the first hospital-based breastfeeding clinic in Canada in 1984 at Toronto's Hospital for Sick Children. He has been a consultant with UNICEF for the Baby Friendly Hospital Initiative in Africa, and has published articles on the subject of breastfeeding in Scientific American and several medical journals. Dr. Newman has practiced as a physician in Canada, New Zealand, and South Africa.

Written & revised (under other names) by Jack Newman, MD, FRCPC 1995-2005©
Revised by Jack Newman MD, FRCPC, IBCLC & Edith Kernerman IBCLC, 2008, 2009©