The Yeast Beast (or Late Onset Sore Nipples)

on January 27, 2014 in Breastfeeding, Sore Nipples

Out of the blue, perhaps after a period of comfortable nursing, you may find that your nipples are sore.  They may appear shiny pink, or perhaps a bit scaly.  In severe cases, the nipples may appear cracked. Some mothers complain of deep shooting pains in their breasts. They may burn or perhaps feel itchy. You may have a yeast infection and your baby may have oral thrush, yeast in his or her mouth.

A yeast infection, also known as candidiasis is caused by yeast known as candida albicans, a type of fungus. Yeast infections usually happen in warm, moist parts of the body, such as the mouth and moist areas of skin.

Candida can overgrow for many reasons. Stress, pregnancy, and illnesses that affect the immune system may allow yeast to multiply, as can certain medicines, especially antibiotics.  The antibiotics can kill “good” bacteria that also live in the body and normally keep the growth of candida in check.

Yeast often follows when a mother or her baby has received antibiotics or when an older baby has recently had a viral infection.  Mothers may be unaware that they may have been given antibiotics during labor or cesarean birth.  Some mothers may pass yeast onto their babies if they unknowingly have had a normal birth and they had a vaginal yeast infection during the pregnancy and delivery.  It is not uncommon for mothers to have an asymptomatic yeast infection during pregnancy and birth.

Younger babies with thrush typically have plaques of white on the insides of their lips and cheeks. Sometimes mothers mistake white areas in the baby’s mouth as milk and overlook the possibility of thrush. Sometimes white areas can be seen on the tongue. But seeing white areas on a baby’s tongue only, does not necessarily mean a baby has yeast.  Fat from breastmilk often can be seen on the tongue.

Older babies may have no signs of oral thrush but they often will have a yeast diaper rash.  A yeast diaper rash is different than a typical diaper rash.  A yeast rash will be very defined, very red and a bit raised. It may also appear in the folds of the baby’s diaper area. There may be “satellite” areas apart from the main rash and the rash may appear scaly.  Another difference is that a yeast rash will not respond to typical remedies like frequent cleaning and the usual diaper rash creams.

Some mothers experience so much pain, that nursing is unbearable!  In this case, using an effective pump with the correct sized flange may be more comfortable until the nipples are treated.  When deciding to pump, use something around the walls of the nipple for more comfortable nursing, including a thin coating of lanolin or other nipple cream.  You will want to pump often, at least 7-8 times each 24 hours so that you maintain high milk production and provide your baby your precious milk!

Treatment of yeast means that both mother and baby must be done at the same time to avoid re-infection.  You can use an anti-fungal cream on your nipples, which you can find over the counter at any drug store in the Athlete’s Foot section of the store. Yes, I said “Athlete’s Foot”, but it can be used safely on the nipples.  My favorite cream for nipples is Lotrimin AF, although Micatin and Monostat 7 can also be used. You can apply a thin coating of these creams after every nursing or pumping.  If you see it at the next feeding, you are probably using too much and you will want to rinse it off.  Some lactation professionals do not recommend using Nystatin cream on the nipples that may be prescribed for the baby’s yeast diaper rash by their doctor.

Treating your baby is another matter.  If you speak with your Pediatrician about thrush, he or she may prescribe Nystatin suspension (Mycostatin) drops to be placed in your baby’s mouth four times a day for 14 days.  Unfortunately, Nystatin suspension is often very ineffective!  Nystatin is also used for adults with thrush.  It is meant to be swished and gargled a few times a day and usually works well.  But, of course, babies don’t swish or gargle!  And with frequent feeds, the Nystatin doesn’t linger in the mouth long enough to be very effective.  So long as there is yeast in the baby’s mouth, it will be difficult to keep it away from the nipples and allow rapid healing.

I prefer using 1% Gentian violet, a purple dye that kills yeast on contact.  It is an inexpensive, over-the-counter medication that works quickly, but it can be difficult to find it in all pharmacies.  It may be best to call around to see if your local pharmacies carry it.  A pharmacist can usually order a small bottle for you. In the U.S., 2% Gentian violet is the most common concentration found, but it is recommended that you ask the pharmacist to dilute it down to a 1% solution or you can dilute it yourself by adding an equal amount of water in the cap of the bottle.

When using Gentian violet, it is best to have help from another adult to get it applied quickly and avoids getting it on the baby’s face.  This treatment gets a bad rap as being messy, but I find it very effective.  Having a helper that can hold the baby’s arms and face still will help keep the baby still while you swab the baby’s mouth.  Using a Q-tip, get a couple of drops of the Gentian violet on the swab and quickly rub it on the insides of the baby’s lips, cheeks, and once over the tongue. If you get some of it outside the baby’s mouth, have some rubbing alcohol ready on another swab to remove it. Your baby will now look a bit purple around the lips.  This will mostly disappear after several hours.  Gentian violet should be applied every 12 hours for THREE days only.  Using it more often or for longer than three days can result in ulcers in the baby’s mouth.  Some mothers use Gentian violet on their nipples, but I find that some mothers find that it is too drying and irritating on delicate and tender nipple tissue.  Of course, you will see faint traces of it on the nipples if you are nursing soon after applying it in the baby’s mouth.

Dr. Jack Newman, a Canadian Pediatrician and some other lactation specialists, suggests that if after a week or so of using topical antifungal creams to your nipples, and they are not improving, also suggest using Grapefruit Seed Extract, with the active ingredient being “citricidal”.  These capsules can be taken by mouth, 250 milligrams three to four times a day.

Taking probiotics with the capsules may also help. Probiotics containing acidophilus with bifidus are suggested. A mother can take one or two capsules (strength of 10 billion cells) two to three times a day. The probiotics should be taken at least 1 hour apart from any oral Grapefruit Seed Extract.  Babies can also be given probiotics.  Some mothers break open a capsule of probiotics and rub it in their baby’s mouth right before a nursing, twice a day for seven days.

Dr. Newman also recommends that Grapefruit Seed Extract can also be used as a nipple solution by mixing the 5-10 drops of the liquid well in one ounce of water.  Rub some of this solution to the nipples and areola after nursings. You can use this in addition to any topical antifungal cream by alternating it with the cream. It can be kept out and covered and used until it is gone. The concentration of the Grapefruit Seed Extract can also be increased slowly up to 25 drops in an ounce of water. If you find that your nipples begin flaking very much, stop using this solution.

Some mothers use another yeast treatment, fluconazole (Diflucan) a prescription oral medication.  Your OB, nurse midwife or your Pediatrician may be willing to order it for you.  The dose is 400 milligrams on the first day followed by 100 mgms a day until the mother is pain free for one week.  The topical medications can also be used at the same time. This drug is very expensive without insurance coverage.  I hear of mothers taking multiple courses of Diflucan with poor results.  If you are taking this medication, and your nipples continue to be sore after two weeks, yeast is probably not the problem and seeking the help of a dermatologist may be a better next move toward calming your nipples.

Yeast thrives in dark, warm places.  Keeping your breasts open to the air can also speed healing.  If you are in a warm weather area or can sit by a window in sunshine, exposing your breasts to sunlight may also help speed healing of the nipples.

You will also need to sanitize your breastfeeding supplies to prevent re-infection. This means changing nursing pads after each and every feeding.  If you are using a breast pump, clean all of your breast pump parts after each use.  Bottle nipples, pacifiers, breast shells, nipple shields and pump flanges should be cleaned and boiled daily for five minutes.

Lastly, if you continue struggling with nipple pain that does not seem to respond to any of the treatment methods described above, yeast may not be the problem.  I find that sometimes yeast is diagnosed when in fact something else it the problem. Chronically sore nipples can occur with other situations or skin conditions. It is probably time to see an experienced lactation professional and/or a dermatologist.  Nursing should not be painful and there is help out there for you!