Treatment of Mucocutaneous Candidal Infection in the Breastfeeding Mother and Child

8/12/2019 Treatment of Mucocutaneous Candidal Infection in the Breastfeeding Mother and Child

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Treatment of Mucocutaneous CandidalInfection in the Breastfeeding Mother and

ChildKatie Reynolds, MD, Betsy Ayers, IBCLC, and John Werdel, MD

Abstract

Candidal infections of the breastfeeding mother and infant are commonly encountered in clinical practice, but can be increasingly difficult to treat successfully. Mothers may complain of severe pain, but sometimes physical examination of the breasts is entirely normal. Diagnosis should be based on assessment of risk factors, history, and examination of the mother and infant. Bothmother and infant must be treated, even if only one is symptomatic. There is increasing fungalresistance to Nystatin; most experts now recommend other topical preparations as first-linematernal treatment (including miconazole, clotrimazole, mupirocin, and Gentian Violet). Optionsfor treatment of the infant are more limited, including topical nystatin or Gentian Violet, andsystemic fluconazole. Lack of response within three to four days of treatment should promptreassessment and consideration of alternate topical therapy of systemic treatment. Treatmentshould be continued at least one week after resolution of symptoms, and environmental controlof yeast overgrowth is essential.

Background

The importance of breastfeeding for mothers' and infants' long-term health is recognized by theAmerican Academy of Family Practic e3, the American Academy of Pediatric s4, and theAmerican College of Obstetrics and Gynecology 5. These organizations, along with the WorldHealth Organization6, recommend six months of exclusive breastfeeding, and at least one to twoyears of breastfeeding combined with other foods. In an effort to promote these goals, physiciansmust become knowledgeable about management of breastfeeding concerns and their treatment.

Nipple pain (often a result of Candidal infection 1) has been shown to be one of the major causesof premature weaning 2. Although research into treatment options is expanding, at present wehave little evidence-based information, and none of the above-referenced organizations provideconsensus recommendations on management of this common problem. The followinginformation and recommendations are based on a review of the current literature, incorporating

expert opinion where controlled trials are not available. It is critical to treat both mother andinfant, even if one is asymptomatic; coordination between care providers will be necessary ifmore than one physician is involved with the dyad.

Diagnosis

Symptoms of Candidal involvement of the nipple can be quite variable, and the differentialdiagnosis is extensive. Mothers often complain of pain that is severe, generally sudden in onset

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(often after weeks or months of successful nursing), burning or shooting, and occurs during and between feedings .7 The mother's nipple may appear entirely normal despite ongoing infection;conversely, the infected infant does not always have clinically evident thrush. Presentation ofsymptomatic nipple involvement may include puffiness, scaling, flaking, weeping, dark pink orshiny red or purple coloration, erythema, striae radiating from the nipple, satellite lesions, or

vesicular rash .2

Symptoms in the infant can include feeding difficult y2

(either refusing to nurseor pulling off the breast repeatedly while still appearing hungry), fussiness and possiblyincreased gassines s7, and may be associated with a Candidal diaper rash. On examination, theinvolved infant generally has white patchy plaques on the oral mucosa, and backgrounderythema, but again there may be no significant findings.

Assessment of maternal risk factors for candidal infection may be useful in making the diagnosiswhen clinical presentation is atypical. These risk factors include history of antibiotics duringlabo r 8, vaginal yeast infection, history of gestational diabetes or ongoing maternalhyperglycemia, antibiotic or corticosteroid use (in mother or infant), nipple trauma (as fromincorrect latch), and pacifier use .9

Treatment of the Mother â€“ Topical Therapy

A recent survey of physician members of the Academy of Breastfeeding Medicine demonstratedthat most lactation experts begin treatment with a topical antifungal .2 For this purpose, ointmentsare preferred, as they provide a better moisture barrier and are less likely to sting .10 Theseointments are applied sparingly to the nipple and areola after each feeding, or at least 3-4 timesdaily. Traditionally, nystatin has been used as first-line treatment for this purpose; however,recent studies show that there is increasing resistance of C. albicans, up to 40-45% of strainstested.11 As a result, some experts recommend that this no longer be used as initial therapy .10,13 Other topical antifungals include miconazole (Monistat, Micatin); this preparation has theadvantage of very poor bioavailability in the infan t10, and therefore need not be wiped off priorto the next feeding. Clotrimazole (Lotrimin, Mycelex) may also be effective, but may be atopical irritant and thus worsen maternal pain and inflammation. There is also systemicabsorption of clotrimazole by the infant, and this can result in elevated liver enzymes, andwiping off the product prior to nursing is recommended .10 Mupirocin ointment has recently beenshown to be efficacious, as it has both antifungal and antibacterial activity .8 There is nosignificant absorption from topical use 10, and it is ideal for nipples with severe cracking ortrauma which may also have bacterial superinfection.

With topical antifungal preparations, improvement is typically seen in 24 to 48 hours, andsymptom exacerbation in the first day of treatment is not uncommon. If a patient is not

improving after three to four days of treatment, a different topical preparation can be tried. Mostsources recommend treating for one to several weeks after symptom resolution .2

Gentian violet is a traditional antifungal and antibacterial agent that remains efficacious. It isavailable without a prescription in a 1% solution, and should be diluted to 0.25-0.5%. It is usedonce daily for no longer than 3 to 4 days, and can damage mucus membranes if overused(uncommon) .10 Patients often experience relief within hours of the first treatment and requireonly a single treatment, with complete resolution of pain by day three. The solution is swabbed






























































onto mother's nipple and areola and onto the child's oral mucosa; alternatively, the child maysimply be allowed to breastfeed after topical application to the nipple and areola. Caution isrequired in the use of this product, as it temporarily stains skin (duration approximately 2 days)and permanently stains all other surfaces with which it comes into contact.

Many lactation experts also recommend bathing the nipples with vinegar solution, to help reducefungal overgrowth. One tablespoon of white vinegar is added to 1 cup water, and applieddirectly. The solution must be made fresh daily to avoid contamination .12

Treatment of the Mother â€“ Systemic Therapy

Failure of topical therapy generally indicates the need for systemic treatment; this is commonlydue to deeper ductal candidiasis. Fluconazole (Diflucan) is generally administered at 200-400 mgPO on the first day of treatment, followed by 100-200 mg PO qd. At this dose, infants receiveless than 6% of the usual pediatric dose.10 Two to four weeks of therapy is recommended ,7,8,10 with some practitioners extending treatment to six weeks. The clinical cure rate for fluconazoleis 86%, compared with 46% for nystatin; however, cost is substantially higher (see Appendix A).

If pain continues despite systemic treatment, the practitioner should consider alteringmanagement. Although Candida albicans remains the most common species to cause humaninfection, less common strains including C. krusei, C. glabrata, and C. dubliniensis are oftenresistant to fluconazole, and require treatment with ketoconazole.8 Alternatively, pain may be

persistent due to non-fungal etiology, including vasospasm, bacterial superinfection, contactdermatitis, or rarely Paget's disease of the nipple. If patients report white discoloration of thenipple associated with the pain (suggestive of vasospasm), they should be instructed to keep thenipples warm and cover after feeds; magnesium and calcium supplements may also be helpful,and occasionally oral nifedipine .8 If there is suspicion of bacterial superinfection, treat withtopical (mupirocin) or oral agents. Visible breaks in the skin may reasonably be assumed to besecondary to bacterial involvement .13 Severely inflamed nipples may have a component ofcontact dermatitis, and may benefit from moderate strength corticosteroids in addition toantibiotics .10,13

Treatment of the Mother â€“ Pain Management

Pain from nipple candidiasis is often severe (8-10 on the pain scale), so prompt treatment iscritical for the successful continuation of breastfeeding .2 Shorter, more frequent nursings may bemore comfortable. Cool packs prior to feedings are recommended, and nipples should be air-dried after each nursing (unless the patient also experiences nipple vasospasm). If pain is toosevere for direct nursing, milk can be expressed and fed via bottle or cup to the infant. Breastshells between feedings may be helpful when nipples are extremely sensitive to touch (caution:

NOT nipple shields) .9 Ibuprofen can be recommended for analgesia; narcotics are rarelyindicated.

Treatment of the Child































First-line treatment of the child by most lactation experts still consists of nystatin solution ,2 despite the above-referenced increasing resistance. Parents should use a cotton swab to rub intoall surfaces of the child's mouth, gums, cheeks, under the tongue, and the roof of the mouth. Themanufacturer recommends four times daily, but some physicians will treat more often (half dose,eight times daily), due to yeast's ability to grow rapidly. Gentian violet may also be used as

described above; again, overuse can potentially result in damage to mucus membranes. Othertopical antifungal preparations are not available in pediatric form.

Fluconazole may be used for treatment failures, and is increasingly used as first-line treatment.The usual dose is 6 mg/kg PO on first day, followed by 3 mg/kg/day for 2 to 4 weeks, or at leastone week after resolution of symptoms. Although not yet approved by the FDA for use in

pediatric patients, a recent survey indicated that 90% of practitioners use it .10

Treatment of the Environment

Many treatment failures and recurrences are due to incomplete eradication of yeast from theenvironment, or from treatment of only one member of the mother-child pair. Patients should beeducated that pumped milk can contain yeast, even if frozen, and may recontaminate the infant'smouth if used at a later time. It should be labeled "yeast" and used immediately, or saved foremergency use only. Good handwashing is important, and all equipment (pacifiers, bottles,rubber nipples, breast shells, and pump kit parts) should be boiled daily and washed after eachuse with hot soapy water. Nursing pads may form a reservoir for yeast growth, and should either

be avoided during treatment or washed in 10% bleach solution. All clothing, towels, and diapersshould be washed in the hottest possible water and dried in sunlight if possible. Mothers shoulduse a clean towel after each shower or bath.

Complementary therapies are gaining popularity in this as in most other ailments. Acidophilussupplements, either via yogurt with active cultures or in capsules (40 million to one billion unitstid) may reduce yeast colonization, and should be used daily for two weeks after symptoms aregone. Other preparations that may discourage yeast growth include grapefruit seed extract (250mg tid), garlic (3 triple-strength deodorized tablets tid), zinc (45 mg qd), and B complex vitamins(one qd) .14

Summary

Candidal infection of the maternal nipple and infant's oral mucosa can seriously impair thechances of successful long-term breastfeeding. Symptoms are often severe, but clinicallyapparent signs of maternal involvement may be subtle, and diagnosis requires a high index ofsuspicion. The most important principal of treatment is recognition that both mother and infantrequire treatment, even if only one has clinically apparent involvement. Although Nystatin has

been the mainstay of therapy, there is now significant resistance and higher chance of treatmentfailure with this regimen. Treatment for mother and infant may incorporate topical or systemicantifungal therapy, and often needs to be continued for up to four weeks, particularly when thereis deeper ductal involvement. Failure of topical therapy generally indicates the need for adifferent topical preparation or a change to systemic therapy; failure of systemic therapy should















prompt consideration of resistant Candida species or alternative diagnoses. Finally, eradicationof fungal organisms from the environment is essential to successful therapy.

References

1. Amir LH, Donath S. Re: breastfeeding, pain and infection. Letter to the editor. GynecolObstet Invest 1999;48:145.2. Brent NB. Thrush in the breastfeeding dyad: results of a survey on diagnosis and

treatment. Clin Pediatr 2001;40:503-6.3. American Academy of Family Physicians. Policies on Health Issues: Breastfeeding.

URL:http://aafp.org/policy/x1641.xml4. American Academy of Pediatrics. Work Group on Breastfeeding. Breastfeeding and the

use of human milk. Pediatrics 1997;100(6):1035-8.5. ACOG Educational Bulletin #258. Breastfeeding: maternal and infant aspects. July 2000.

American College of Obstetricians and Gynecologists 2002 Compendium of SelectedPublications.

6. Wright AL. The rise of breastfeeding in the United States. Pediatr Clin North Am2001;48(1):1-12.7. Tait P. Nipple pain in breastfeeding women: causes, treatment, and prevention strategies.

J Midwifery Womens Health 2000;45(3):212-5.8. Amir LH. Candida: what's new? ABM News and Views 2001;8(4):32.9. Morton L. Lactation fact sheet series. Topic: Yeast. Idaho WIC Program 2002.10. Hale TW. Medications and Mother's Milk, 10th ed. Amarillo: Pharmasoft Publishing,

2002:133-6, 284-7, 324, 536.11. Flynn PM, Cunningham CK, Kerkering T, San Jorge AR, Peters VB, Pitel PA, Harris J,

Gilbert G, Castagnaro L, Robinson P. Oropharyngeal candidiasis inimmunocompromised children: a randomized, multicenter study of orally administered

fluconazole suspension versus nystatin. The MultiCenter Fluconazole Study Group. JPediatr 1995 Aug;127(2):322-8.12. Ayers, Betsy, IBCLC. Personal communication. January 30, 2003.13. Huggins KE, Billon SF. Twenty cases of persistent sore nipples: collaboration between

lactation consultant and dermatologist. J Hum Lact 1993;9(3):155-60.14. Mohrbacher N, Stock J. The Breastfeeding Answer Book. La Leche League International.

Revised edition 2003:483.

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Treatment of Mucocutaneous Candidal Infection in the Breastfeeding Mother and Child