Candida albicans is the most common naturally occurring candida species found as a commensal on the mucosal tissue of mother and child. It is also a pathogen that can cause fungal infections in both mother and baby. These infections may result in nipple and breast pain for the women and feeding difficulties for the infant. It is found less frequently in bottle-fed babies but can still cause concern for mother and child (Zöllner and Jorge, 2003).
Up to 96% of women who breastfeed experience nipple pain in the first 6 weeks of feeding (Tait, 2000; Amir et al, 2007). One of main reasons women stop breastfeeding early is due to breast or nipple pain (Mass, 2004). Although most cases of persistent nipple pain can be resolved by revisiting the positioning and attachment of the infant to the breast, some nipple pain may be caused by bacterial or candida infections (McClellan et al, 2012). In the past, nipple pain was often attributed to C. albicans (MacDonald, 1995) and Andrews et al (2007) found C. albicans to be the main cause of pain in mothers who reported having pain while breastfeeding. However, bacteria is often considered as the cause of breast pain (Mass, 2004). Staphylococcus aureus has commonly been found in samples of breast milk and oral swabs of babies (Amir et al, 2013) and other common organisms, such as strains of methicillin-resistant S. aureus and anaerobic Streptococci have been identified in breast milk although these generally cause mastitis (Dixon and Khan, 2011). S. aureus is also associated with nipple fissures (Weiner, 2006). There is some doubt as to whether there is a relationship with fungal organisms and the deep breast pain associated with breastfeeding (Dixon and Khan, 2011). Carmichael and Dixon (2002) suggest that there is little direct evidence to support the aetiological role of C. albicans in this condition and that further research needs to be done.
Presuming that nipple or breast pain is due to C. albicans has resulted in an overuse of systemic antifungal therapy in many patients (Mass, 2004; Anderson et al, 2004). For patients this has led to adverse drug reactions and antifungal resistance. It is therefore important to diagnose C. albicans effectively. In Anderson et al's (2004) study of Raynaud's syndrome, 8 of the 12 mothers and their infants received multiple courses of antifungal therapy as a wrong diagnosis was made. In a further study by Barrett et al (2013), 91% of the patients received inappropriate antifungal treatment for Raynaud's syndrome.
Diagnosis
In the infant, thrush is commonly seen in the first few weeks of breastfeeding if the mother has had vaginal candida and has had a vaginal delivery. Babies acquire candida from a mother who is breastfeeding who has candida (Tanguay et al, 1994; Tait, 2000); there is little evidence to show transmission from child to mother. The infant may develop a white/greyish coat on their tongue, white plagues on their tongue or nappy rash (Epstein et al, 2008) (Figure 1). The tongue, soft and hard palates can become inflamed and painful for the child, making it hard for them to latch on or feed (Johnstone and Marcinak, 1990; Benjamin et al, 2010).
The woman may experience breast or nipple pain or both. A history of symptoms will help the clinician formulate diagnosis. Over 80% of diagnoses are made on a patient's history alone rather than clinical tests (Epstein et al, 2008).
Nipple pain can be caused by trauma due to feeding problems, engorgement, infection, or skin conditions (Breastfeeding Network, 2009a; Strong, 2011). Nipple pain due to a candida infection can be diagnosed when the nipple and areola are pink, sensitive to touch with a high level of pain, out of proportion to what is presented in the clinical examination (Amir et al, 2013). This pain is persistent and often severe, not relieved by nipple shields (which are not recommended for use, but commonly seen in pharmacies), massaging, expressing or applying heat.
Differential diagnosis for breast pain can include bacterial mastitis, bacterial lactiferous duct infection, trauma or Raynaud's syndrome, (Anderson et al, 2004; Eglash et al, 2006; Barrett et al, 2013). Raynaud's syndrome also causes severe pain similar to a C. albicans infection, but there are additional symptoms such as precipitation by cold stimulus and biphasic or triphasic colour changes, (Anderson et al, 2004; Barrett et al, 2013).
Symptoms of candida are considered as a sudden incident of deep, radiating breast and/or nipple pain in both of the woman's breasts or itching of surrounding breast tissue (Montgomery, 2000; Brent, 2001; Heller et al, 2012). This can occur after several weeks of pain-free breastfeeding. The pain can be so severe that it can last up to an hour and usually occurs every time the woman breastfeeds (Breastfeeding Network, 2009b). A candida infection can also appear similar to other skin conditions such as eczema (Strong, 2011). If the pain is in one nipple/breast, the women has never had pain-free breastfeeding, the nipples are shaped oddly after breastfeeding and the baby has a tongue tie, candida is not indicated (Breastfeeding Network, 2009b).
There is certainly confusion among clinicians managing these cases (Amir et al, 2013). Amir et al (2013) suggest that thrush should be diagnosed when there is no evidence of mastitis—the breast is therefore not erythematous and the woman afebrile and systemically well.
Not only is the patient's history important but a diagnosis should be made on microscopy (Epstein et al, 2008; Breastfeeding Network, 2009b). It is important to remember, however, that candida species are commensal organisms. Their presence on a swab does not does not always mean the patient has an active infection (Amir et al, 2013). C. albicans in also difficult to detect in breast milk because lactoferrin has an inhibitory effect on candida (Morrill et al, 2003). A decision for treatment therefore has to take all these facts into consideration.
Management
Early intervention is important to support the continuation of breastfeeding (Lewallen, 2006). The management of a candida infection should be holistic, considering a woman's hygiene practices, diet, medication and the infant's oral hygiene (Strong, 2011). The mother should be advised not to freeze any breast milk as it will contain fungal spores. Candida is only effectively irradiated with heat. All equipment and clothing that comes in contact with the mother's breast or the baby's mouth need to be cleaned thoroughly or sterilised.
The most common medical treatment for a candida nipple infection is Miconazole 2% cream which should be used sparingly, allowed to absorb into the breast and washed before feeds (Brent, 2001; Breastfeeding Network, 2009b; Joint Formulary Comittee, 2014) (Table 1). Clotrimazole cream 1% is not recommended as it has been associated with allergic reactions (Brent, 2001). Furthermore, more than 40% of yeasts are resistant to nystatin (Weiner, 2006).
| Localised treatment (mother): Miconazole 2% cream applied sparingly to each nipple and breast after each feed |
| Localised treatment (infant): Miconazole oral gel first-line (although this is off-label use in children younger than 4 months of age) |
| Second line treatment (infant): Nystatin suspension 0.5ml after each feed. Maximum of 4ml per day prescribed for 7 days (and the mother advised to continue treatment for 2 days after symptoms resolve). If infection has not completely gone, the course can be continued for a further week |
| Oral treatment (mother): Fluconazole capsules 400mg first dose followed by 200mg daily |
It should be borne in mind that the cream can be washed off or absorbed into the breast pads so needs to be used more frequently than on other areas of the skin. If the women's nipples are very red and inflamed then a mild steroid cream can also prescribed (Weiner, 2006).
In cases of recurrent, persistent infections or ductal candida, oral fluconazole can be prescribed for the mother to treat breast candidiasis (Brent et al, 2001; Weiner, 2006; Breastfeeding Network, 2009b). The dosage of 200 mg daily oral fluconazole is not secreted in a high enough dosage in the breast milk to sufficiently treat oral thrush in the infant. Infants aged 0–12 months should be prescribed miconazole oral gel as their first-line treatment (National Institute for Health and Care Excellence (NICE), 2013). If the candida becomes systemic candidiasis or spreads to the oesophagus the infant needs to be seen by a specialist service such as a paediatric gastroenterology (NICE, 2013). Nystatin suspension can be used if miconazole oral gel is contraindicated, such as in cases where there is also liver disease.
Conclusions
Knowing the presentation of a candida breast infection in breastfeeding women should remove the confusion and uncertainty among clinicians in managing these cases (Amir et al, 2013). The evidence also suggests that nipple pain is very common in the first 2 weeks of breastfeeding and can persist up to 6 weeks as women adjust to breastfeeding, and may also be why they stop. It is therefore important to be aware of all the differential diagnosis for both breast and nipple pain and manage it accordingly, and support these women as they continue to breastfeed.