What is the recommended treatment for a postpartum patient with thrush?

Treatment of Thrush in Postpartum Patients

For postpartum patients with thrush (candidiasis), fluconazole is the most effective treatment, with a recommended regimen of 150 mg every other day for a total of 3-6 doses (median of 6 capsules needed for resolution). 1

Diagnosis

• Thrush in the breastfeeding dyad typically presents with continuous burning nipple pain, often associated with post-feed radiating breast pain in the mother 1
• Diagnosis is primarily made through history and physical examination of both mother and baby, though laboratory tests are rarely ordered 2
• In infants, thrush may present without the classic white plaques on oral mucosa, making diagnosis challenging 3

Treatment Recommendations

First-line Treatment

• Maternal treatment:

  • Oral fluconazole is recommended for mothers with breast/nipple thrush 1, 4
  • Initial dosing: 400 mg loading dose followed by 100 mg twice daily for at least 2 weeks 4
  • Most women require more than three capsules of fluconazole (mean 7.3, median 6) for complete resolution 1

• Infant treatment:

  • Oral nystatin is the most common initial treatment for infants 2
  • Treatment should be administered simultaneously to both mother and infant to prevent reinfection 3

Important Considerations

• Fluconazole is safe during breastfeeding and does not require interruption of breastfeeding during treatment 4
• The American Academy of Pediatrics considers fluconazole compatible with breastfeeding 5
• Only minor side effects have been reported with fluconazole treatment for breast thrush 1

Differential Diagnosis

• Persistent nipple and breast pain is often misattributed to Candida infection when other conditions may be responsible 6
• Alternative diagnoses to consider include:
  • Subacute mastitis/mammary dysbiosis 6
  • Nipple bleb 6
  • Dermatitis 6
  • Vasospasm 6
  • Milk crust 6

Treatment Failures

• For cases that fail to respond to initial therapy, consider:
  • Reevaluation of diagnosis 6
  • Extending the duration of fluconazole treatment 1
  • Women with more severe breast pain are more likely to require extended treatment (>3 capsules) 1
  • Simultaneous treatment of both mother and infant is crucial for resolving persistent cases 3

Special Considerations

• Breastfeeding can safely continue during fluconazole treatment 4
• Fluconazole has a good safety profile and is also used in the treatment of fungal diseases in infants 4
• Accurate diagnosis is crucial as pain is a risk factor for premature cessation of breastfeeding 6