From the Guidelines
For a breastfeeding mother with oral candidiasis (thrush), it is recommended to treat both the mother and the baby simultaneously to prevent recurrence and ensure effective management of the infection. The treatment approach should involve a combination of antifungal medications and good hygiene practices.
Treatment Approach
- The mother should use an antifungal cream such as miconazole or clotrimazole on her nipples after each feeding, gently wiping it off before the next feeding 1.
- If the mother has symptoms of breast thrush (pain, redness, or itching), she may need oral fluconazole, typically 150-200 mg as an initial dose followed by 100 mg daily for 7-14 days 1.
- The baby will need oral nystatin suspension (100,000 units/mL), applying 1 mL to each side of the mouth four times daily after feeds for 7-14 days, or miconazole oral gel for infants.
Importance of Hygiene Practices
- Good hygiene practices are essential: washing hands before and after feeding, sterilizing pacifiers and bottle nipples daily, and replacing them after treatment.
- Breast pump parts should be thoroughly cleaned.
Duration of Treatment
- Treatment should continue for at least 48 hours after symptoms resolve to prevent recurrence. This dual treatment approach is necessary because the infection can pass back and forth between mother and baby during breastfeeding, as Candida thrives in warm, moist environments and can colonize both the baby's mouth and the mother's nipples.
From the FDA Drug Label
Nystatin Oral Suspension, USP, is indicated for the treatment of candidiasis in the oral cavity. For a breastfeeding mother with oral candidiasis (thrush), nystatin is recommended as the treatment, as it is specifically indicated for the treatment of candidiasis in the oral cavity 2.
- Nystatin is the preferred choice because there is no information in the provided fluconazole drug label that directly supports its use for oral candidiasis in breastfeeding mothers, despite its discussion of use in nursing mothers.
- The fluconazole label does provide information on its presence in breast milk, but it does not directly address the treatment of oral candidiasis in breastfeeding mothers.
From the Research
Treatment Options for Breastfeeding Mothers with Oral Candidiasis
- The most common initial treatment for oral candidiasis in breastfeeding mothers is oral nystatin for the infant and cream for the mother's breasts, followed by oral nystatin for the infant and oral fluconazole for the mother 3.
- For the treatment of oral candidiasis in infants, fluconazole has been shown to be superior to nystatin suspension, with a clinical cure rate of 100% compared to 32% for nystatin 4.
- Nystatin is still a commonly used treatment for oral candidiasis, and compounded preparations with nystatin for oral and oromucosal administration are available 5.
- Miconazole gel has been shown to be an effective treatment for oropharyngeal candidiasis in immunocompetent infants, with a clinical cure rate of 84.7% by Day 5 of treatment, compared to 21.2% for nystatin suspension 6.
- A randomized comparison of two nystatin oral gels with miconazole oral gel found that miconazole oral gel was significantly more effective in curing oral thrush in infants, with a clinical cure rate of 85.1% on day 14 7.
Treatment Considerations
- Treatment of recurrence or persistence of oral candidiasis in breastfeeding mothers and infants may involve the use of nystatin or fluconazole, depending on the severity of the infection and the response to initial treatment 3.
- The choice of treatment for oral candidiasis in breastfeeding mothers and infants should be based on the severity of the infection, the response to initial treatment, and the potential for side effects or interactions with other medications.