What is the treatment for breast thrush?

Treatment for Breast Thrush

Treat both mother and infant simultaneously with oral fluconazole for the mother (100-200 mg/day for 7-14 days) and topical nystatin for the infant, as this dual approach prevents reinfection and resolves symptoms more effectively than topical therapy alone. 1, 2

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis based on:

• Maternal symptoms: Burning, stinging nipple pain that radiates into the breast, persisting throughout and after feedings, often following antibiotic use or in the setting of cracked nipples 3
• Infant examination: Look for oral thrush (white plaques on oral mucosa), though absence of visible plaques does not exclude the diagnosis 4
• Clinical history: Diagnosis relies primarily on history and physical examination rather than laboratory testing 2

Important caveat: If symptoms persist despite 1 week of antibiotics, consider inflammatory breast cancer and obtain core needle biopsy, particularly if erythema occupies at least one-third of the breast 5

First-Line Treatment Regimen

For the Mother:

• Oral fluconazole: 100 mg daily for 7-14 days 1
• Alternative loading approach: 200 mg loading dose, then 100 mg daily 3
• Fluconazole is superior to topical therapy and is safe during breastfeeding 1, 6

For the Infant:

• Oral nystatin suspension: 100,000 U/mL, 4-6 mL four times daily for 7-14 days 1
• Alternative: Nystatin pastilles (200,000 U) 1-2 pastilles 4-5 times daily 1

Adjunctive Topical Therapy:

• Topical antifungal cream (nystatin, clotrimazole, or miconazole) applied to nipples/areola after each feeding 1, 7
• Clotrimazole vaginal suppositories are safe if concurrent vaginal candidiasis is present, as topical formulations have negligible systemic absorption 8

Treatment Duration and Escalation

Most women require more than 3 fluconazole capsules, with the median being 6 capsules (range 1-29) 9:

• Mild cases: 3 capsules (150 mg every other day) may suffice 9
• Moderate to severe cases: Continue fluconazole 100-200 mg daily for 2-6 weeks until complete symptom resolution 3, 9
• Women with more severe breast pain typically require longer courses 9

Critical pitfall: Stopping treatment prematurely leads to recurrence. Continue treatment until pain completely resolves, which may take several weeks 3

Management of Persistent or Recurrent Cases

If symptoms persist after initial 7-14 day course:

1. Extend fluconazole duration: Increase to 200 mg daily for an additional 30 days (total 6 weeks) 3
2. Ensure simultaneous infant treatment: Reinfection occurs if only one member of the dyad is treated 7
3. Add prolonged topical therapy: Continue topical antifungal to nipples for up to 8 weeks 3
4. Consider itraconazole solution: 200 mg daily for 7-14 days as alternative (equally efficacious to fluconazole) 1

Common pitfall: Treating the infant alone without treating the mother's breasts results in continuous reinfection 7

Pain Management

For severe pain interfering with breastfeeding:

• Over-the-counter analgesics and acetaminophen with codeine may be insufficient 3
• Hydrocodone/acetaminophen (10/650 mg) provides adequate pain relief to continue breastfeeding in refractory cases 3
• Pain should improve within 48-72 hours of initiating antifungal therapy 1

Safety Considerations During Breastfeeding

• Fluconazole: Safe during breastfeeding, though minimal amounts pass into breast milk 1, 6
• Nystatin: Safe for infant use with minimal systemic absorption 1
• Topical azoles: Negligible passage into breast milk; safe to continue breastfeeding 8
• Monitor infant for gastrointestinal effects (diarrhea) due to alteration of intestinal flora 6

Prevention of Recurrence

• Keep nipples dry between feedings 1
• Address any maternal vaginal candidiasis simultaneously 1
• Sterilize pacifiers, bottle nipples, and breast pump parts daily during treatment 2
• Consider suppressive therapy if recurrent infections occur frequently 1