What is the treatment for a breastfeeding mother with thrush (candidiasis) of the nipple?

Treatment of Nipple Thrush in Breastfeeding Mothers

For breastfeeding mothers with nipple candidiasis, apply topical azole antifungals (miconazole 2% or clotrimazole) to the nipples and areola after each feeding for 7-14 days, while simultaneously treating the infant's oral thrush with nystatin or fluconazole. 1, 2

First-Line Topical Treatment

• Topical azole antifungals (miconazole 2% or clotrimazole cream) are more effective than nystatin for candidal nipple infections and should be applied to nipples and areola after each breastfeeding session 1
• Remove excess cream before the next feeding to minimize infant exposure 1
• Treatment duration is typically 7-14 days 1, 2
• Nystatin cream can serve as an alternative when azoles are unavailable, though it is less effective 1

Important caveat: Oil-based antifungal creams may weaken latex barrier contraceptives, which matters for postpartum contraception planning 1

Concurrent Infant Treatment is Essential

• Both mother and infant must be treated simultaneously to prevent reinfection 2
• Treat the infant with oral nystatin or fluconazole even if oral thrush is not visibly apparent 3, 4
• Sterilize all items contacting the breast or infant's mouth (pacifiers, bottle nipples, breast pump parts) 2

Systemic Therapy for Persistent or Severe Cases

When topical therapy fails after 7-14 days or symptoms are severe (burning, stabbing pain radiating into breast tissue):

• Oral fluconazole: 200 mg loading dose, then 100-200 mg daily for 14 days minimum 2, 5
• Continue topical antifungal application to nipples alongside oral therapy 2
• Most women require 6-7 fluconazole capsules (150 mg every other day), though some need up to 29 capsules for complete resolution 6
• Fluconazole is compatible with breastfeeding - only 13% of the pediatric dose reaches the infant through breast milk, and no serious adverse reactions have been reported in a survey of 96 breastfeeding women 5

Clinical Recognition

Suspect nipple candidiasis when there is:

• Severe burning or stabbing nipple pain persisting after feeds or radiating into breast tissue 2
• Pain that worsens during or is precipitated by nursing 2
• Erythema, hyperkeratosis, or flaking of nipple/areola (though these may be absent) 1
• Recent antibiotic use or cracked nipples predisposing to infection 7

Microbiological confirmation is rarely obtained in clinical practice; diagnosis relies on history and physical examination 2

Essential Adjunctive Measures

• Keep nipples dry between feedings and avoid breast pads that trap moisture 2
• Treat any concurrent maternal vaginal candidiasis 2
• Wash hands thoroughly before and after breastfeeding 2
• Continue breastfeeding throughout treatment unless nipples are actively bleeding 2

Special Considerations for Non-Albicans Species

• For non-albicans Candida (particularly C. glabrata), topical boric acid or flucytosine may be more effective than azoles 2
• Consider infectious disease consultation for refractory cases 2

Common Pitfalls to Avoid

• Do not treat the mother alone - simultaneous treatment of the infant is mandatory even without visible oral thrush 2, 3
• Do not discontinue treatment prematurely; many cases require longer courses than initially anticipated 7, 6
• Do not assume treatment failure if symptoms persist beyond 1-2 weeks - some cases require 6+ weeks of fluconazole 7
• Avoid itraconazole, voriconazole, and posaconazole during breastfeeding due to lack of safety data 1