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It
is important to get the best latch possible
when you have sore nipples. Even if the
cause of sore nipples is Candida, improving
the latch can decrease the pain. Note that
with the “ideal” latch, the baby
covers more of the areola (brown or darker
part of the breast) with his lower lip than
the upper lip. Note also that the baby's
nose does not usually touch the breast (except
when the mother's breasts are very large,
and even then, most babies well latched
on will not have their noses touching the
breast). It is not always easy, though,
to change the latch of the older baby. See
videos
showing how to latch on a baby. Start with local treatment
(applied on the nipple) with:
1.
Gentian violet (see handout #6 Using
Gentian Violet). Use once a day for
four to seven days. If pain is gone after
four days, stop gentian violet. If better,
but not gone after four days, continue for
seven days. Stop after 7 days no matter
what. If not better at all at four days,
stop the gentian violet, continue with the
ointment as below and call or email. Gentian
violet comes as a 1% solution in water.
It also usually dissolved in 10% alcohol,
as gentian violet is not soluble in pure
water. This amount of alcohol is negligible,
as the baby will only get a drop of gentian
violet. Apparently some pharmacists will
dissolve it in glycerine instead of alcohol,
if you wish. 2% gentian violet should not
be used. Plus:
2. APNO (All Purpose Nipple
Ointment) as below:
- Mupirocin 2% ointment
(15 grams)
- Betamethasone 0.1% ointment
(15 grams)
- To which is added miconazole
powder so that the final concentration
is 2% miconazole. This combination gives
a total volume of just more than 30 grams.
Clotrimazole powder to a final concentration
of 2% may be substituted if miconazole
powder is unavailable, but both exist
(the pharmacist may have to order it in,
but compounding pharmacies almost always
have it on hand). I believe clotrimazole
is not as good as miconazole. Using powder
gives a better concentration of antifungal
agent (miconazole or clotrimazole) and
the concentrations of the mupirocin and
betamethasone remain higher. Sometimes
we will add ibuprofen powder to a final
concentration of 2%.
The combination is applied
sparingly after each feeding (except the
feeding when the mother uses gentian violet).
“Sparingly” means that the nipple
and areola will shine but you won’t
be able to see the ointment. Do not wash
or wipe it off, even if the pharmacist asks
you to. I used to use nystatin ointment
or miconazole cream (15 grams) as part of
the mixture, and these work well enough,
but I believe the use of powdered miconazole
(or even clotrimazole powder) gives better
results. These ointments can be used for
any cause of nipple soreness ("all
purpose nipple ointments"), not just
for Candida (yeast). Use the ointment until
you are pain free and then decrease frequency
over a week or two until stopped. (See Handout
#3b Treatments for Sore Nipples and Sore
Breasts under “all purpose nipple ointment”).
If you are not having less pain after 3
or 4 days of use, or if you need to be using
it for longer than two or three weeks to
keep pain free, get help or advice.
3. Grapefruit seed extract
(not grape seed extract, ACTIVE INGREDIENT
MUST BE “CITRICIDAL”), 250 mg
(usually 2 tablets) three or four times
a day orally (taken by the mother), seems
to work well in many cases. If preferred
the liquid extract can be taken orally,
5 drops in water three times per day (though
this is not as effective). Oral GSE can
be used before trying fluconazole, instead
of fluconazole or in addition to fluconazole
in resistant cases. See below for information
on grapefruit seed extract used directly
on the nipples.
4. If pain continues
and it is sure the problem is Candida, or
at least reasonably sure, add fluconazole
400 mg loading, then 100 mg twice daily
for at least two weeks, until the mother
is pain free for a week. The nipple ointment
should be continued and the gentian violet
can be repeated. If fluconazole is too expensive,
ketoconazole 400 mg loading, then 200 mg
twice daily for same period of time (or
grapefruit seed) can be used instead. If
Candida is resistant, itraconazole, same
dose and time period as fluconazole, can
be used and has worked, though Candida actually
is less sensitive to itraconazole, generally,
than it is to fluconazole. (See handout
#20, Fluconazole).
Fluconazole is apparently now available
as a generic product (therefore less expensive).
Fluconazole should not be used as a first
line treatment or if nystatin alone does
not work (which it usually doesn’t).
Before using fluconazole, nipple pain should
be treated aggressively with good latch,
gentian violet, all purpose nipple ointment
and grapefruit seed extract. If used, fluconazole
should be added to treatment of the nipples,
not used alone. Fluconazole takes three
or four days to start working, though occasionally,
in some situations, it has taken 10 days
to even start working. If you have had no
relief at all with 10 days of fluconazole,
it is very unlikely it will work, and you
should stop taking it.
5. For deep breast pain,
ibuprofen 400 mg every four hours may be
used until definitive treatment is working
(maximum daily dose is 2400 mg/day).
Grapefruit Seed Extract
(GSE)
Grapefruit seed extract (ACTIVE INGREDIENT
MUST BE “CITRICIDAL”) should be
used in conjunction with the APNO (All Purpose
Nipple Ointment). Apply the diluted liquid
grapefruit seed extract on the nipples,
and then follow with the ointment (always
after the feeding).
Apply solution directly
on the nipples. It does not need to be refrigerated.
It may be covered and used until solution
is finished.
- Mix very well five to
10 drops in 30 ml (1 ounce) of water (preferably,
but not necessarily, distilled).
- Use cotton swab or Q-tip
to apply on both nipples and areolas after
the feeding.
- Let dry a few seconds,
then apply “all purpose nipple ointment”.
- If using Gentian Violet,
do not use GSE on that particular feed
but use after all other feeds.
- Should be used in conjunction
with oral GSE, either tablets, capsules,
or liquid extract (see above)
- Use until pain is gone
and then wean down slowly over the period
of at least a week.
- If pain is not significantly
improving after two to three days, increase
the dose by 5 drops per 30 ml (ounce)
of water. Can continue increasing until
25 drops per 30 ml of water.
- If flaking, drying,
or whiteness appears on the skin, substitute
vitamin E oil or pure olive oil for APNO
1-3x/day.
- Laundry can be treated
as well: add 15-20 drops in the rinse
cycle of all wash loads
If not using Gentian
Violet, it may be helpful to treat baby
with acidophilus by rolling a wet finger
in acidophilus powder (break open a capsule),
and let baby suck on the finger right before
a feeding. Use 2x first day, 2x second day
only. Mother may want to ingest Acidophilus
as well, 3x/day for 1-2 weeks.
Questions? (416) 813-5757
(option 3) or drjacknewman@sympatico.ca
or my book Dr. Jack Newman’s Guide
to Breastfeeding (called The Ultimate Breastfeeding
Book of Answers in the USA)
Handout C: Candida
Protocol
Jack Newman, MD, FRCPC. © 2005
Revised: January 2005
This handout may be copied and distributed
without further permission,
on the condition that it is not used in
any context in which the WHO code on the
marketing of breastmilk substitutes is violated
1. Breastfeeding:
Starting out right
a) The
importance of Skin-to-Skin contact
2. Colic in the Breastfed Baby
3. a) Sore Nipples
b) Treatments
for Sore Nipple and Sore Breasts
4. Is my baby getting enough?
5. Using a Lactation Aid
6. Using Gentian Violet
7. Breastfeeding and Jaundice
8. Finger Feeding
9. a) You should continue breastfeeding
(Medications and breastfeeding)
b) You
should continue breastfeeding (Illness in the mother or baby)
10. Breastfeeding and other foods
11. Some breastfeeding myths
12. More breastfeeding myths
13. Still more breastfeeding
myths
14. More and more breastfeeding
myths
15. Breast compression
16. Starting solid foods
17. What to feed the baby when
the mother is working outside the home
18. How to know a health professional
is not supportive of breastfeeding
19. a) Domperidone 1
b) Domperidone
2
20. Fluconazole
21. Breastfeed a toddler –
Why on earth?
22. Blocked ducts and
mastitis
23. Breastfeeding your adopted baby
24. Miscellaneous treatments for problems
25. Slow weight gain after
the first few months
26. When the Baby refuses to
latch on
27. Expressing Milk
28. Toxins and Infant Feeding
How breastmilk protects Newborns
Risks of formula feeding
Breastfeeding and guilt
Candida protocol
Protocol to increase the intake
of Breastmilk by the Baby ("Not enough milk")
When latching
Protocols for Induced Lactation
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