Medicalising Sore Nipples – thrush and breastfeeding July 2018

The origin of the BfN Breastfeeding and Thrush leaflet and factsheet

It feels a very long time since I recorded this video and it is now 25 years since Dr Magda Sachs and I wrote the first BfN leaflet about Thrush in Breastfeeding. At that time, as experienced breastfeeding supporters, we had seen maybe 6 mothers between us whose nipple pain had not been resolved by attention to positioning and attachment after months of breastfeeding without problem. We researched and found research about thrush and breastfeeding which exactly described what we were seeing. Those original references included :

Brent N., Thrush in the Breastfeeding Dyad: Results of a survey on diagnosis and treatment, Clin Paed. 2001; 40:503506.

Francis-Morrell J, Heinig MJ et al, Diagnostic value of signs and symptoms of mammary candidosis among lactating women. JHL 2004; 20:288-95 ›

Kaufman D, et al., Fluconazole prophylaxis against fungal colonisation and infection in preterm infants, N Eng J Med 2001; 345(23):1660-6.

Morrill JF et al. Risk factors for mammary candidosis among lactating women. J.Obstet.Gynecol. Neon.Nurse. 2005;34:37-45

We wrote the leaflet and then watched what became an avalanche of queries, recommendation and self diagnoses. Women repeated back to us the words such as “shark’s teeth” that we had used and we noted how hard they were trying to obtain treatment. We updated the leaflet a few years later and then wrote a factsheet as finances didnt allow further printing of leaflets.

Current research

There remains little research on thrush as a cause of nipple pain although it remains in the ABM Clinical Protocol #26: Persistent Pain with Breastfeeding https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/26-persistent-pain-protocol-english.pdf

Do I still believe thrush affects breastfeeding women and causing nipple pain? Yes but in a small minority of cases. I think that most pain still comes from not quite positioning and attachment in the early days and often around 6 weeks when babies feed frequently and we assume that the latch is ok. I see another rush of instances of pain often described as thrush when babies are teething and again I think in most cases the latch has altered fractionally to take the pain off sore gums.

Miconazole oral gel

I do believe that miconazole gel is much more effective than nystatin drops and that is supported by research.

In 2008 Janssen-Cilag the manufacturers of Daktarin oral gel ® altered the licensed application of the product with respect to the age from which it is recommended. They recommend that it is not licensed for use in babies under 4 months of age and only with care between 4 and 6 months (EMC). I co-authored a paper published in the BMJ about this. https://www.bmj.com/content/338/bmj.a3178.long

This change appears to originate from a published report (De Vries 1996) documenting a 17 day old baby (born at 36 weeks gestation) who choked when exposed to miconazole oral gel applied to her mother’s nipples before and after feeds on the advice of a pharmacist. The baby suddenly stopped feeding and breathing, became cyanotic and lost consciousness. The mother scooped out the visible miconazole gel and the baby recovered within a few moments. The doctor who was called could find no abnormalities and the baby recovered without further problem. The report mentions nine other cases of babies who suffered some form of difficulty with breathing, one of who was admitted to hospital, but all recovered spontaneously.

The current research evidence for nystatin is poor according to Hoppe (1996, 1997).

If practitioners choose to continue to recommend miconazole oral gel they should ensure that the mother/carer is aware that the gel should be applied gently, in small amounts at a time until all the surfaces of the mouth are covered. It is important that a spoon is not used to administer the gel and that the back of the throat is not touched either by the adult’s finger or by the gel (Ainsworth 2009). Healthcare providers must ensure that when recommending this product that the parent/carer is aware of how to apply the gel safely i.e. using a clean finger, apply small amounts of gel at a time, four times a day after feeds. Practitioners who recommend miconazole oral gel that responsibility in a baby under 4 months lies with the person who prescribes or recommends its use. The licensed application does not necessarily imply a risk if used appropriately but each prescription should be considered on an individual basis. Under no circumstances should miconazole oral gel be applied to the mother’s nipples as a means of treating the baby or the mother.

• • Ainsworth S and Jones W. It sticks in our throats too. BMJ 2009;337:3178
  • De Vries TW, Wewerinke ME, de Langen JJ. [Near asphyxiation of a neonate due to miconazole oral gel Ned Tijschr Geneeskd 2006;148:1598–600
  • Electronic Medicines compendium – miconazole oral gel SPC emc.medicines.org.uk
  • Hoppe JE, Hahn H. Randomized comparison of two nystatin oral gels with miconazole oral gel for treatment of oral thrush in infants. Antimycotics Study Group. Infection. 1996 Mar-Apr; 24(2): 136-9.
  • Hoppe JE. Treatment of oropharyngeal candidiasis in immunocompetent infants: a randomised multicenter study of miconazole gel vs. nystatin suspension. The Antifungals Study Group. Pediatr Infect Dis J. 1997 Mar; 16(3): 288-93.

Clotrimazole cream applied to the nipples

The lack of efficacy of clotrimazole cream applied to the nipples is anecdotal after supporting many women. The risk of it causing irritation comes from data supplied personally by Chloe Fisher and Sally Inch at the once famous breastfeeding clinic in Cambridge. Miconazole cream remains preferable in my opinion

The future?

I continue to believe that thrush affecting the breastfeeding dyad is rare and should only be used after all other reasons have been excluded or in the presence of positive swabs.

I refer you to another paper which I was involved in writing. “Identifying the cause of breast and nipple pain during lactation” https://breastfeeding-and-medication.co.uk/wp-content/uploads/2024/06/bmj.n1628.full-.pdf

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2024/06/bmj.n1628.full-.pdf

and to this information from others https://breastfeeding-and-medication.co.uk/fact-sheet/what-do-mothers-want-healthcare-professionals-to-know-about-breast-and-nipple-pain-in-lactation

Queries can be sent to me wendy@breastfeeding-and-medication.co.uk

Many people know that I have had Crohns disease since I was 22 years old  – that was when it was officially diagnosed but probably from 4 years before when I was 18 years old. It has had an immense effect on my life firstly medically – I have had 3 bowel resections and been on medications since the last one in 2002 which very nearly killed me. The only times when I was really fit in and well were when I was pregnant and breastfeeding which sparked my interest in becoming a breastfeeding counsellor 35 years ago. It meant I fed my second and third daughters for much longer (I became very ill soon after I weaned my first) and became passionate about supporting women to breastfeed. As a pharmacist that rolled into an interest and then passion about drugs in breastmilk.

When I regularly had contact with mums with IBD asking about their medication I decided to set up the Facebook group as a mutual support group. Mums who understood the urgency of toilet visits when out shopping, understood how debilitating it was to be in constant pain, that we could discuss anything in a private forum with others in the same situation. Coincidentally it has become a place where people ask each other about drugs and look to me to provide evidence of safety in breastfeeding – that wasn’t the original intent but an excellent spin off.

I havent set up any other specialist interest groups – this is out of my personal interest. Unsurprisingly the diagnosis and treatment of inflammatory bowel disease has taken up a lot of space in my book Breastfeeding and Medication and I am keen that professionals understand that breastfeeding protects our babies but is also something which we value above many things.

As of this morning we have 1.6K members from all over the world, climbing steeply recently January 2022).

Specialists seem to be very concerned about the safety of the drugs – which are strong admittedly and breastfeeding. But we also need to bear in mind that IBD is at least partly linked with being formula fed so we want to maintain breastfeeding and use specialist sources.

Live vaccines may be delayed or omitted – particularly the rotavirus vacc. However, this is as much to protect the mother who may contract the illness from the viral particles shed through the faeces, Exclusively breastfed babies are at low risk if contracting rotavirus in any case.

I am going to admit that I am passionate about the subject – this is the core of my life

See also Facebook live video

Inflammatory bowel disease and breastfeeding – facebook live

CONCLUSIONS: In a study of women receiving treatment for IBD and their infants, we detected low concentrations of infliximab, adalimumab, certolizumab, natalizumab, and ustekinumab in breast milk samples. We found breastfed infants of mothers on biologics, immunomodulators, or combination therapies to have similar risks of infection and rates of milestone achievement compared with non-breastfed infants or infants unexposed to these drugs. Maternal use of biologic therapy appears compatible with breastfeeding.

With the help of the Breastfeeding and IBD facebook page I wrote this article:

what would you like your healthcare tean to know about IBD and breastfeeding

Finally I have put together all the information on studies on anything to do with prescribing, procedures and vaccines for breastfeeding mums with IBD. If you have IBD take this with you to appointments. If you are a professional please make sure everyone in the team has a copy. I am happy to offer Teams Training to any group of professionals who support mums with IBD.

All you need to know about investigating and treating IBD in breastfeeding mothers factsheet

Having had the pleasure of presenting this on Matflix it has made me think a lot about the impact of entenox for midwives, for mothers and the environment.

You can access the matflix hour here

These are the slides I used

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/04/Nitrous-oxide-Entenox-and-the-risks.pptx

A live video recorded for Matflix Maternity and Midwifery Forum

https://www.youtube.com/watch?v=cYMxZlQrJPc