Breast feeding is a blessing for Mom and baby!
But what if it becomes a difficult one...
Mom might feel it a curse and stop the blessed act!
Gosh, the pain from sore nipples is something that is nearly ... unbearable.
Complete history taking and examination is the core for diagnosis. Cracked nipples and fungal infections are common reasons. Moms need support and empathy during cracked nipples and infected nipples. Fungal infection seems to be common but under-recognized and under-treated. Else, the baby will re-infect the mother at each feed. The amount of pain would be so bad that some discontinue feeding... Both need to be treated.
Daktarin Cream (Miconozole) 2% is the first choice of anti-fungal cream. Quite effective. Skin Cream should be prescribed not the skin GEL for the nipples. Because, GEL doesn’t penetrate the skin of the nipple, and is unlikely to be effective.
Nyastatin cream is not as effective as Daktarin for treatment of nipple thrush, although it is safe because it doesn’t get absorbed in GIT.
If topical treatment doesn't work for mom, then we need to try oral Fluconazole, which is recognised to be compatible with breastfeeding by the World Health Organisation. But, in some countries like UK, Fluconazole is not licensed for lactating women. There is growing evidence that it is a safe and effective form of treatment and using it clears the nipple infection better and enables mom to continue breastfeeding.
A dose of 150 mg stat oral is followed by a dose of 50 mg/day for 7-10 days based on how the nipple symptoms progress. The amount of fluconazole secreted in breast milk (when mom takes oral treatment) is insufficient for baby's oral thrush. Hence, baby need to be treated as well.
Below 4 months age babies, NY statin oral suspension and oral Fluconazole suspension are only licensed.
For babies above 4 months of age, Daktarin oral GEL is preferable to Nystatin suspension, with greater efficacy within a shorter period. Daktarin is not used in babies below 4 months age as gel is thick to cause choking.
For example if the baby is 6 weeks old, we can’t use Daktarin... So, for this baby, Oral fluconazole suspension (3 mg/kg, once a day for seven days) is be used. Oral treatment has a good cure rate - better than nystatin and miconazole.
Apart from the medications, it is essential to make sure that the mom is practising good feeding techniques and proper hygiene measures. It is essential to Change breast-pads regularly, and also ask her to hot-wash her clothes and linen. Loose clothing to expose breasts in air for few hours per day would help healing if the nipples are too sore. The regular skin advice such as not to use chemical soaps, etc should be given as verbal advice or supplemented by an information leaflet.
Most importantly, we should review every week to see how mom and baby are coping. If symptoms have not improved at all after we try the second line drugs - like a 10 day course combined with topical treatment- then it is worth to re-consider the diagnosis. We should never hesitate to re-visit the symptoms and re-examine the nipple and baby's oral mucosa appearance. We could refer to the neonatal team to review if persistent rather than continuing it for a longer time.
Hopefully most of the time, we could bring smiles to mom and the baby with the appropriate reassurance and first line medications along with the good communication and support.