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Fluconazole (Diflucan™)
is a synthetic antifungal agent that can
be used for the treatment of a variety of
Candida albicans and other fungal infections.
For the breastfeeding mother in particular,
it can be used to treat recurrent Candida
infections of the nipples, and, if such
a thing exists, as I believe it does, Candida
infections of the milk ducts.
Candida (yeast) infections
of the nipple and ducts
Candida infections of
the nipples may occur any time while the
mother is breastfeeding. Candida albicans
likes warm, moist, dark areas. It normally
lives on our skin and other areas, and 90%
of babies are colonized by it within a few
hours of birth. It, like many other germs
that live on us normally, only becomes a
problem under certain circumstances.
Candida infections of
the skin or mucous membranes are more likely
to occur when there is a breakdown in the
integrity of the skin or mucous membrane—another
reason why a good latch is very important
from the very first day. Many Candida infections
would, perhaps, not have occurred if the
mother had not had sore nipples and a breakdown
of the skin of the nipples and areola. The
oozing of liquid that occurs often in cracked
nipples encourages Candida albicans to change
from its harmless form to a disease causing
form.
The widespread use of
antibiotics also encourages the overgrowth
of Candida albicans. Many pregnant women,
women in labour, and new mothers, as well
as their babies receive antibiotics, sometimes
with very little justification.
Diagnosis of Candida
infections of the nipples and/or ducts
There is no good test
which helps makes the diagnosis. A positive
culture from the nipple(s) does not prove
your pain is due to Candida. Neither does
a negative culture mean your pain is not
due to Candida. The best way to make a diagnosis
is by history.
The presence or absence
of a Candida infection in the baby is not
helpful. A baby may have thrush all over
his mouth, but the mother may have no pain.
A mother may have the classic symptoms of
a Candida infection of the nipples, and
the baby may have no thrush or diaper rash.
The typical symptoms of
a Candida infection of the nipples are:
- Nipple pain that begins
after a period of pain free nursing. Though
there are a few other causes of nipple
pain that begin later, Candida infection
is definitely the most common. The nipple
pain of Candida may begin without an interval
of pain free nursing, however.
- Burning nipple pain
that continues throughout the feeding,
sometimes continuing after the feeding
is over.
- Pain in the breast that
is “shooting” or “burning”
in nature and which goes through to the
mother’s back and shoulder. This
pain is usually worse toward the end of
the feeding, and worsens still more after
the feeding is over. It also tends to
be much worse at night. This pain may
occur without any nipple pain.
- Pain, as above, which
is made much better with the use of gentian
violet, though unfortunately, gentian
violet does not seem to work as well as
it used to.
Treating Candida Infections
Our first approach to treating these infections
is gentian violet (handout #6 Using
Gentian Violet) plus all purpose nipple
ointment and sometimes grapefruit seed extract
(see handout #3b Treatments
for Sore Nipples and Sore Breasts and
Handout Candida Protocol).
This approach is safe, works rapidly, and
almost always, though there seems to have
been a decrease in the effectiveness of
gentian violet over the past few years.
For this reason, I now use the combination
of the ointment and the gentian violet as
well as the grapefruit seed extract. A good
response to gentian violet confirms that
the mother’s nipple pain is caused
by Candida since little else will respond
to gentian violet. It thus also justifies
the use of fluconazole, if needed. Even
if the above treatment does not help, fluconazole
should not be used alone to treat sore nipples
and should be added to treatment on the
nipples, not used instead. I have not found
nystatin to be particularly useful either
in treatment of the baby’s mouth or
in the treatment of the mother’s nipples.
Clotrimazole cream alone is also not particularly
effective in my opinion, but others obviously
feel differently.
Fluconazole
Fluconazole is an antifungal
agent that is taken systemically (by mouth
or intravenously). It stops fungi (such
as Candida albicans) from multiplying, but
does not actually kill them. This accounts
for the fact that sometimes it takes several
days to have an effect. Fluconazole powder
is also available and can be mixed with
the all purpose nipple ointment instead
of miconazole powder.
Side Effects
Fluconazole is generally well tolerated,
but there is no such thing as a drug that
never has side effects. Concern about liver
injury is exaggerated, since this complication
seems quite rare, and usually occurs in
people who are taking other medications
as well, and who have taken fluconazole
for months or longer, and who have immune
deficiencies. But it is a possibility that
needs to be kept in mind and if it does
occur, it can be very serious.
Vomiting, diarrhea, abdominal
pain and skin rashes are the most common
side effects. These are not usually severe,
and only occasionally is it necessary to
stop the medication because of these side
effects. Allergic reactions are possible
but uncommon. Call or email immediately
if you have any concerns.
Fluconazole in the milk
Fluconazole does appear in the milk, and
this is as it should be, since the idea
is to treat infection in the ducts and nipples.
It is thus superior to ketoconazole, which
gets into the milk in only tiny amounts.
The baby will obviously get some, but this
drug is now being promoted for use in babies
for the treatment of simple thrush. There
have been no complications in the baby reported
from exposure to fluconazole in the breastmilk.
Continue breastfeeding while taking fluconazole,
even if you are told that you should stop.
Dose of fluconazole
Candida albicans is learning to become resistant
to fluconazole, and the dose we use has
increased over the past few years. Only
a few years ago, 100 mg daily for 10 days
cured 90% of women of their symptoms. We
have now found this to be inadequate. For
resistant cases, a newer antifungal agent,
itraconazole, can be used, though it may
not be the answer either as it does not
have a very powerful effect against Candida.
Your prescription will
be for fluconazole 400 mg as a first dose,
followed by 100 mg twice daily until you
are pain free for a full week, which usually
means at least two weeks. This seems, on
the basis of our experience, a fairly good
guarantee against relapse. If you have nipple
pain continue with the “all purpose
nipple ointment” (± gentian
violet and grapefruit seed extract) while
you are taking fluconazole. However, this
means that although most mothers require
only the usual two weeks, some need longer
treatment. Occasionally it may take up to
seven to ten days for the pain to even start
going away. Call if there is no relief in
seven days. If there is no relief in 10
days, none at all, it is very unlikely fluconazole
is going to be of any help.
It is sometimes useful
to treat the baby as well. The dose for
the baby would be 6 mg/kg as a first dose,
followed by 3 mg/kg/day as one dose for
the same period of time as the mother.
Note: The mother’s
two week prescription is likely to cost
between $300 and $350, though there is now
a generic fluconazole available which is
less expensive.
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 #20 Fluconazole
revised January 2005
Written by Jack Newman, MD, FRCPC. ©
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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