Breast And Nipple Thrush - Pdf
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1. Policy Guideline and Procedure Manual ites Breast and Nipple Thrush ieee the royal women s hospital 1 Purpose This guideline provides details for the diagnosis and management of women with breast and nipple thrush candida at the Women s This guideline procedure is related to Breastfeeding Policy 2 Definitions Breast and nipple thrush is the over growth of candida albicans on the nipples and in breast ducts which can cause significant breast and nipple pain 3 Responsibilities Maternity and neonatal medical nursing and midwifery staff need awareness of the condition and to refer women to appropriate care Lactation consultants and medical staff should be aware of the guideline and be able to treat accordingly 4 Guideline 4 1 Breast and nipple thrush diagnosis The diagnosis of breast or nipple thrush is usually made after consideration of the mother s symptoms for example mother may complain of nipple pain that does not resolve despite improved attachment of the baby to the breast The pain of maternal thrush infections may lead to early weaning which can be avoided with early diagnosis and treatment There may be a history of antibiotic treatment preceding thrush symptoms This may have been prescribed postnatally for example to prevent infection following a caesarean section birth or for mastitis The mother may have a past history of vaginal thrush Nipple trauma commonly precedes nipple2. Algorithm soi the royal women s hospital Candida guide in nipple and breast pain algorithm For women with likely diagnosis of nipple breast Candida stinging burning nipple pain shooting radiating intermittent breast pain Initial treatment Baby Mother Other measures Nipple pain only Nipple and breast pain Miconazole oral Fluconazole 150 mg Fluconazole 150 mg capsules Hygiene gel four times a capsules every pa day every gi day 3 doses with a Wash hands day for 1 week X3 doses followed repeat prescription for frequently then once daily by Nystatin 500 000 fluconazole 150 mg every on day Wash Is dail for one week units x2 three times a 3 doses followed by Nystatin asn towe Coty day and Miconazole tablets 500 000units x2 three Boil dummy daily oral gel to nipples x4 times a day and Miconazole oral and replace weekly times a day gel to nipples x4 times a day if possible if using Y 4 Review in one week YES Complete treatment Is pain improving gt including Nystatin NO Breast pain not resolving Consider a NO Nipple pain is not resolving further course of fluconazole 150mg capsules Consider gentian violet 0 5 aqueous paint either one capsule every second day for 3 applied after breastfeeding twice a day for up doses or one capsule daily up to 10 days to 7 day NO Breast pain not resolving after further course of fluconazole Reconsider the diagnosis or con
3. thrush symptoms It is assumed that the break in the skin allows organisms to enter 4 2 Signs and symptoms Nipple areola e Mother may describe burning stinging nipple pain which continues during and after the feed e The nipples are often very tender to touch and even light clothing can cause pain e Nipples may appear pink and or shiny and areola may be reddened dry or slightly flaky e Consider dermatitis if significant itching and or rash Refer to RWH guideline Nipple Eczema Dermatitis e f nipple pain is exacerbated by cold and or nipples blanch consider nipple vasospasm Refer to guideline Nipple and Breast pain in Lactation which includes algorithm Breast e Mother may describe shooting stabbing or deep aching breast pain Pain may also be felt radiating into the back or down the arm The breast pain typically occurs after feeding or expressing The let down reflex may be more painful than normal e The pain may be localized to one nipple or breast or may be bilateral e Breasts will appear normal If inflamed consider mastitis Refer to guideline Mastitis and Breast Abscess Baby e The baby may have signs of thrush such as white oral plaques in the mouth tongue and inside cheeks or red papular rash with satellite lesions around the anus and genitals Although these signs are not always present it should be assumed that the baby is colonised with the organism if the mother has evidence of nipple thrush Uncontrolled
4. document when printed Publication date 05 06 2013 Page 1 of 6 Policy Guideline and Procedure Manual ites Breast and Nipple Thrush ieee the royal women s hospital Once diagnosis of nipple and or breast thrush has been made then both mother and baby should be treated at the same time to prevent re infection 4 3 Treatment Baby Baby s mouth Use miconazole oral gel Miconazole Oral Gel Daktarin 4 times a day for 1 week then once daily for 1 week after signs symptoms resolve Use the spoon to measure a 1 4 teaspoon dose The spoon should not be used for administering the gel Using a clean finger apply small amounts of gel at a time to the inside cheeks and over the tongue Note In May 2006 Janssen Cilag the manufacturers of Daktarin gel issued an alert advising pharmacists not to supply Daktarin miconazole oral gel for use in infants less than 6 months of age This alert originates from concerns regarding the administration of the gel not the medication itself Health care providers must ensure when recommending this product that the client understands how to administer the product safely see administration above If the client mother is unsure about how to use the gel or is unable to purchase the product from her pharmacy she can be advised to try another pharmacy or to use Nilstat oral drops see below However it should be noted that the drops are not as effective for oral thrush in infants as th
5. e gel Mother Topical e Nipple treatment for mother miconazole oral gel cream or nystatin cream applied to nipples after each feed or 3 4 hourly during the day It is not necessary to wipe the gel cream from the nipples before the next breastfeed Oral e f nipple pain only fluconazole 150 mg capsules one capsule every second day for 3 doses followed by course of oral nystatin quantity prescribed 50 2 tablets capsules 3 times per day preferably with food e f nipple pain persists consider a further course of fluconazole 150mg capsules either one capsule every second day for 3 doses or one capsule daily up to 10 days available only on private prescription followed by a further course of oral nystatin 2 tablets capsules 3 times per day preferably with food quantity prescribed 50 e f nipple AND breast pain fluconazole 150 mg capsules one capsule every second day for 3 doses plus a repeat prescription for a further course of fluconazole If pain is not significantly reduced after the first 3 fluconazole capsules followed by course of oral nystatin 2 tablets capsules 3 times per day preferably with food quantity prescribed 50 then the repeat prescription of fluconazole should be filled to have another course of 150mg fluconazole every second day for 3 doses followed by course of oral nystatin 2 tablets capsules 3 times per day preferably with food quantity prescribed 50 See Appendix Candida guide in nipple and b
6. erpretations of it Whilst appreciable care has been taken in the preparation of clinical guidelines which appear on this web page the Royal Women s Hospital provides these as a service only and does not warrant the accuracy of these guidelines Any representation implied or lexpressed concerning the efficacy appropriateness or suitability of any treatment or product is expressly negated In view of the possibility of human error and or advances in medical knowledge the Royal Women s Hospital cannot and does not warrant that the information contained in the guidelines is in every respect accurate or complete Accordingly the Royal Women s Hospital will not be held responsible or liable for any errors or omissions that may be found in any of the information at this site ou are encouraged to consult other sources in order to confirm the information contained in any of the guidelines and in the event hat medical treatment is required to take professional expert advice from a legally qualified and appropriately experienced medical practitioner NOTE Care should be taken when printing any clinical guideline from this site Updates to these guidelines will take place as necessary It is therefore advised that regular visits to this site will be needed to access the most current version of these guidelines Uncontrolled document when printed Publication date 05 06 2013 Page 5 of 6 Appendix 1 iis OD Candida Guide in Nipple or Breast
7. l cavity four times per day Miconazole interacts with many drugs such as warfarin oral sulfonylureas calcium channel blockers phenytoin Nystatin Nilstat Mycostatin Nystatin is an antifungal agent used in the treatment of thrush candidiasis and is available as topical preparations and oral preparations such as tablets or capsules Oral absorption is poor with undetectable plasma levels following oral doses Dose Nystatin drops brand names Nilstat Mycostatin N statin Baby apply 1mL to mouth four times a day for one week then once a day Nystatin topical cream brand names Nilstat Mycostatin Nipples apply after feeds at least 4 times a day Nystatin tablets or capsules 500 000 units Oral mother 2 tablets capsules three times a day preferably with food for a course of 50 tablets Possible side effects of nystatin Mother bad taste in mouth diarrhoea nausea vomiting Baby None reported commonly used in infants Possible drug interactions None noted Fluconazole Diflucan Fluconazole is an antifungal agent commonly used for systemic candida infections Oral absorption is high at gt 90 with peak plasma concentration occur in 1 2 hours after the dose Plasma half life 30 hours Dose See under 4 2 Treatment Possible side effects and drug interactions of fluconazole Mother Fluconazole is generally very well tolerated Reported side effects include vomiting diarrhoea abdominal pai
8. lmic use Note Gentian violet is a purple dye and may stain any material it comes into contact with eg bathroom basin clothing Side effects Gentian violet is generally well tolerated however side effects have been reported e Temporary staining of the skin and clothing e Overuse can result in gentian violet present in baby s mouth and consequently can cause ulceration of the mouth and throat e Skin irritation such as contact dermatitis Concerns Gentian violet use is restricted to application to unbroken skin because of concerns about carcinogenicity and mutagenicity effects shown in animal studies This research involves rats and mice that were fed large quantities of gentian violet over a period of time An increased rate of cancer was found to have occurred in these animals This has not been reported when used on the skin in humans but its use should be limited to nipples where other antifungal treatments have failed Important Store in a safe place away from children and discard after 2 weeks 5 Evaluation monitoring and reporting of compliance to this guideline Compliance to this guideline or procedure will be monitored evaluated and reported through review of clinical practice in the Breastfeeding Service All guidelines or procedures must have compliance measures developed and implemented 6 References 1 Moorhead AM Amir LH O Brien PW Wong S A prospective study of fluconazole treatment for breast and nipple th
9. n and skin rashes Baby No complications have been reported from exposure via breastmilk Cyclosporin zidovudine rifabutin theophylline oral hypoglycemics warfarin phenytoin and terfenadine can decrease hepatic clearance of fluconazole Rifampin and cimetidine can reduce fluconazole plasma level See product information for further detail Gentian Violet 0 5 Paint Gentian violet is a topical antifungal and antibacterial agent It is effective against fungi such as Candida species and bacteria such as Staphylococcus species Currently gentian violet has a place in the treatment of nipple thrush when other treatment options have failed Use of gentian violet Available as a 0 5 aqueous paint A prescription is required for this preparation and can be made up in some pharmacies on request E g Royal Women s Hospital Monash Medical Centre and compounding pharmacies This paint is applied twice a day to the nipples using a cotton bud Breastfeed the baby before each application The recommended duration is a few days and should not be used for longer than 7 days Uncontrolled document when printed Publication date 05 06 2013 Page 3 of 6 Policy Guideline and Procedure Manual iid a Breast and Nipple Thrush Icaman the royal women s hospital Contra indications for use e Hypersensitivity to gentian violet e On ulcerative lesions open or broken wounds e In patients with porphyria e Optha
10. reast pain algorithm If breast pain not resolving e f breast pain does not respond to fluconazole reconsider the diagnosis or consider oral ketoconazole as the infection may be caused by non albicans candida which may be resistant to fluconazole If nipple pain is not resolving e Consider gentian violet 0 5 aqueous paint applied after breastfeeding twice a day for up to 7 days gentian paint is made up by pharmacy departments RWH amp Monash Medical Centre See Appendix Candida guide in nipple and breast pain algorithm Miconazole oral gel Miconazole Oral Gel Daktarin Miconazole oral gel is an antifungal agent with poor oral absorption 25 30 When applied topically onto the nipples miconazole has minimal systemic absorption 0 1 The first line treatment of nipple thrush is direct application of gel to nipples and to baby s mouth Uncontrolled document when printed Publication date 05 06 2013 Page 2 of 6 Policy Guideline and Procedure Manual sides eye Breast and Nipple Thrush Inueni the royal women s hospital Possible side effects and drug interactions of miconazole gel Mother gel may irritate skin if irritation occurs cease using gel Consider changing to miconazole cream or nystatin cream It is not necessary to wipe the cream from the nipples before the next breastfeed Baby may cause some babies to gag or vomit Consider changing to nystatin oral drops apply 1mL in bucca
11. rush Breastfeed Rev 2011 19 3 25 29 2 Richter SS Galask RP Messer SA Hollis RJ Diekema Du Pfaller MA Antifungal susceptibilities of Candida species causing vulvovaginitis and epidemiology of recurrent cases J Clin Microbiol 2005 43 5 2155 2162 3 Walker M Maternal Pathology Breast and Nipple Issues In Breastfeeding Management for the Clinician Using the Evidence 2nd edn Sudbury Massachusetts Jones and Bartlett Publishers 2011 4 Wiener S Diagnosis and management of Candida of the nipple and breast J Midwifery Womens Health 2006 Mar Apr 51 2 125 8 7 Legislation Regulations related to this guideline Not applicable 8 Appendices Appendix 1 Candida Guide in Nipple or Breast Algorithm Uncontrolled document when printed Publication date 05 06 2013 Page 4 of 6 Policy Guideline and Procedure Manual siden the womens the royal women s hospital Breast and Nipple Thrush PGP Disclaimer Statement he Royal Women s Hospital Clinical Guidelines present statements of Best Practice based on thorough evaluation of evidence and are intended for health professionals only For practitioners outside the Women s this material is made available in good faith as a resource for use by health professionals to draw on in developing their own protocols guided by published medical evidence In doing so practitioners should themselves be familiar with the literature and make their own int
12. sider oral ketoconazole as the infection may be caused by non albicans candida which may be resistant to fluconazole Uncontrolled document when printed Publication date 05 06 2013 Page 6 of 6
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