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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.
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)
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.
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