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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 C:
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.
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