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 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). It is not always easy,
though, to change the latch of the older baby.
Start with local
treatment (applied on the nipple) with:
violet Use once a day for 4 to 7 days. If
pain is gone after 4 days, stop gentian
violet. If better, but not gone after four
days, continue for 7 days. Stop after 7 days
no matter what. If not better at all at 4
days, stop the gentian violet, continue with
the ointment as below and call. 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. 2% gentian
violet should not be used.
2. APNO (All
Purpose Nipple Ointment) as below:
2% ointment (15 grams)
Betamethasone 0.1% ointment (15
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). I believe clotrimazole is
not as good as miconazole, but I
have no proof of that. Using
powder gives a better
concentration of antifungal
agent (miconazole or
clotrimazole) and the
concentrations of the mupirocin
and betamethasone remain higher.
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. In
Canada, Kenacomb (easier to find) or Viaderm
KC (less expensive) ointments (not cream)
can be substituted for the above
combination, but are distinctly inferior. 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 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 Treatments for Sore Nipples & Sore Breasts).
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 2 or 3 weeks to keep pain
free, get help or advice.
seed extract (not grape seed extract), 250
mg (usually 2 tablets) three 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/day (though this is not as
effective). 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 2 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 extract can be
used). 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
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.
Fluconazole takes 3 or 4 days to start
working, though occasionally, in some
situations, it has taken 10 days to even
start working. If you have had no relief
with 10 days of fluconazole, it is very
unlikely it will work, and you should stop
5. For deep
breast pain, ibuprofen 400 mg every four
hours may be used until definitive treatment
is working (maximum daily dose is 2400
extract 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).
directly on the nipples. It does not need to
be refrigerated. It may be covered and used
until solution is finished.
well five to 10 drops in 30 ml
(1 ounce) of water (preferably
swab or Q-tip to apply on both
nipples and areolas after the
Let dry a
few seconds then apply “APNO”
(all purpose nipple ointment).
Gentian Violet, do not use GSE
on that particular feed but use
after all other feeds.
used in conjunction with oral
GSE, either tablets, capsules,
or liquid extract (see above)
be treated as well: add 5-20
drops in the rinse cycle of all
pain is gone and then wean down
slowly over the period of at
least a week.
If pain is
not significantly improving
after 2-3 days, increase the
dose by 5 drops per 30 ml
(ounce) of water. Can continue
increasing until 25 drops per 30
ml of water.
drying, or whiteness appears on
the skin, substitute vitamin E
oil for APNO 1x/day.
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.
About The Author: Dr. Jack Newman is a Toronto
pediatrician who has practiced medicine since 1970. In 1984 he established the
first hospital based breastfeeding clinic in Canada, at the Hospital for Sick
Children in Toronto. He now holds breastfeeding clinics in several Toronto area
hospitals. Jack has been a consultant with UNICEF's Baby Friendly Hospital
Initiative and has spoken at conferences around the world. He is the father of
three children, all breastfed. Dr. Newman is the author of
"The Ultimate Breastfeeding Book of Answers"
NOTE: The article above titled "Candida
Protocol" was written by Dr. Jack Newman and is the opinion of its author. "The New Parents Guide" does not guarantee the information to
be factual. Always use the guidance of your personal
doctor or your child's doctor over information you read on this site or elsewhere; your doctors know what is
best for you and your baby.