|
Fluconazole (Diflucan™) is a synthetic antifungal agent which can be used for
the treatment of a variety of Candida albicans infections. For the
breastfeeding mother in particular, it can be used to treat recurrent Candida
infections of the nipples, and, if such an 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 lives
normally on us, and 90% of babies are colonized by it within a few hours of
birth. It 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 serum which occurs often in cracked nipples turns
Candida albicans 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 labor, 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) proves little. Neither does a negative culture. 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 have no pain. A mother
may have the classic symptoms of a Candida infection of the nipples, and
the baby have no thrush or diaper rash.
The
typical symptoms of a Candida infection of the nipples are:
-
Nipple pain which begins after a period of
pain free nursing. Though there are a few other causes of nipple pain
which 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 which continues
throughout the feeding, sometimes continuing after the feeding is over.
-
Pain in the breast which 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
|
Treating Candida Infections
Our first approach to treating these infections is gentian violet (Using Gentian Violet) plus all purpose nipple ointment (Treatments for Sore Nipples & Sore Breasts). 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 a combination. 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.
Fluconazole
Fluconazole is an antifungal agent which is taken systemically (taken by mouth
or intravenously). It is fungistatic, which means that 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.
Side
Effects
Fluconazole is generally well tolerated, but there is no such thing as a
drug which 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 your doctor 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, unless told by your doctor that you cannot.
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 for at least two weeks. If you have nipple pain continue with the
“all purpose nipple ointment” while you are taking fluconazole. We like the
mother to be symptom free for at least a week before stopping the
medication. This seems, on the basis of our experience, a fairly
good guarantee against relapse. However, this means that although most mothers
require only the usual two weeks, some need longer treatment. Occasionally it
may take up to a week for the pain to even start going away. Call
your doctor if there is no relief in seven days.
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.
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 "Fluconazole
(Diflucan™)" 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.
|
