Out With Nipple Yeast
And stop rubbing that banana on your nipples!
Advances in medical knowledge are a cause for both celebration and chagrin. Case in point is the growing scientific consensus that yeast is not a common cause of nipple pain during lactation. Also called thrush, many respected breastfeeding websites and books are still filled with advice on how to combat Candida albicans (yeast) nipple infections with treatments like miconazole ointment (an antifungal) and cutting sugar intake. As it takes awhile for new advances to trickle throughout clinical practice, lots of people are still being inappropriately diagnosed and treated for yeast infection.
Candida Albicans - abstract art!
It’s painful to recognize that any breastfeeding advice I gave in the past was wrong. Still, better to face the facts and keep up to date than to stick my head under the sand and ignore new science. This is one I’ve known for awhile but the old thinking is still prevelant enough to warrant more attention.
It makes intuitive sense that yeast could cause breastfeeding pain - most women and people with vaginas experience the excruciating burning of a vaginal yeast infection at some point in their lives. All that moisture from the baby’s mouth… if you’ve had a vaginal yeast infection, it’s a natural explanation for burning, painful, rashy, shiny, nipple irritation. Yet, scientists have consistently failed to find overgrowths of Candida in the biopsies and milk cultures of people suspected to have thrush on the nipple. Researchers no longer believe Candida is a cause for breast or nipple pain.
Fundamentally, the nipple is different from the vagina as it does air out in between feedings. Yeast infections happen in folds of skin that stay touching. People are more likely to get fungal infections on the undersides of large breasts where they meet and rest against the abdominal skin (also called the inframammary fold) than on the nipples, which do not contact other skin.
So what is going on with all those rashy, painful nipples? Mostly, contact dermatitis, which means skin inflammation due to contact with an irritating or allergy-causing substance.
There are the usual suspects, like scented laundry detergent, dryer sheets, fabric softeners, soaps, lotions, new clothing such as nursing bras and breast cups, and chlorinated pools. Someone may have no problem with these until the constant friction of nursing or pumping causes increased sensitivity.
Many of the nipple care products I recommended in the past should be eliminated, like lanolin, to which many people do have allergic reactions. And those antifungal topical medications prescribed to treat yeast often end up causing, instead, yet more contact dermatitis.
Seemingly benign sources can also cause irritation, such as bananas. Apparently, a lot of people have reactions to bananas, so when babies start eating solids, and have banana residue in their mouths, they pass that on to the nipple. Voila! Rash. Most of us aren’t going around rubbing bananas on our nipples, so you’d never find this out ahead of time. The baby could be eating other foods that can cause dermatitis. This can be helped by giving the baby a sip of water or expressed breast milk right before nursing.
Years ago I had a midwifery client with chronic postpartum nipple pain she thought was yeast, because the only thing that helped it was Jack Newman’s APNO ointment, which combines antifungal, antibiotic, and steroid medications. As much as I appreciate Newman’s advocacy for nursing dyads, I have been won over by the APNO critics and believe it should not be used. Probably she was experiencing some pain relief from the steroid part of APNO, but it never fixed the problem.
So what should you do?
A differential diagnosis for breast and nipple pain might include vasospasm, shallow latch, blebs, and subacute mastitis. Assuming you have the healthcare access everyone should, it’s worth talking to a lactation consultant or breastfeeding medicine specialist about any unexplained symptoms.
But if you have that tell-tale eczema-looking white or red rash, itchiness, burning, or pain, there are steps you can take right away to minimize exposure and start the healing.
Stop using lanolin, antifungals, and other potentially irritating topical products.
Do apply a very mild, hypoallergenic balm after nursing, such as plain olive oil or Motherlove cream.
Some people also like plain coconut oil, others are allergic - experiment.
Cover oiled nipples in between feedings with wound care products like hydrogel pads (there are many brands that make hydrogels specific to lactation - Lansinoh Soothies, Medela, whatever is available).
If your baby is eating solids, consider possible food irritants.
Consider household items such as new bras, laundry detergent, soaps, etc.
Continue directly nursing your baby when possible. Pumping won’t necessarily make the skin inflammation better and could worsen it.
If you are in a lot of pain, talk to your clinician about a prescription for a short-course steroid ointment. Topical triamcinolone 0.1% can be used three times a day for 1 week, then twice a day.
Breastfeeding medicine expert Dr. Katrina Mitchell has an excellent article about yeast versus contact dermatitis with lots of helpful pictures and also a colorful one page handout with nipple care basics.
People do heal from contact dermatitis although it could take a few weeks to fully recover. You may have to be a bit of a detective in figuring out your trigger!
If you are clinician and want to learn more, I recommend the continuing education courses on nipple care and diagnosis from IABLE.