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Treating candidiasis of the breast in a woman who is breast feeding

Dear Editor,
I have a female patient who is taking oral sporanox (itraconazole) for presumed candidiasis of the breast – she is continuing to breastfeed her seven-month-old baby while taking it. I initially prescribed it intending it to be a short course but she has kept asking for repeat prescriptions as she says that as soon as she stops it, the symptoms recur. She had been referred to the breast clinic for advice and they apparently told her it was “not their area” and suggested she see me. She is paying for it herself so I have not needed to involve a specialist. She is now asking if she can have a month’s worth at a time with repeats. She wants to continue feeding for as long as she can. Please can you advise me whether this is safe?

General Practitioner,

Itraconazole is excreted in small amounts in breast milk, so it is recommended to avoid if possible during breast feeding. Fluconazole is also present in breast milk, but in amounts unlikely to cause harm, so it is preferred in breast feeding if an oral azole antifungal must be used.1,2 If itraconazole is used for more than one month, liver function needs to be monitored as it can cause hepatotoxicity.2

To manage candida infection of the breast, the mother and baby should be treated simultaneously. For the mother the first line option is miconazole 2% cream applied to the nipples after each feed with the excess wiped off before the next feed. This should be continued for two weeks.3,4 Miconazole oral gel applied four times daily is recommended for the infant.4

If symptoms do not improve or worsen during treatment, oral fluconazole is the next appropriate option for the mother. Fluconazole is given as a 150–300 mg single dose, followed by 50–100 mg, twice daily, for ten days.4 Topical treatment for both the mother and the child should be continued at the same time.

If symptoms still persist, it would be appropriate to refer the patient to a specialist in the area which may be a lactation consultant.

During treatment for candidiasis of the breast, the patient can be advised to:

  • Continue to breastfeed
  • Wash hands frequently, especially after nappy changes
  • Wash and sterilise dummies, teats, nipple shields and toys that are put in the infants mouth

Given the persistence of symptoms, it may be appropriate to re-think the diagnosis of candidiasis. Symptoms of candida infection of the breast include; intense pain (often described as deep shooting pain) after a period of pain-free breastfeeding, pain in both nipples or breasts, and pain after feeds or beginning near the end of a feed. These symptoms are not accompanied by pyrexia or inflamed areas of the breasts as in mastitis.5

It is difficult to confirm a Candida infection of the breast. One study compared a group of breastfeeding women with sore, inflamed or traumatized nipples or intense stabbing or burning pain in their breasts with breastfeeding women without symptoms. They found that Candida species could not be cultured from either group suggesting that Candida infection is not present in milk ducts.6 Despite this, based on the presence of symptoms, treatment is often effective and allows the mother to continue breastfeeding.3

Differential diagnoses for pain in the nipples and breasts include:3

  • Feeding issues e.g. incorrect attachment, tongue tie in the infant (unlikely to be the cause in the present case given the mother has been breastfeeding for seven months)
  • Eczema, including a reaction to creams or breast pads
  • Raynaud’s disease of the nipple
  • A blocked duct which may appear as a white spot at the end of the nipple
  • Bacterial infection (may be present at the same time as candida infection)


  1. Australian Medicines Handbook (AMH). Adelaide; AMH Pty Ltd, 2011.
  2. British National Formulary (BNF). BNF 62. London: BMJ Publishing Group and Royal Pharmaceutical Society of Great Britain, 2011
  3. The Breastfeeding Network. Thrush and breastfeeding. 2009. Available from: (Accessed Oct, 2011).
  4. Clinical Knowledge Summaries (CKS). Breastfeeding problems. CKS, 2011. Available from: (Accessed Oct, 2011).
  5. Jones W, Breward S. Thrush and breastfeeding. Community Pract 2010;83(10):42-3
  6. Hale TW, Bateman TL, Finkelman MA, Berens PD. The absence of Candida albicans in milk samples of women with clinical symptoms of ductal candidiasis. Breastfeed Med 2009;4(2):57-61

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