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)