Common Problems Encountered by Breastfeeding Women

Yeast infection; bacterial infection; sensitive skin

Sore Nipples Caused by a Yeast Infection
Persistent nipple pain sometimes results from a yeast infection of the nipples. The problem occurs more commonly than appreciated, as few medical personnel are familiar with yeast infection of the nipples. Most women know about vaginal yeast infections, and new mothers soon learn that a persistent infant diaper rash can be due to a yeast infection. Yeast, also known as candida, thrive in moist environments, such as the mouth, the vagina, the diaper area, and the nipples of a breastfeeding woman. Although yeast commonly are harbored in these areas, they normally live in balance with bacteria and cause no symptoms. Certain conditions make a yeast infection more likely to occur. For example, treatment with antibiotics diminishes the growth of normal bacteria and allows yeast to overgrow and produce symptoms. Yeast aren't likely to invade normal skin, but once the skin barrier has been broken, damaged skin is more susceptible to a yeast infection. An ordinary diaper rash might develop when a wet/soiled diaper is left on too long. Once the rash persists for a few days, you should suspect that a yeast infection is now present.

Because some yeast are present in every infant's mouth, candida can easily be transferred to a mother's nipples. A yeast infection is more likely to develop if a mother has chronic nipple trauma from improper infant latch-on or incorrect suckling or if she has a crack, fissure, or opening in the nipple skin. A crack that has been present for several days may become infected by yeast, which can keep it from healing. Most breastfeeding specialists recognize the symptoms of a suspected yeast infection of the nipples. Unfortunately, relatively few obstetricians, pediatricians, or family physicians are familiar with the problem, which is seldom mentioned in traditional medical textbooks. An awkward situation often arises when a lactation consultant suggests the diagnosis, and the mother's physician is reluctant to prescribe treatment since he or she is unfamiliar with the condition. Some dermatologists will diagnose and treat yeast nipple infections.

The diagnosis of a yeast infection of the nipples is often based on circumstantial evidence. Proving that yeast are the culprit can be difficult, as culture results may be inconclusive. The following clues will help you suspect that your nipple pain is due to a yeast infection:

The timing and nature of the pain
The pain from yeast nipples typically starts after the first couple of weeks, although it can begin anytime. Usually, the mother has weathered early, mild sore nipples and has been nursing comfortably before pain starts anew. Mothers frequently describe their discomfort as burning, shooting, or stabbing pain that radiates from the nipples deep into the breast. Pain is present both during feedings and after nursing. Often, discomfort is so severe that the mother decides to wean. Nipple pain can be very chronic, sometimes present for weeks or months, virtually spoiling a woman's breastfeeding experience.

Appearance of the Nipples
Yeast infection of the nipples may cause surprisingly little change in nipple appearance. In fact, some practitioners wonder how a mother could complain of severe pain when her nipples may look relatively normal. Occasionally, they will appear pinkish. Rarely, the skin is inflamed with reddened bumps, typical of a baby's yeast diaper rash. I tend to suspect yeast if a crack, fissure, or other irritated area has been present for several days. Any break in the skin can be invaded by yeast.

Previous Problems with Yeast
Yeast infection of the nipples occurs more commonly among women who have experienced vaginal yeast infections during pregnancy and previous problems with yeast. Some women seem to be more yeast-prone than others. o Recent treatment of mother with antibiotics. Yeast infection of the nipples often starts during or after a mother's treatment with antibiotics. The antibiotics promote an overgrowth of yeast by destroying bacteria. A woman may have received a course of antibiotics to treat a uterine infection, breast infection, or other illness before she began experiencing nipple pain.

The Presence of Yeast Diaper Rash or Oral Thrush in the Baby
The possibility that nipple pain is due to a yeast infection should be considered whenever a baby has thrush (yeast in the mouth) or a yeast diaper rash. Yeast infections in the baby often occur after a course of antibiotics, for example to treat an ear infection. Oral yeast, called thrush, causes white patches on the baby's tongue (often assumed to be milk). It also can look like stringy white matter inside the baby's lips or cheeks (see photograph page 246). A yeast diaper rash looks bright red (common in the thigh creases and between the buttocks), with red bumps at the margins.

Other Risk Factors for Yeast
Diabetic women suffer more yeast infections than others, making them more prone to yeast nipples. Yeast infections are also more common among women taking birth control pills.

Treatment for Yeast Infection of the Nipples
If you suspect that you could have a yeast infection of one or both nipples, you will need to see a practitioner who can diagnose the problem and prescribe medication, such as your obstetrician or family physician. Although a lactation consultant may be more familiar with the problem, she may need to ask your doctor to write a prescription for you. A few pediatricians are willing to treat the problem in lactating women, and occasionally women seek help from a dermatologist. No studies have been conducted to determine the most effective treatment for yeast nipples, but several therapies are commonly prescribed, including a topical antifungal cream or ointment and/or an oral antifungal medication widely used to treat vaginal and other yeast infections (brand name, Diflucan; generic, fluconazole). Sometimes a topical cortisone cream is also recommended to reduce inflammation.

If the baby has a yeast diaper rash or oral thrush, proper treatment of the infant's yeast infections should be considered an essential part of your own therapy. Some practitioners recommend treating the baby even when no infant symptoms are present. Other things that will help combat a yeast infection of the nipples include the following suggestions:

Exercise good hygiene

• Wash your hands often, including after changing your baby's diaper or using the toilet and before and after breastfeeding.
• Keep your nipples free from surface moisture. Remember, yeast thrive best in a moist environment. Change your breast pads as soon as they become wet. Allow your nipples to air dry a few minutes after nursings.
• Boil pacifiers and bottle nipples at least once daily. Pacifiers and bottle nipples can harbor yeast and reintroduce it into your baby's mouth while you are trying to treat a yeast infection. If you use a breast pump, boil the breast shield that is placed over your nipple and the bottle at least once a day.
• Observe your baby for any signs of a yeast diaper rash or oral thrush. Ask your pediatrician or family physician to treat a possible yeast infection in your infant. Creams and ointments are available for diaper rashes and an oral medication is available for thrush. Babies and mothers often reinfect one another, so simultaneous treatment of the breastfeeding dyad is best.
• If you have any signs of a vaginal yeast infection, ask your obstetrician or family physician to prescribe treatment for you. Women with vaginal yeast infections are more prone to nipple yeast problems. One advantage of oral therapy is that it can eradicate yeast from other sites as well as your nipple infection.
• Consider interrupting breastfeeding temporarily by using a hospital-grade rental electric breast pump. Sometimes, when nursing is too painful to tolerate, pumping proves to be a comfortable alternative. Temporarily pumping instead of nursing also can speed your recovery from yeast nipples by breaking the mouth-nipple cycle of reinfection.
• It is popularly believed that yeast infections can be prevented by making dietary changes. Advocates of this belief recommend reducing one's intake of sugary foods and eating more yogurt with acidophillus.

Fortunately, many women who receive treatment for a yeast infection of their nipples can expect to notice improvement within a few days. However, women vary tremendously in how rapidly and completely they respond to therapy. For some, the pain relief seems nothing short of miraculous, while others continue to have nipple pain, despite persistent attempts to treat the problem. It is possible that some women whose symptoms do not improve with antiyeast therapies actually have another cause for their pain that is wrongly assumed to be yeast. A few women suffer chronic pain attributed to yeast and become so discouraged that they choose to wean rather than endure continuing discomfort. I am convinced that if more enlightened physicians took an interest in this common and frustrating problem, more effective therapies for yeast nipples would be found.

Sore Nipples Caused by Infection with Bacteria
Sore nipples can also become infected with bacteria. When bacteria invade the broken skin barrier, the result can be worse pain, delayed healing, and the risk of progressing to a full-blown breast infection. The offending germs that invade a crack or break in the skin usually are those found in the baby's mouth, including staph germs. Germs found in feces also can cause nipple infections, especially when breastfeeding women forget to wash their hands after diaper changes. Yellowish drainage and surrounding redness may be evident in the infected area. A bacterial infection of the nipple is more likely to be present when a mother's nipple pain is severe, when a break in the nipple skin is present, and when the baby is less than one month old. A bacterial infection is also likely when an older nursing baby bites the mother's nipple and breaks the skin. Your doctor can confirm such an infection by taking a culture with a swab or make a presumptive diagnosis by judging from the appearance of the nipple. In addition to correcting any problems with the baby's latching technique, bacterial infections of the nipple should be treated with a course of oral antibiotics to assure prompt healing and to prevent mastitis. If you are prone to yeast infections, your health care provider may prescribe an anti-fungal medication to be taken simultaneously.

Sore Nipples Caused by Sensitive Skin
In addition to the causes of sore nipples just described, differences in skin sensitivity make some women more prone to nipple discomfort during breastfeeding. In the past it was commonly accepted that redheads and fair-skinned women were more likely to have sore nipples. While some experts dispute this popular belief, others, including myself, find some truth in it. In my experience, women who have very sensitive skin on other parts of their bodies often have more trouble with sore nipples. I think seasonal and geographic differences have an influence as well. In Denver, we see more women with nipple complaints in the fall and spring. Our humidity is so low that excessive drying of the nipples contributes to nipple breakdown. You might accurately guess that lanolin is very popular here!