Make It Go Away
(Following this personal introduction is a Q & A with breastfeeding specialist Dr. Ann Witt of Breastfeeding Medicine of Northeast Ohio. Read on for sound advice and solid answers on the topic of thrush.)
I felt I had tried everything. I still feel like I tried everything. Sometimes I pretend Rad and I didn’t even have it. Thrush ruined the first three months of our relationship together, of our time together. “Ruined” seem like a pretty loaded word? It is. But, that’s what it felt like.
I realize that thrush – a yeast infection in the mouth that can easily occur in newborn babies and can also bring on painful symptoms for a new mom’s breasts – and can be so, so difficult to get rid of – affects everyone differently. It sounds as though some cases are quite terrible. And some are not so terrible. Ours wasn’t that bad, now that I know what I know. I often find my now-self wanting to say to my new-mom-self, “If only you could have approached it differently, you would have enjoyed that time.”
But, every day was scraping by with me desperately hoping I would soon be able to have a normal day with Rad, see what it would be like to nurse normally, go for walks, play with toys, do tummy time.
(You see, I had read that anything your baby drools on or that his mouth comes into contact with – i.e. Sophie the Giraffe and Grandma-sewn play mats – could become a landing spot for the yeast, which could live on it and cause a thrush recurrence. My fatigued brain clung to that one piece of (it turns out, incorrect) information and thought it sounded like a nightmare. And I didn’t have a sound medical voice speaking to me yet that could school me otherwise.)
The problem was, once I recognized that thrush might be what Rad and I had (I still don’t know if I had symptoms or not. I feel like not, but something obviously had clued me in to check his mouth at three weeks) I speedily typed it into Google and started an unraveling, never-ending feed of anecdotal advice and useless outlines of failed experiences.
Thrush is a being unto its own on the Internet and I was sucked right into it. Reading every last possible solution and seeking positive conclusions. And instead of weighing out options, I proceeded to head down every route at once, taking my distressed self and my newborn baby on a treatment attempt that felt never-ending.
I’ll start at the beginning. I have this faint memory of our pediatrician saying on our very first visit in those early days that there was a little bit of white on Rad’s tongue and that it could be … My mind started to space at this point, apparently, because I certainly didn’t catch the word thrush, and to keep an eye on it but that it was likely milk. So, of course, all I heard was, it is likely milk. And then three weeks passed by. My nipples were sore but nothing terrible. Once I made it through the first couple of days with magical gel-healing pads, and my cracked nipples recovered from my early days of nursing, everything seemed fine. And then, something a little funky came about. My nipples were a little sore again. Like, each time Rad went to feed, I was a little apprehensive. And then he would latch and then everything was fine. I chalked it up to, “It’s just us still being new at this.” But, it had been going really well. He would latch great and he would feed great. So, I looked it up. I did the Google thing. And, in that moment, everything changed for us.
I was a tired, new mom who was loving figuring out my little guy and was loving the sleepless nights because I was still pumped full of so much excitement but now I was faced with a beast I didn’t know or understand. I mean, honestly, if I had never read a single thing on the Internet, my Mom and I would have gone to the doctor’s, Rad would have been given a prescription and I would have been given a prescription and that would have been that. But because thrush is so widely debated and feared across every baby message board, there was so much information for me to question. I was trying to understand this thing – this thing that maybe could have been so simple but became so awful.
I called in to our pediatrician’s office and because it was a Saturday afternoon I spoke with a nurse who offered a prescription. Nystatin. I had already read about it and knew that I didn’t want to give it to Rad. When we picked it up, I was even more put-off by it. It was yellow. And, the taste was so sweet. Why colors and flavors? They tend to make me uncomfortable. I didn’t read the ingredients list though – I was worried that if in the future I did need to use nystatin, I would be overwhelmed by what I was about to put in Rad’s mouth. At home, I turned to Ina May Gaskin’s “Guide to Breastfeeding.” The book suggests a baking soda mixture every couple of hours and then Gaskin works through other possible cures, suggesting why some are potentially ineffective.
I had this wild deadline in my mind – five days I wanted this to be cleared up. We were headed out on a family trip to Ontario, a trip I had been looking forward to for months.
And, in this wildness, this attempt at DIY-curing my son and myself, it wasn’t just baking soda that was tried. Within 24 hours I also read that grapefruit seed extract was effective. And that I should stock up on Mother Love Diaper Rash and Thrush Cream. My mother, who is a retired nurse, was studying me with a look of, It’s not clearing at all, use the nystatin.
My pediatrician was woefully unavailable over the course of the next week and when I called back again, the nurse didn’t have much more to add. When I asked if there were other prescriptions (there is – Diflucan, also referred to later in this post as fluconazole) she said, “Nope. Nystatin is it.”
Days were passing. Nothing was changing. I was in complete panic mode. I thought I needed to rinse my nipples with vinegar before and after feeding Rad. I thought I had to eat only kale and drink volumes and volumes of kefir. (Literally all I consumed while everyone around me had sandwiches and ice cream and fruit – things with sugar – yeast’s favorite food – and what I had once again, read on the Internet, not to consume.)
(What everyone else ate on vacation.)
(What I ate on vacation.)
(Ok, the salad is not a far stretch from my usual, but still, those sweets there would have been a heavenly treat.)
I was a new mom – tired, deflated (I went from so super excited to absolutely floundering) and now every day I was on my way to some health food store or quirky compound pharmacy or reading some blog to find a new remedy and those damn white patches just kept staying their course. I finally broke down and tried the nystatin. (Along with all of the other elixirs, though. I literally carried around a basket with all of the creams and ointments and possible cures.)
(Z used a ski cup shot glass to make nystatin more fun.)
And, to make sure that I was doing everything that I possibly could to make sure this went away in the quickest amount of time, with no lingering yeast around the house to reinfect us, Rad didn’t get put in his baby carrier, not in his stroller, not on his play mat. I didn’t give him any toys. I was even disconnected from him sometimes when we were nursing. I didn’t want us to get too close – what if our clothes ended up being hosts to yeast? (Do you see where this path of a consumed, anxious, lost mind is going?) I boiled everything for 20 minutes (now, that’s a very real nightmare) and washed everything on hot water, over and over again. It really was awful. I didn’t know how to help this go away.
And it still took two-and-a-half weeks for the nystatin to be effective. And when those patches were gone (at a total of three weeks) I was elated. We went for walks. We played with toys. We didn’t carry a basket of treatment around with us everywhere.
It was two weeks of respite. Amazing.
And then it was back. And then it was nystatin for three more weeks. The patches seemed so persistent. I wish I had kept going with the treatments from the first round – even when the white patches are gone, I have learned that you should keep going to be sure you have eradicated those yeast.
(If you look close, you’ll see what Rad thought about thrush returning.)
To give an overview again, here is what my schedule with Radley looked like. Every two hours a mouth rinse with baking soda and water after feeding Rad, then a vinegar rinse on my nipples (sounds great, doesn’t it?), followed by a nipple cream (most often the Mother Love cream mentioned above but then later on in our treatment, the nystatin cream prescribed to me) then when we would feed two hours later, I would wipe off the nystatin cream, feed Rad and then swab his mouth with his nystatin treatment. So, no matter what, every two hours for weeks and weeks and weeks (and, remember, that’s 24 hours a day, no stopping throughout the night) I was swabbing my newborn son’s mouth with something and wiping or lathering up my nipples with something.
And that’s aside from all of the constant washing of spit up cloths, clothes, blankets, sheets, and morning, afternoon and evening boiling of pacifiers (I lost the battle on using these, specifically because I didn’t want to have to worry about boiling them, but everyone else in my family loves pacifiers) and any toys that Rad would put in his mouth (a shout out to Green Sprouts who immediately replaced my melted teethers – and to my amazing older brother who bought, like, 36 new teething toys for Radley – as well as to Bamboobies who replaced my Boobease Soothing Therapy Pillows. I did have to give up wearing my luxurious organic bamboo reusable breast pads in lieu of throw-aways but Bamboobies was quick to tell me how to treat them and quick to support me with new product for the ones that couldn’t be treated.) I ruined clothes. I ruined toys. (Sophie the Giraffe does not go in water. Word to the wise on that $24 toy.) And, I never pumped milk. I didn’t want to get into boiling breast pump parts for 20 minutes too. And, my friends would say to me – “It’s just thrush.”
Nearing the end of November (Rad was born at the beginning of September) I e-mailed a La Leche League leader to see if she had any insight into what was going on. I was then guided to a doctor who specializes in breastfeeding medicine, Dr. Ann Witt of Breastfeeding Medicine of Northeast Ohio.
In Dr. Witt’s office, we were immediately settled. This was no big deal, I was told. Stop doing everything that I was doing. There was a bunch of misinformation on the Internet. Her confidence and assured way of speaking started to reach to my rational being, the part of me who had taken off into hiding months ago. She prescribed probiotics (Rad’s mouth was actually pretty much cleared of patches by the time we went in for our appointment – our second course of nystatin had essentially cleared them from view the day before. But, remember, that doesn’t mean the thrush is gone.) And, while after trying the probiotics for the weekend and not seeing any natural improvement (one night off of nystatin and those patches came right back) we simply went back in to see Dr. Witt, no big deal, and she prescribed a 10-day course of Diflucan.
I will admit, I cried big buckets the first night we had to give Rad the Diflucan. I didn’t want anything other than my milk in my little baby’s body. But there we were. And, it’s what we needed to do to get back to sanity.
And, guess what? By morning, a mere 10 hours later, every single patch was completely gone.
From the end of September to the second week of December, this is what we dealt with. And we dealt with it on our own for so much of it. Not a good place to be. I received – and so then my husband and of course Radley also received – so much relief from Dr. Witt. That moment when we sat in her office and she told us this was not a big deal, reality really did start to come back to me. Radley didn’t seem bothered by the patches in his mouth one bit – he had continued nursing like a champion all those months. I may have experienced that soreness in those first couple of weeks when I first started nursing, but, I certainly didn’t show or feel symptoms of thrush either. Could you imagine if I had not completely fallen apart over this whole episode? Could you imagine if I’d had guidance in not letting it take over my and my new baby’s day-to-day?
I wanted to interview Dr. Witt for all of the moms and families out there who end up experiencing thrush. Plus, I still had questions myself. Could I have prevented this? Could I have done something differently? I am a balanced eater and consider myself quite healthy in my day-to-day. Will this happen again with our next baby due in August? I also wanted to clear the air on some of the misinformation that I had read in those early days of Internet scrutiny. Dr. Witt was so generous with her time to go through the below interview with me. To be honest, I would say, don’t read anything else. Just this. And then, if you haven’t yet, go talk to your doctor. And, relax. I know that it is going to be ok.
Q & A with Dr. Ann Witt of Breastfeeding Medicine of Northeast Ohio
Dr. Witt begins with an overview of pain. This is important to read. There are many factors that lead to breast pain and while my soreness led me to check Rad’s mouth, as Dr. Witt explains, there could be many reasons for the breast pain and a jump to the thrush conclusion might be incorrect.
W: Thrush most commonly comes up in breastfeeding when a mother is having pain. There are many factors to keep in mind when considering pain with breastfeeding. Is the pain in the nipples or the breasts or both? Is it worse with feedings? Is it there all the time? Are the nipples or breasts tender to touch? Pain can be caused by mechanical factors (such as a shallow latch, tongue tied infant, pumping with the incorrect flange sizes). Pain can also be caused by milk stasis (the milk sitting and not be removed as well) as in engorgement or plugged ducts as well as other conditions including vasospasm and infection. With infections there can be bacterial infections or yeast infections. Often there can be more than one cause of the pain and for the pain to be resolved all the factors need to be addressed.
K: What is thrush?
W: Thrush is caused by a yeast infection. Most commonly by Candida. While some Candida is normal for our bodies, thrush occurs when there is an overgrowth of Candida.
K: Is it most common in breastfeeding moms and babies?
W: No, I would not say it is most common in breastfeeding moms and babies. While it does occur with breastfeeding moms and babies it can occur in many other settings. For example, yeast infections can occur in the mouth, skin, and vaginal areas. For infant’s, thrush presents as an overgrowth of yeast in the infant’s mouth. Candida is present in the mouth of many infants. Difficulty occurs when there is overgrowth of the yeast and typically presents as white patches on the infant’s tongue and inside of the cheeks. For some infants they will have pain with feeding and other infants will not be bothered by it. Yeast can also cause skin rashes in many people. It most commonly causes skin rashes in warm, moist environments that encourage the yeast to grow such as in the diaper area, and skin folds (i.e. under the breasts or around the nipples, especially if there is a lot of moisture from breast pads).
K: What are the symptoms a parent should be on the lookout for and when does thrush typically arise? (Could a parent notice within days or would it take a couple of weeks with a newborn?)
W: For breastfeeding moms and babies thrush can occur at a variety of times. Symptoms of classic thrush include the infant having a thick white coat on its tongue along with white patches on the cheeks and inside of lips. At the same time, mom could have a rash on her nipples/areola. The rash can include some mild nipple cracking along with a raised red rash over the areola with nipple/areola pain and tenderness. Sometimes early on the mom may notice nipple tenderness and a pink color to the areola/nipple without cracking.
K: Do a mother and a baby both have thrush, even if a mom does not show symptoms? For example, should a mother and baby both be treated at the same time?
W: Common advice is that both a mother and infant should be treated. However there have been no studies done examining this question. Because there have been no studies most likely you could obtain different opinions from different physicians to the question if both need to be treated.
If a baby has visible thrush and a mom has the rash and pain noted in the previous question, then both should be treated. If the infant only has mildly visible thrush such as a light coating just on the tongue and is not bothered by the thrush and the mom has no pain, then there would be no need to treat. In these instances you could monitor and if either the infant’s symptoms worsen or the mom then develops pain or a rash, then treatment could be started. If the infant was not having symptoms but there was visible thrush in the infant and the mom was having recurrent episodes of thrush with pain then it would be appropriate to treat both. However it is also important to remember to rule out other causes of pain if there is persistent pain and the infant does not have visible symptoms. If the baby has visible thrush (i.e. on their cheeks as well as tongue) and this is a first episode it is reasonable to treat the mom with a topical ointment but I would not treat the mom with oral medications if she had no pain and it was a first episode.
K: Radley’s case of thrush did not stop him from breastfeeding – it didn’t seem to bother him at all from what we could see. I did not really show any symptoms myself, aside from some initial soreness at the beginning. But, just for any readers who do not have any experience with thrush and wonder why I was so intense about treating it – how bad can thrush get? What can it impact?
W: Thrush can get very painful for the mom. Some mothers can get cracked nipples with break down in the skin. Sometimes those cracks can also get a bacterial infection. With untreated infection the pain can worsen causing a mom to stop breastfeeding.
K: What are the common medical treatments for thrush?
W: The typical prescription medications are nystatin suspension or fluconazole for the infant. For the mother there can be topical nystatin or oral fluconazole.
K: When we were treating Radley with nystatin, I noticed that it carries a lot of sugar in it – I assume this is to make it palatable to babies, but does the yeast feed off of this sugar? Does this have anything to do with why nystatin takes a while to work?
W: I am not aware of the sugar in nystatin impacting the effectiveness of nystatin. Nystatin works best at the mucous membrane (i.e. mouth) and therefore requires multiple, frequent treatments 4 times per day to maintain contact with the yeast on the mouth’s surface. Because it is difficult to maintain contact in the mouth (i.e. it gets swallowed) it takes more time to work effectively. In contrast, fluconazole gets absorbed into the blood stream and then works to kill the Candida.
K: Are there tips for using nystatin to try to get the best possible outcome? We were extremely diligent – we did the nystatin every four hours and then a homeopathic treatment every two hours in between the nystatin, and it still took us 12 weeks to clear it up for Radley. Is there anything we could have done differently?
W: No, typically if the thrush is not clearing with the nystatin, then I would switch to fluconazole. For the nystatin you can put ½ cc in each cheek to help it spread and make contact with more areas of the thrush.
K: For moms like me who are nervous about giving their young babies medicine, can you tell us why nystatin is safe to use? What about fluconazole?
W: Nystatin is not orally absorbed and therefore is less likely to cause side effects. Fluconazole is orally absorbed into the blood stream. There are case reports of prolonged use of fluconazole affecting the liver. However those instances are very rare. Because of the expense of fluconazole and its oral absorption, I do start with nystatin. However fluconazole can be more effective as it works through a different mechanism, so if the nystatin does not work I would switch to fluconazole as it is well tolerated and typically there are no side effects. However, for those parents with concerns about taking medication, it raises the question of, do you need to treat thrush if neither the mom nor the infant are bothered by it? This goes back to question number #4. If there is pain, I would treat and realize that typically the medications are well tolerated.
K: Can a case of thrush then sometimes clear on its own in newborns?
W: Yes, mild thrush can be self-limiting and clear on its own. I do not have any numbers on the frequency with which that occurs.
K: After Rad’s thrush returned (or perhaps more correctly, had never actually gone away) following our first course of nystatin, and then persisted through a second course of nystatin, we came in to see you. After our second visit with you – you wanted to still give us a few days to finish off the second course of nystatin – you prescribed Diflucan for Radley, and our lives changed. Really. We gave him his first dose before bed and by the next morning every patch was gone. We had struggled through two treatments of nystatin from September until December – is there a reason why most doctors will not prescribe Diflucan straight away? Or, offer it after the first course of nystatin treatment?
W: Diflucan is orally absorbed and processed through the liver. Theoretically it could affect the liver, though this is rare. Though fluconazole is thought to be a safe medication, it is because of the oral absorption and the potential (but rare) side effects and the fact that nystatin is often effective, that most physicians will start with nystatin. Some studies do show that fluconazole is more quickly effective so if the diagnosis is clear and severe it is reasonable to start with fluconazole. Given nystatin is also often effective it is reasonable to start with nystatin too. The decision to start with one versus the other is not a standard.
K: You also suggested – before we started on the Diflucan – that we try probiotics. Can you explain to readers what this therapy is like and how it can help with thrush?
W: Our bodies normally have bacteria on our skin, intestines, mucous membranes (i.e. in our mouth). These healthy, normal bacteria help decrease the ability for other harmful bacteria and yeast to grow. By improving the growth of the healthy bacteria, it is harder for the yeast to grow. Given thrush and yeast infections occur when there is an overgrowth of yeast, if we can prevent the overgrowth by encouraging the growth of healthy bacteria, then we can decrease the chance of symptomatic thrush.
K: Speaking of other therapies, when I first noticed Radley’s thrush at three-weeks-old, I immediately took to the Internet and found a wealth of intense information – many tried-and-failed attempts at curing it naturally. After reading up on a multitude of blog posts (which, looking back, I think was a terrible idea for me to enter into) I tried swabbing Radley’s mouth with a baking soda and water mixture, a grapefruit seed extract and water mixture; I tried a vinegar rinse on my nipples, a baking soda rinse on my nipples. Which homeopathic therapies are worth trying out and which ones are not a good idea at all?
W: I think the most important thing is to make certain that what is being treated is thrush. I commonly see mom’s coming in believing they have thrush because they have burning nipple or breast pain. Burning nipple and breast pain can be caused by thrush but it can also have many other causes including bacterial causes and mechanical causes. For mechanical causes it can be because of a bad latch, an infant with torticollis or tongue tie or from pump trauma. I did a study with moms with chronic breast pain and asked moms to describe their symptoms. Burning breast pain occurred in moms with bacterial infections and in moms without bacterial infections. Some of the moms that came in thinking they had thrush, ended up having bacterial infection and after treating the bacterial infections, their burning pain resolved.
I do not have much experience with the homeopathic remedies. The theory with some of these presumably is that by changing the environment, the yeast is less likely to grow. However if any remedy is tried and the symptoms are not resolved I would reevaluate if yeast was really the cause.
K: Women may also read quite a bit about Dr. Newman’s All-Purpose Nipple Ointment. I had been using this as well and when I came in to see you, you said you don’t suggest the APNO for long-time use. Would you be able to tell our readers why this nipple ointment isn’t the best for prolonged use and which nipple ointments would be good?
W: The main reason the APNO is not good for long-time use is because it contains a steroid and prolonged use of steroid on the skin can cause thinning of the skin. Any time you use a treatment you want to make certain you’re not causing any difficulties. All the components of APNO (a topical antibacterial, anti-fungal and steroid) can be helpful at certain times but sometimes using them all together leads to some unnecessary use of medications.
K: How long does it usually take for a case of thrush to be eradicated?
W: Typically one to two weeks. There is not a standard length of treatment. In Australia, for the mother they use fluconazole, 1 pill every other day, for 3 doses. In the United States you can get nystatin for 10 to 14 days or fluconazole from anywhere from 1 to 14 days for the infant. For the mom in the United States you can get topical antifungals or fluconazole anywhere from 1 to 14 days. There is no standard treatment length because there have been no trials comparing the ideal length of treatment for breastfeeding moms and infants. Many of the treatments are extrapolated from treating adults in other settings. That said, if there is documented thrush in the infant and the mom is having pain it is reasonable to start treating the infant with 10 to 14 days of either fluconazole or nystatin and then to treat mom topically with nystatin ointment if she is just having superficial nipple pain. If she is having more severe pain, then treating with oral fluconazole.
K: How strict does a parent have to be about toys and clothes – will the yeast carry on fabric for a while? I understood needing to boil any pacifiers or teething toys – or, if a mother is pumping, then her pumping equipment – but I think I may have gone a bit overboard with everything. I was washing everything (any of my clothes, Radley’s clothes, burping cloths, blankets, etc.) in very hot water and drying on a very lengthy antibacterial setting. I accidentally melted a couple of teething toys. (With the suggested 20-minute boil for everything, some plastics just couldn’t handle the heat!) I didn’t want to expose Radley to his play mat or his toys fearing that the thrush would linger – I mean, I feel like a lot of that was crazy. It allowed my mind to become obsessive about everything in our home, making our first three months as a new little family very not normal. Any thoughts on how diligent a parent needs to be?
W: I think in general moist environments that the yeast can grow on should be eliminated. In general I do not think there is a need to boil and clean everything. Pacifiers and teething toys are reasonable as is the pump equipment though even these measures are not studied. Again if there are concerns for recurrent thrush and that is why people are going through all the measures you mentioned I would be questioning if thrush is the cause of the problem. However for some individuals (such as Radley) who have recurrent thrush then I would treat things at the beginning of treatment and in the middle- but primarily those things associated with a warm, moist environment as that is what thrush needs to grow.
K: I always wonder why Radley and I had thrush – are there certain reasons why a mom and baby might develop thrush? I’ve wondered about a few things that may have led us down our path – I had cracked nipples for the first few days of nursing and I also used washable, reusable nipple pads, but because I leaked a lot, they were often moist – would both of these things have been contributing factors? Or, would they have just helped the existing yeast grow?
W: Again some yeast is normal, it is the overgrowth that causes difficulties. Having cracked nipples gives the yeast from an infant’s mouth a chance to get into mom’s skin, grow and cause a skin rash that combined with the moisture from the pads creates an environment for the thrush to grow. Infants’ immune systems are still developing, so some infants may just still be developing the ability to prevent the yeast from overgrowing and that is why they have recurrent episodes.
K: Is it more likely that a mother’s subsequent children will also get thrush? Because my first child had thrush, is it likely that my next child will?
W: There is no reason to think this is more likely.
K: Are there ways that a mother could prepare her body – and her baby’s body – before birth to fight off a possible yeast overgrowth? Perhaps a change in diet? Perhaps adding probiotics to her diet?
W: I am not aware of any studies to support this. There is general interest in some of the homeopathic world about yeast overgrowth. I think it is always a good idea to eat a well balanced diet with fruits and vegetables, which is nature’s way of maintaining a good balance with probiotics.
Thank you again Dr. Witt. Helpful, insightful and reassuring. Readers, if you have any questions or personal experiences, please comment below.
K & R