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Candida Protocol
Written by Jack Newman, MD, FRCPC. © 2005
Revised: December 22, 2005
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It is important to get the best
latch possible when you have sore nipples. Even if the cause
of sore nipples is Candida, improving the latch can decrease
the pain. Note that with the “ideal” latch, the baby
covers more of the areola (brown or darker part of the breast) with
his lower lip than the upper lip. Note also that the baby's nose
does not usually touch the breast (except when the mother's breasts
are very large, and even then, most babies well latched on will
not have their noses touching the breast). It is not always easy,
though, to change the latch of the older baby. For videos showing
how to latch on a baby, go to www.thebirthden.com/Newman.html.
Start with local treatment (applied on the
nipple) with:
Gentian violet (see Handout #6 Using
Gentian Violet). Use once a day for four to seven days.
If pain is gone after four days, stop gentian violet. If better,
but not gone after four days, continue for seven days. Stop after
7 days no matter what. If not better at all at four days, stop the
gentian violet, continue with the ointment as below and call or
email. Gentian violet comes as a 1% solution in water. It is also
usually dissolved in 10% alcohol, as gentian violet is
not soluble in pure water. This amount of alcohol is negligible,
as the baby will only get a drop of gentian violet. Apparently some
pharmacists will dissolve it in glycerine instead of alcohol, if
you wish. 2% gentian violet should not
be used.
Plus:
APNO (All Purpose Nipple Ointment) as below:
- Mupirocin 2% ointment (15 grams)
- Betamethasone 0.1% ointment (15 grams)
- To which is added miconazole powder so that the final concentration
is 2% miconazole. This combination gives a total volume of just
more than 30 grams. Clotrimazole powder to a final concentration
of 2% may be substituted if miconazole powder is unavailable,
but both exist (the pharmacist may have to order it in, but compounding
pharmacies almost always have it on hand). I believe clotrimazole
is not as good as miconazole. Using powder gives a better concentration
of antifungal agent (miconazole or clotrimazole) and the concentrations
of the mupirocin and betamethasone remain higher. Sometimes we
will add ibuprofen powder to a final concentration of 2%.
The combination is applied sparingly after each feeding (except
the feeding when the mother uses gentian violet). “Sparingly”
means that the nipple and areola will shine but you won’t
be able to see the ointment. Do not wash or wipe
it off, even if the pharmacist asks you to. I used to use nystatin
ointment or miconazole cream (15 grams) as part of the mixture,
and these work well enough, but I believe the use of powdered miconazole
(or even clotrimazole powder) gives better results. These ointments
can be used for any cause of nipple soreness
("all purpose nipple ointments"), not just for Candida
(yeast). Use the ointment until you are pain free and then decrease
frequency over a week or two until stopped. (See Handout #3b Treatments
for Sore Nipples and Sore Breasts under “all
purpose nipple ointment”). If you are not having less
pain after 3 or 4 days of use, or if you need to be using it for
longer than two or three weeks to keep pain free, get
help or advice.
Grapefruit
seed extract (not grape seed
extract, ACTIVE INGREDIENT MUST BE “CITRICIDAL”),
250 mg (usually 2 tablets) three or four times a day orally (taken
by the mother), seems to work well in many cases. If preferred the
liquid extract can be taken orally, 5 drops in water three times
per day (though this is not as effective). Oral GSE can be used
before trying fluconazole, instead of fluconazole or in addition
to fluconazole in resistant cases. See below
for information on grapefruit seed extract used directly on the
nipples.
If pain continues and it is sure the problem is Candida,
or at least reasonably sure, add fluconazole 400 mg loading,
then 100 mg twice daily for at least two weeks, until
the mother is pain free for a week. The nipple ointment
should be continued and the gentian violet can be repeated. If fluconazole
is too expensive, ketoconazole 400 mg loading, then 200 mg twice
daily for same period of time (or grapefruit seed) can be used instead.
If Candida is resistant, itraconazole, same dose and time
period as fluconazole, can be used and has worked, though Candida
actually is less sensitive to itraconazole, generally, than it is
to fluconazole. (See handout #20, Fluconazole).
Fluconazole is apparently now available as a generic product (therefore
less expensive). Fluconazole should not be used as a first line
treatment or if nystatin alone does not work (which it usually doesn’t).
Before using fluconazole, nipple pain should be treated aggressively
with good latch, gentian violet, all purpose nipple ointment and
grapefruit seed extract. If used, fluconazole should be added
to treatment of the nipples, not used alone. Fluconazole takes three
or four days to start working, though occasionally, in some situations,
it has taken 10 days to even start working. If you have had no
relief at all with 10 days of fluconazole, it is very unlikely
it will work, and you should stop taking it.
For deep breast pain, ibuprofen 400 mg every four hours may be used
until definitive treatment is working (maximum daily dose is 2400
mg/day).
Grapefruit Seed Extract
(GSE)
Grapefruit seed extract (ACTIVE INGREDIENT
MUST BE “CITRICIDAL”) should be used in conjunction
with the APNO (All Purpose Nipple Ointment). Apply the diluted
liquid grapefruit seed extract on the nipples, and then follow
with the ointment (always after the feeding).
Apply solution directly on the nipples. It does
not need to be refrigerated. It may be covered and used until
solution is finished.
If not using Gentian Violet, it may be helpful to treat
baby with acidophilus by rolling a wet finger in acidophilus powder
(break open a capsule), and let baby suck on the finger right before
a feeding. Use 2x first day, 2x second day only. Mother may want
to ingest Acidophilus as well, 3x/day for 1-2 weeks.
This
handout may be copied and distributed without further permission,
on
the condition that it is not used in any context in which
the WHO code on the marketing of breastmilk substitutes is violated
