I have stabbing pain between breastfeeds. Is it thrush? The case of Emily and her 3-month-old. Dr Pamela Douglas 23_11_22

What’s been happening with Emily’s breastfeeding?

“My nipples still hurt, and I’ve had a stabbing pain in my breast between feeds for the last two weeks. Both my nipples are pink and shiny with little white flakes of skin. I’m sure the thrush has come back!”

Emily’s firstborn is now three months old, and she’s endured nipple pain from the very beginning.

“The obstetrician told me it was normal to have nipple pain for the first twenty seconds of a breastfeed, and that I should just count and breathe through it,” she says.

Emily was given different fit and hold (or ‘latch and positioning’) advice from every midwife she saw, both in the hospital and when they visited her at home. For the first eight weeks Emily used nipple shields and pumped her breast milk whenever the pain was too great to feed even with shields.

When the baby was four weeks old, a GP advised Emily to apply miconazole oral gel on her nipples every four hours for a week. The GP also prescribed fluconazole 150 mg orally every second day for six doses. The baby was prescribed nystatin drops 1ml four times daily for a week, then once a day for another seven days. Emily wondered if the pain was improving for a time – but then it seemed to become even worse.

Emily is very committed to breastfeeding her baby. She has already consulted with three International Board Certified Lactation Consultants. Two said that the baby’s latch and positioning was fine; the third recommended that she use the ‘biological nurturing’ or ‘baby-led’ approach, with the baby straddled across her thigh or diagonally across her tummy as she leaned back. Unfortunately this made the pain worse and the baby began to fuss during feeds, so she stopped (Box 1). One of the lactation consultants referred the baby to a dentist at six weeks, who performed a laser frenotomy for the diagnosis ‘posterior tongue tie’, after which the baby went on a 48-hour feeding strike.

“But once he would breastfeed again, nothing much else changed,” Emily explained. Nevertheless, she diligently stretched open the wound under his tongue three times a day for three weeks, as she’d been instructed.

Another lactation consultant advised Emily to take her baby to an osteopath every week, which she still does. She really likes the osteopath, who is caring and spends a lot of time with her. The osteopath taught Emily to perform various stroking and massaging exercises on the baby’s face, inside the mouth, and under his little tongue. Emily was also taught to perform movement exercises of her baby’s body and limbs, which the osteopath said would help with his sucking action.

Despite all this, her nipple pain persists.

“I’ve come in for more thrush treatment,” she says. “I’m willing to give it one more go.” Then she says with tears in her eyes: “But if it doesn’t work, I think I am going to have to stop breastfeeding. It’s awful having pain all the time! I just can’t keep going like this ….”

Nipple pain is often excruciating, and even in Emily’s case, where the pain during feeds is not as intense as it had been, nipple pain remains a distressing sensory and emotional experience. It interferes with maternal mood, activity, and sleep. This is regardless of the presence or absence of visible damage. It is also is linked with an increased risk of breast inflammation (for example, engorgement and mastitis).1 Even without visible trauma, nipple pain is associated with low supply.2 3 Unsurprisingly, nipple pain predisposes to postnatal depression.4-6

Pink nipples with fine white flakes of skin and stabbing breast pain between feeds are not diagnostic of mammary candidiasis

Emily hasn’t been using an antibiotic or topical steroids. Her baby remains exclusively breastfed, settled, and is gaining weight well. The pain with feeding has eased somewhat, though there is often some stinging. But a burning radiating pain from the nipples into the breast between feeds continues to cause Emily distress.

A 2011 Australian study found that breastfeeding women with nipple pain were receiving up to 29 doses of fluconazole, with seven of the 96 women studied reporting side-effects in their babies.7 Currently, a wide range of breastfeeding problems are treated with unnecessary medical and surgical interventions, consistent with international trends to overdiagnosis and overtreatment.8-10

Emily agrees to allow me to examine her breasts and nipples. She removes her bra and breast pads, and winces as she removes the hydrogel discs she’d applied that morning.

“I do try to go without a bra sometimes at home, under a soft cotton shirt,” she says. “And I don’t wear a bra at night.”

“Trying to keep the nipples dry is best!” I respond. “Even hydrogel pads can make the nipple more prone to inflammation and damage because they keep the nipple moist, so we have to use them sparingly.”11

There is nothing to find on breast examination, other than the generalised lumpiness of a lactating breast, and no enlarged axillary nodes. Both Emily’s nipples are inflamed, without visible cracks or wounds. I note a few fine white flakes of skin on each.

“Is it thrush?” she asks.

I take a deep breath. “No, I don’t believe that you are experiencing a thrush infection,” I reply kindly.

“But shouldn’t we take a swab to be sure?” she asks tentatively.

“I honestly don’t think that will help us,” I say carefully, “because the truth is that Candida albicans occurs normally in any skin microbiome, including on the nipples – it will often show up on a swab, but that doesn’t mean it is causing you breast or nipple pain.”

“But what are those white flakes? Isn’t that thrush? And the shiny pink colour?”

“The white flakes results from what we call hyperkeratosis. That’s an overproduction and shedding of the outer keratin layer in the epithelium, which happens when there is ongoing inflammation. The shiny pink colour again tells us there is persisting inflammation, which is very important for you and me to attend to. But it’s not a sign of thrush, despite what you hear! Same with the stabbing breast pain between feeds – an awful thing to be experiencing, and a sign that we need to address the inflammatory process in both the skin and the tissue in the core of the nipple. But not a sign of breast thrush.”

“But I know women who’ve been taking treatments for thrush for weeks and weeks!”

I nod. “We used to think that the symptoms you describe were due to Candida. But now we know that Candida is found in a woman’s breastmilk and on her nipple and areola, regardless of whether she has pain or not. Breastfeeding mothers experience pain related to ongoing microtrauma of the nipple in various ways, including stabbing breast pain between feeds, but this doesn’t point to thrush.11

“The problem with using medications which aren’t absolutely necessary is that the gel or cream on your nipple can make the nipple even more vulnerable to damage, because the application unnecessarily hydrates the skin.”11

With Emily’s consent I perform an oral examination on the baby. The little one’s mucosa is clear.

“We don’t need to treat your baby’s mouth with antifungals unless there are visible white plaques from a true thrush infection.”

On rare occasions I may trial a single course of antifungal treatment in the breastfeeding mother. The following factors increase the risk of a genuine, difficult-to-control overgrowth of C. albicans in a disrupted nipple skin mycobiome, which could benefit from treatment (though addressing these predisposing factors alone may be enough):

• The environment of the mother’s nipple-areolar complex has been kept severely moist and humid in the occlusive environment of the bra for very long periods, which fosters high humidity, low pH, high carbon dioxide levels, and also moisture-associated skin damage (MASD);11
• Moist applications (like hydrogel, purified lanolin, or other balms) to the nipples for long periods, which predispose to MASD;11 and
• Use of oral antibiotics or prolonged topical steroid cream applications.

A single course of fluconazole 150 mg alternate days for 3 doses, and miconazole cream four times daily for five days, is enough: there is no evidence to suggest that failure of nipple pain to resolve with antifungal treatment indicates a need for prolonged antifungal treatment. (Box 3)

“My baby has a nappy rash though, and I am also prone to vaginal thrush. That’s why the midwives thought I should get the treatment for nipple thrush,” Emily says uncertainly, trying to make sense of all the different recommendations she’s received.

“There is in fact no connection between your baby’s nappy rash, or your own vaginal thrush infections, and your nipple pain,” I explain gently. “I know everyone says that, but it misunderstands human microbiomes.”

The widespread overtreatment of nipple pain with antifungals results from failure of our current approaches to fit and hold to effectively resolve the effects of repetitive micro-trauma during breastfeeding.8 11 12 Stabbing nipple and breast pain between feeds is a direct result of nipple epidermal and nipple stromal inflammation.

To find out what we can do to help Emily and other breastfeeding women with nipple pain, please read the next article in this three-part series, to come out in the new year of 2023.

Box 1. Teaching the biological nurturing approach to fit and hold before hospital discharge may modestly decrease the prevalence of nipple pain but doesn’t impact on breastfeeding rates

‘Baby-led’ or ‘biological nurturing’ methods, when applied preventatively in the first 3 days after birth, have been shown in a randomised controlled trial (RCT) of 504 mother-baby pairs to decrease the incidence of nipple pain by up between 5 to 8% at 3 months post-birth.13 The decrease in nipple pain in the first two months, if the biological nurturing method of fit and hold is applied in the first three days, is corroborated in a meta-analysis of this and another 11 studies.14 However, rate of nipple shield use, of breastfeeding problems at 4 months, and overall breastfeeding rates were not impacted.14 15 The biological nurturing approach did not help when applied as an intervention in a Swedish RCT of 102 babies who had severe difficulty latching in the first six weeks.16 In summary, whilst biological nurturing methods are foundational, they are not enough to prevent nipple pain in most women, or to resolve latching problems once they emerge. This is why the gestalt method of fit and hold includes the principles of the biological nurturing approach, but also integrates a range of strategies for optimising the biomechanics of infant suck.8 12 17

Box 2. The prevalence of lactation-related nipple pain

Nipple pain during breastfeeding is common, particularly in the first week after the birth,18 and one of the most common reasons for introducing formula.19-21 In 2014, Buck et al found that 79% of 317 first-time breastfeeding Australian mothers experienced nipple pain by the time they were discharged home after birth of their baby, despite being motivated to breastfeed, well-educated, and in a ‘Baby Friendly’ accredited institution with extensive postnatal support.22

A 2014 Cochrane review found that nipple pain reduced to mild levels 7-10 days after birth for a majority of breastfeeding women, regardless of treatment used.23 Unfortunately though, it is not possible to know which women will go on to develop persistent nipple pain and damage, and any report of nipple pain needs to be addressed promptly if breastfeeding is to be protected. Women should not be told to expect pain at the beginning of a breastfeed.

Even at 8 weeks post-birth in Buck et al’s study, 20% of mothers reported current nipple pain and 8% current nipple damage; 58% reported experiencing nipple pain at some time after the birth.22

Large studies suggest that nipple pain occurs more commonly in Australia, the United States and the United Kingdom than in other parts of the world, such as Brazil, Denmark, South Africa, or Peru. This finding points to the importance of variable environmental factors.2 24-28 To give one example of possible environmental variables, one popular fit-and-hold strategy (shaping the breast with cross-cradle hold) has been associated with a fourfold increase in nipple pain.29

Box 3. A systematic review shows no association between signs typically diagnosed as mammary candidiasis and Candida albicans

In 2021 this author conducted three systematic reviews.30 The first looked at the relationship between C. albicans and the symptoms of burning or radiating nipple and breast pain in breastfeeding women who have been diagnosed with mammary candidiasis. Despite three comparative studies, one cohort study, and two prospective cohort studies, there was no conclusive evidence to support the hypothesis that C. albicans causes Emily’s symptoms.

In the second search I looked for studies evaluating the efficacy of fluconazole in the treatment of breastfeeding-related nipple and breast pain – and found none.30

The third investigated the presence of C. albicans in the human milk mycobiome (the fungal portion of the milk microbiome). Candida spp, including C. albicans, is often found in normal human milk mycobiomes, and are also commonly found in the microbiome of the skin of the nipple areolar complex.30

References

1. Cullinane M, Amir LH, Donath SM, et al. Determinants of mastitis in women in the CASTLE study: a cohort study. BMC Family Practice 2015;16:181.
2. Kent JC, Ashton E, Hardwick C, et al. Nipple pain in breastfeeding mothers: incidence, causes and treatments. International Journal of Environmental Research and Public Health 2015;12:12247-63.
3. Geddes DT, Gridneva Z, Perrella SL, et al. 25 years of research in human lactation: from discovery to translation. Nutrients 2021;13:1307.
4. McClellan HL, Hepworth AR, Garbin CP, et al. Nipple pain during breastfeeding with or without visible trauma. Journal of Human Lactation 2012;28(4):511-21.
5. Watkins S, Meltzer-Brody S, Zolnoun D. Early breastfeeding experiences and postpartum depression. Obstetrics and Gynecology 2011;118:214-21.
6. Brown A, Rance J, Bennett P. Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing 2016;72(2):273-82.
7. Moorhead A, Amir LH, O'Brien PW, et al. A prospective study of fluconzaole treatment for breast and nipple thrush. Breastfeeding Review 2011;19(3):25-29.
8. Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Midwifery 2018;58:145–55.
9. Brownlee S, Chalkidou K, Doust J, et al. Evidence for overuse of medical services around the world. The Lancet 2017;390:156–68.
10. Coon ER, Quinonez RA, Moyer VA, et al. Overdiagnosis: how our compulsion for diagnosis may be harming children. Pediatrics 2014;134(5):1-11.
11. Douglas PS. Re-thinking lactation-related nipple pain and damage. Women's Health 2021;18:DOI: 10.1177/17455057221087865.
12. Douglas PS, Perrella SL, Geddes DT. A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series. BMC Pregnancy and Childbirth 2022;22(94):https://doi.org/10.1186/s12884-021-04363-7.
13. Yin C, Su X, Liang Q, et al. Effect of baby-led self-attachment breastfeeding technique in the postpartum period on breastfeeding rates: a randomized study. Breastfeeding Medicine 2021;16(9):734-40.
14. Wang Z, Liu Q, Min L, et al. The effectiveness of laid-back position on lactation related nipple problems and comfort: a meta-analysis. BMC Pregnancy and Childbirth 2021;21:248.
15. Milinco J, Travan L, Cattaneo A, et al. Effectiveness of biological nurturing on early breastfeeding problems: a randomized controlled trial. International Breastfeeding Journal 2020;15(1):21.
16. Svensson KE, Velandia M, Matthiesen A-ST, et al. Effects of mother-infant skin-to-skin contact on severe latch-on problems in older infants: a randomized trial. International Breastfeeding Journal 2013;8:1.
17. Douglas PS, Keogh R. Gestalt breastfeeding: helping mothers and infants optimise positional stability and intra-oral breast tissue volume for effective, pain-free milk transfer. Journal of Human Lactation 2017;33(3):509–18.
18. Jiminez Gomez MI, Monroy AM, Martin JC. Prevalence of nipple soreness at 48 hours postpartum. Breastfeeding Medicine 2021;16(4):325-31.
19. Odom E, Scanlon K, Perrine C, et al. Reasons for earlier than desired cessation of breastfeeding. Pediatics 2013;131:e726-32
20. Dias JS, Vieira TDO, Vierira GO. Factors associated to nipple trauma in lactation period: a systematic review. Revista Brasileira de Saude Materno Infantil 2017;17(1):27-42.
21. Li R, Fein SB, Chen J, et al. Why mothers stop breastfeeding: mothers' self-reported reasons for stopping during the first year. Pediatrics 2008;122:S69-S76
22. Buck ML, Amir LH, Cullinane M, et al. Nipple pain, damage and vasospasm in the first eight weeks postpartum. Breastfeeding Medicine 2014;9:56-62.
23. Dennis C, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews 2014(12):doi:101.1002/14651858.CD007366.pub2.
24. Puapornpong P, Paritakul P, Suksamarnwong, et al. Nipple pain incidence, the predisposing factors, the recovery period after care management, and the exclusive breastfeeding outcome. Breastfeeding Medicine 2017;12:169-73.
25. Feenstra MM, Kirkeby MJ, Thygesen M, et al. Early breastfeeding problems: a mixed method study of mothers' experiences. Sexual and Reproductive Health 2018;16:167-74.
26. Santos KJ, Santana GS, Vierira TdO. Prevalence and factors associated with cracked nipples in the first month postpartum. BMC Pregnancy and Childbirth 2016;16:209.
27. Doherty T, Sanders D, Jackson D. Early cessation of breastfeeding amongst women in South Africa: an area needing urgent attention to improve child health. BMC Pregnancy and Childbirth 2012;12:105.
28. Strong GD. Provider management and support for breastfeeding pain. Journal of Obstetric, Gynecologic, and Neonatal Nursing 2011;40:753-64.
29. Thompson RE, Kruske S, Barclay L, et al. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women and Birth 2016;29:336-44.
30. Douglas PS. Overdiagnosis and overtreatment of nipple and breast candidiasis: a review of the relationship between the diagnosis of mammary candidiasis and Candida albicans in breastfeeding women. Women's Health 2021;17:DOI: 10.1177/17455065211031480.