| Gentian violet (1% solution in water) is an excellent treatment for Candida albicans. Candida albicans is a fungus which may cause an infection of skin and/or mucous membranes (inside of mouth, for example) in both children and adults. In small children, this yeast may cause white patches in the mouth (thrush), or diaper rash. When the nursing mother has a Candidal infection of the nipple, she may experience severe nipple pain, as well as deep breast pain. Nipple pain caused by Candida albicans The pain caused by a Candidal infection is generally different from the pain caused by poor positioning and/or ineffective suckling. The pain caused by a Candidal infection: 1. is often burning in nature, rather than the sharp, stabbing or pinching pain associated with other causes. Burning pain may be due to other causes, however, and pain due to a Candidal infection does not necessarily burn. 2. frequently lasts throughout the feeding, and occasionally continues after the feeding has ended. This is in contrast to the pain due to other causes which usually hurts most as feeding begins, and gradually improves as the baby nurses. 3. may radiate into the mother's armpit or into her back. 4. may cause no change in appearance of the mother's nipples or areolas, though there may be redness, or some scaling, or the skin of the areola may be smooth and shiny. 5. not uncommonly will begin after a period of pain free nursing. This characteristic alone is reason enough to try treatment for Candida. However, milk blisters on the nipple also may cause nipple pain after a period of pain free nursing as may eczema or other skin condition. 6. may be associated with recent use of antibiotics by the baby or mother, but not necessarily. 7. may be quite severe, may or may not be itchy. 8. may occur only in the breast. This pain is often described as "shooting", or "burning" in nature, and is often worse after the feeding is over. It is often said to be worse at night. At the same time, the breast appears or feels normal. This is not mastitis and there is no reason to treat with antibiotics. On the contrary, antibiotics may make the problem worse. Please Note: a) The baby does not have to have thrush in his mouth. b) A Candidal infection of the nipple may be combined with other causes of soreness. Using Gentian Violet We believe that gentian violet (combined with "all purpose nipple ointment", see Treatments for Problems handout #24) is the best treatment of nipple soreness due to Candida albicans for the breastfeeding mother. This is because it works almost always, and relief is rapid. It is messy, and will stain clothing (actually, it usually will wash out), but not skin. The baby's lips will turn purple, but the purple will disappear after a few days. Gentian violet is available without prescription but is not available at all pharmacies. Call around before going out to get it. 1) About 10 ml (two teaspoons) of gentian violet is more than enough for an entire treatment. 2) Many mothers prefer doing the treatment just before bed so that they can keep their nipples exposed and not worry about staining their clothing. The baby should be undressed to his diaper, and the mother should be uncovered from the waist up. Gentian violet is messy. 3) Dip an clean ear swab (Q-tip) into the gentian violet. 4) Put the purple end of the ear swab into the baby's mouth and let him suck on the swab for a few seconds. The gentian violet usually spreads around the mouth quickly. If it does not, paint the inside of the mouth to cover as much of the inside of the cheeks and tongue as possible. 5) Put the baby to the breast. In this way, both the baby's mouth and your nipple are treated. 6) If, at the end of the feeding, you have a baby with a purple mouth, and two purple nipples, there is nothing more to do. If only one nipple is purple, paint the other one with the ear swab and the gentian violet. In this way, the treatment is finished in one go. 7) Repeat the treatment each day for three or four days (see handout Candida Protocol for how long to use gentian violet). 8) There is often some relief within hours of the first treatment, and the pain is usually gone or virtually gone by the third day. If it is not, it is unlikely that Candida was the problem, though it seems Candida albicans is starting to show some resistance to gentian violet, as it already has to other antifungal agents. Of course, there may be more than one cause of nipple pain, but after three days the contribution to your pain caused by Candida albicans should be gone. However, if your pain is virtually gone after 3 or 4 days, but not completely, you can use gentian violet a few more days if necessary. 9) All artificial nipples that the baby uses should be boiled daily during the treatment, or well covered with gentian violet. Consider stopping artificial nipples. 10) There is no need to treat just because the baby has thrush in his mouth. The reason to treat is the mother's and/or the baby's discomfort. Babies, however, do not commonly seem to be bothered by thrush. 11) Uncommonly, babies who are treated with gentian violet develop sores in the mouth which may cause them to reject the breast. If this occurs, or if the baby is irritable while nursing, stop the gentian violet immediately, and contact the clinic. The sores clear up within 24 hours and the baby returns to feeding. If the infection recurs, treatment can be repeated as above. But if the infection recurs a third time, a source of reinfection should be sought out. The source may be the mother who may be a carrier for the yeast (but may have no sign of infection elsewhere), or from artificial nipples the baby puts in his mouth. Treatment of the mother (usually with a medication other than gentian violet) at the same time as treatment is repeated for the nipples will usually eliminate reinfection. Contact the clinic. Questions? (416) 813-5757 (option 3) or [email protected] Handout #6. Using Gentian Violet Revised January 2000 Written by Jack Newman, MD, FRCPC May be copied and distributed without further permission |
| USING GENTIAN VIOLET FOR YEAST |
| Fluconazole (Diflucan�) is a synthetic antifungal agent which can be used for the treatment of a variety of Candida albicans infections. For the breastfeeding mother in particular, it can be used to treat recurrent Candida infections of the nipples, and, if such an thing exists, as I believe it does, Candida infections of the milk ducts. Candida (yeast) infections of the nipple and ducts Candida infections of the nipples may occur any time while the mother is breastfeeding. Candida albicans likes warm, moist, dark areas. It lives normally on us, and 90% of babies are colonised by it within a few hours of birth. It only becomes a problem under certain circumstances. Candida infections of the skin or mucous membranes are more likely to occur when there is a breakdown in the integrity of the skin or mucous membrane�another reason why a good latch is very important from the very first day. Many Candida infections would, perhaps, not have occurred, if the mother had not had sore nipples and a breakdown of the skin of the nipples and areola. The oozing of serum which occurs often in cracked nipples turns Candida albicans from its harmless form to a disease causing form. The widespread use of antibiotics also encourages the overgrowth of Candida albicans. Many pregnant women, women in labour, and new mothers, as well as their babies receive antibiotics, sometimes with very little justification. Diagnosis of Candida infections of the nipples and/or ducts There is no good test which helps makes the diagnosis. A positive culture from the nipple(s) proves little. Neither does a negative culture. The best way to make a diagnosis is by history. The presence or absence of a Candida infection in the baby is not helpful. A baby may have thrush all over his mouth, but the mother have no pain. A mother may have the classic symptoms of a Candida infection of the nipples, and the baby have no thrush or diaper rash. The typical symptoms of a Candida infection of the nipples are: Nipple pain which begins after a period of pain free nursing. Though there are a few other causes of nipple pain which begin later, Candida infection is definitely the most common. The nipple pain of Candida may begin without an interval of pain free nursing, however. Burning nipple pain which continues throughout the feeding, sometimes continuing after the feeding is over. Pain in the breast which is "shooting" or "burning" in nature and which goes through to the mother�s back and shoulder. This pain is usually worse toward the end of the feeding, and worsens still more after the feeding is over. It also tends to be much worse at night. This pain may occur without any nipple pain. Pain, as above, which is made much better with the use of gentian violet. Treating Candida Infections Our first approach to treating these infections is gentian violet (handout #6 Using Gentian Violet) plus all purpose nipple ointment (handout #24 Treatments for Problems). This approach is safe, works rapidly, and almost always, though there seems to have been a decrease in the effectiveness of gentian violet over the past few years. For this reason, I now use a combination. A good response to gentian violet confirms that the mother�s nipple pain is caused by Candida since little else will respond to gentian violet. It thus also justifies the use of fluconazole, if needed. Fluconazole Fluconazole is an antifungal agent which is taken systemically (taken by mouth or intravenously). It is fungistatic, which means that it stops fungi (such as Candida albicans) from multiplying, but does not actually kill them. This accounts for the fact that sometimes it takes several days to have an effect. Side Effects Fluconazole is generally well tolerated, but there is no such thing as a drug which never has side effects. Concern about liver injury is exaggerated, since this complication seems quite rare, and usually occurs in people who are taking other medications as well, and who have taken fluconazole for months or longer, and who have immune deficiencies. But it is a possibility that needs to be kept in mind and if it does occur, it can be very serious. Vomiting, diarrhea, abdominal pain and skin rashes are the most common side effects. These are not usually severe, and only occasionally is it necessary to stop the medication because of these side effects. Allergic reactions are possible but uncommon. Call immediately if you have any concerns. Fluconazole in the milk Fluconazole does appear in the milk, and this is as it should be, since the idea is to treat infection in the ducts and nipples. It is thus superior to ketoconazole, which gets into the milk in only tiny amounts. The baby will obviously get some, but this drug is now being promoted for use in babies for the treatment of simple thrush. There have been no complications in the baby reported from exposure to fluconazole in the breastmilk. Continue breastfeeding while taking fluconazole, though you may be told you cannot. Dose of fluconazole Candida albicans is learning to become resistant to fluconazole, and the dose we use has increased over the past few years. Only a few years ago, 100 mg daily for 10 days cured 90% of women of their symptoms. We have now found this to be inadequate. For resistant cases, a newer antifungal agent, itraconazole, can be used, though it may not be the answer either, as it does not have a very powerful effect against Candida. Your prescription will be for fluconazole 400 mg as a first dose, followed by 100 mg twice daily for at least two weeks. If you have nipple pain continue with the "all purpose nipple ointment" while you are taking fluconazole. We like the mother to be symptom free for at least a week before stopping the medication. This seems, on the basis of our experience, a fairly good guarantee against relapse. However, this means that although most mothers require only the usual two weeks, some need longer treatment. Occasionally it may take up to a week for the pain to even start going away. Call if there is no relief in seven days. It is sometimes useful to treat the baby as well. The dose for the baby would be 6 mg/kg as a first dose, followed by 3 mg/kg/day as one dose for the same period of time as the mother. Questions? (416) 813-5757 (option 3) or [email protected] Handout #20 Fluconazole. Revised January 2000 Written by Jack Newman, MD, FRCPC May be copied and distributed without further permission |
| DIFLUCAN FOR YEAST |
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