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Thrush in Breastfeeding Mothers and Babies Care Pathway Overview

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  • Pink/red shiny areola,
  • Permanent loss of colour in nipple,
  • Cracked nipples that do not heal,
  • White plaques on folds of nipple/areola skin,
  • Itchy nipples, sensitive to touch and cold temperatures,
  • Burning sensation in nipples,
  • Severe pain when infant attaches-worsening with each re-attachment, nipple pain that intensifies during breastfeeding and after feed, shooting pain after feeds.
  • Ductal thrush may present with persistent severe and burning pain-radiating throughout breast, typically after feeds.

  • Creamy white patches inside mouth, tongue, cheeks and lips which do not rub off easily. If rubbed off, the base is raw and may bleed.
  • A white sheen on Infant’s tongue/lips.
  • Infant restless during feed, pulls off/away from the breast, presents as unhappy or uncomfortable due to sore mouth.
  • Nappy rash, red spots, soreness to nappy area that does not heal. (Anal thrush presents as red shiny rash radiating outwards from anus- does not heal with nappy ointment) 
Differential Diagnosis
  • Sore nipples are the most common breastfeeding problem in the first few days after birth
    • Generally transient and resolves with proper positioning and latch on of the baby to the nipple
  • Persistent pain without improvement needs to be evaluated
    • Possible causes include;
      • Eczema of the areola and nipple
      • Raynaud’s syndrome of the nipple
      • Bacterial infection of the nipple – presents with red, inflamed, cracked nipples with or without exudate or fever
    • Note that on occasion, nipples with any one of these syndromes can also appear normal, which makes diagnosis challenging

Please also see the Breastfeeding Network guidance on differential diagnosis of breast pain. 

Initial Assessment

A full breastfeed should be observed prior to diagnosing thrush and/or commencing thrush treatment. This will usually be done by either the local midwife or health visitor prior to referral to the GP.

Effective positioning and attachement is crucial to ensure adequate milk production, milk transfer and breast health. This should be the primary concern when assessing any breastfeeding problems. Once effective positioning and attachment is confirmed then other causes of nipple pain can be considered.

If any breastfeeding difficulties are identified please refer to the Countywide Infant Feeding pathway.

Before a diagnosis of thrush is made, consider taking swabs of the mother’s nipples and of the baby’s mouth to detect bacterial or candida growth.

Guidelines for The Identification and Management of Candida Albicans (Thrush) in the Breastfeeding Mother and their baby - Gloucestershire Health and Care Services (GHC)

The guidelines aim to assist health practitioners with the accurate diagnosis and treatment of thrush in the breastfeeding mother and baby.

Please follow the resource link below to view.

Initial Primary Care Management

If any breastfeeding difficulties are identified please refer according to the Countywide Infant Feeding pathway.


Miconazole cream (Daktarin) 2% is 1st choice - applied sparingly to nipple after a feed - excess to be wiped not washed off and/or Hydrocortisone (Dactacort) 1% cream for inflamed nipples. Please see the BNF guidance on Miconazole dosage.

Deep breast pain may indicate Ductal Thrush - may require oral systemic treatment in addition to topical treatment - refer to GP.

Fluconazole is not licenced for breastfeeding mothers, however it is the preferred treatment for ductal thrush. Please see the BNF guidance on Fluconazole or the Breast Feeding Network Guidelines for dosing. Consent for treatment with a product "off-licence must be obtained from the mother before treatment is prescribed and be documented in the medical records. Mother can still breastfeed whilst taking fluconazole.

Paracetamol and Ibuprofen can be taken to relieve inflammation and pain.

Provide advice;

  • Washing hands carefully after nappy changes and using separate towels to help prevent the infection spreading.
  • Wash and sterilise any dummies, teats or toys the baby puts in their mouth.
  • Wash any breastfeeding bras at a high temperature and change breast pads frequently whilst being treated.
  • If expressing any breast milk while whilst being treated for thrush, ensure the patient gives the milk to the baby whilst still having treatment. Do not freeze to use at a later date
  • Probiotics e.g. Acidophilus can help restore ‘good bacteria’ to manage thrush. These can be purchased from health food shops or pharmacies.

Miconazole oral gel 2% - pea size amount applied with clean fingertip to all affected areas in infant’s mouth four times a day ("off-licence for infant less than 4 months old or 5-6 months if born preterm due to risk of choking). (Prescribing practitioners must ensure carers are aware of the correct method of application). Consent for treatment with a product "off-licence" must be obtained from the mother or carer before treatment is prescribed and be documented in the records. Please see the BNF guidance on Miconazole dosage.

Nystatin suspension 100,000units/ml 4 times a day- applied with clean fingertip to affected areas to ensure effective contact with oral mucosa.

Miconazole cream applied to nappy area

Please follow this link for information regarding Thrush and use of expressed breastmilk whilst having treatment which may be useful for patients.

Ongoing Primary Care

Follow up

Health visitor to arrange follow up within 1 week to review.

Signpost to Breastfeeding support in the Community and National Information Resources:

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