Nipple pain is caused by two major things: a poor latch and a bacteria called
staph aureus. Other things can cause pain: vasospasm (or a constriction of
the blood vessels of the nipple), Reynaud's phenomenon (where the nipple turns
white, red, then blue) , pump trauma, certain skin conditions, tongue-tie,
pregnancy, and other infections, like yeast. It's not meant to be an
all-inclusive list, but you get the idea. Lots of things cause pain.
we do know , from lots of studies, that the vast majority of pain is due to a
poor latch (and probably vasospasm after the latch is fixed ) and staph aureus.
And the staph can't get there unless the skin is broken and the nipple is
injured, so back to the latch. The point is, bacteria are much more common as a
cause of nipple pain. But we blame yeast for everything.
When nipples are injured from a poor latch the nipple gets itchy as it heals.
And vasospasm (constriction of the blood vessel) happens inappropriately because
that injured nipple tissue is a little stupid as it heals. That hurts.
And it's likely the culprit for the deep breast pain women experience after bad
a little on yeast. The typical symptoms described for yeast are redness,
itching and burning of the nipples and shooting pain in the breast. The
diagnosis is made by looking at the nipple and correlating it with symptoms. No
culture is done and if it was, it's probably useless. Lactoferrin in human
milk makes culturing yeast from milk very difficult unless the right technique
is used. And you have to culture nipples very carefully and interpret the
results carefully. Many studies have shown that women with no nipple pain
will often grow yeast on a skin culture. It also doesn't "invade" tissues; in
normal people it stays on the surface of tissues. That's why the diagnosis of "ductal
yeast" has never made sense to me. The yeast would have to invade to cause that
pain. Dr. Hale's study (below) calls into very serious question whether ductal
Yeast is found naturally in everyone's GI tract, and helps with the health of
the GI tract. If you culture random people, you can get Candida (which
I'm going to continue to call yeast) from the mouth of 31-55% of them. Yeast is
everywhere. It only becomes a disease -causing agent when something else is
wrong. For example, you got antibiotics and killed the good bacteria in
your gut. When there are less good bacteria to balance the amount of
yeast, the yeast "overgrow" and have a party. Yeast can also go from
benign to pathogen if you have HIV, are receiving chemo or have otherwise really, really messed up your immune
terms of treatment, there are no ("gold-standard"
)randomized controlled trials. Fluconazole (Diflucan) is often used, and
can cause blood vessel constriction and make vasospasm symptoms worse.
Expert opinion says treat mom and baby even if one has no symptoms, but again,
no data supports that practice. Sounds messy to me and maybe we should know we
are treating yeast before we actually treat it. Because if we treat yeast and
it isn't yeast, we are keeping that mother in pain unnecessarily. And pain
causes weaning. We need to get this right, for the sake of the dyad.
haven't treated yeast for nipple pain in ages in my own practice because I know
(and hopefully you do too now) that the overwhelming causes of nipple pain are
related to poor latch and staph. I use Mupirocin (Bactroban) for the
staph and fix the latch. What frustrates and saddens me are the stories
from women I care for who come to see me because of their history
of "resistant yeast" and the failure of numerous courses of yeast-treating things
with no relief. They have been suffering. How many times do we need to treat the same thing before
we begin to think we have the wrong diagnosis? (To
compare with other yeast infections, for example, vaginal yeast infections are
often treated with one to three days of Diflucan. Why would a nipple need
months of treatment?)
my practice, these "yeast" symptoms are often oversupply, where the baby bites and pulls
back, injuring the nipple. Some are missed, significant tongue-ties. I've
diagnosed more than a few women with Reynaud's phenomenon. I've seen pump
trauma, usually from incorrect use (too high of a suction) or an old motor (too
low of suction) - that resolves with a new or no pump. I've found a few
pregnancies (much to the surprise of the mom...eek.) One mother was
pumping in her car in January and I'm pretty sure her "yeast" was frostbite.
not saying nipple yeast doesn't exist. But it shouldn't be our first or
or even second guess.
hope you can access this study from Dr. Hale because it's excellent: http://www.liebertonline.com/doi/pdfplus/10.1089/bfm.2008.0144
Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM