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, 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 membraneóanother 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
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
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
- Pain in the breast which is "shooting"
and which goes through to the motherís 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).
It is safe, works rapidly, and almost always, though there seems
to have been a decrease in its effectiveness over the past few years.
A good response to gentian violet confirms that the motherís 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 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
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.
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
Your prescription will be for fluconazole
200 mg as a first dose, followed by 100 mg twice daily for at least
two weeks. 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.
Note: The motherís 2 week prescription
is likely to cost between $300 and $350.
Handout #20. Fluconazole
(Diflucan). Revised January 1998
Written by Jack Newman, MD, FRCPC
This page's content (NOT its design) may be copied and distributed
without further permission.