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Identifying and treating thrush in breastfeeding mothers and babies
When the Breastfeeding Network thrush leaflet1 was first written in 1995, there was little available information and the condition seemed rare. Many mothers are now diagnosed and treated for thrush, but identifying it can be far from straightforward and medication may offer an easier option than spending time to help a mother achieve pain-free attachment. However, exposing mother and baby to unnecessary topical or oral treatments is unethical and unfair, delaying resolution of the true cause and necessitating the prescriber to take responsibility for the use of the medicines often outside of their license application.
Research into incidence seems limited to anecdotal reports and small case studies, and some have questioned its existence.2 However, despite this controversy, practitioners must continue to provide care.
Is it thrush?
Thrush should be a diagnosis of exclusion and positioning and attachment should have been optimised by an experienced breastfeeding worker. It is identified by putting a full clinical picture together (see Boxes 1 and 2). Recognised symptoms include intense pain after a period of painfree breastfeeding, pain in both nipples or breasts, and pain after feeds or starting toward the end of the feed. It does not produce pyrexia in the mother or inflamed areas on the breast. It is important that symptoms are distinguished from those of inadequate attachment, characterised by pain on attachment, a misshapen nipple after feeds or never achieving pain-free feeds. Thrush often originates from attachment problems, resulting in mastitis antibiotic prescription (see Figure 1).
Other reasons for nipple pain include tongue tie, Raynaud's syndrome or vasoconstriction (often from poor attachment - look for flattened nipple after feeds and a temporary white tip). Ointment, cream or breast pad allergies can also make nipples flake and itch. For a differential diagnosis, certain questions should be considered.
When is the pain at its worst?
If before a feed or during the night, the breast may not be emptying properly and ducts may become over distended, also a symptom of unresolved engorgement. Improve attachment and feed frequently to drain both breasts effectively.
If during a feed and lasting for more than five seconds, it is likely that positioning and attachment are not as good as they could be....