Thrush – Yeast – Candida

Thrush is a common diagnosis when mom is experiencing nipple pain. Thrush is an overgrowth of a yeast that lives on the skin and in the gut of healthy humans. Thrush may also be referred to as candida albicans.

How Common is Nipple Thrush?

If you ask a group of moms, they’ll tell you thrush or yeast is very common. If you look at the research, a very different picture emerges. Mothers frequently complain of burning nipple pain, nipple damage, yellow or white discoloration in damaged areas of the nipple, sensations of heat or itching, and pain that radiates into the breast. These symptoms are then lumped together as thrush and treatment is prescribed often without a culture. Frequently, mom’s symptoms improve then return. Frequently, another round of anti-microbial treatment is begun.

The latest research on candida and breast yeast informs us that thrush is often the incorrect diagnosis. More women are shown to have staphylococcus aureus than candida, and not all women with one or both positive cultures have pain. In fact, only 15% of the study group experiencing nipple pain had yeast in the culture from swabbing the nipple. Even fewer, 9% had candida in the milk sample (Amir et al). Does ductal thrush even exist? Could it be something else?

Staph aureus has a white to golden color when present on the breast nipple. The common prescribed treatment for candida is miconazole or clotrimazole. Both of these drugs are effective in treating staph aureus as well as candida.

The largest common denominator in these studies on mothers experiencing nipple pain was nipple damage. Nipple damage is caused by a sub-optimal latch.

How Sub-optimal Latch is Misdiagnosed as Thrush

When a baby latches shallow to the breast and does not draw plenty of the areola into the mouth, the nipple is often exposed to inappropriate friction. The baby then must use the jaw and a clamping motion or bite to hold the nipple in the mouth. This can cause a very common condition called a vasospasm. The pressure from the poor latch causes an interruption of blood flow around the nipple. When blood flow returns to normal, a pain called a vasospam may occur. This pain can feel like shooting or burning pain in or around the nipple or deep into the breast. This pain can happen during, after, or between feeds. The solution for this pain is to fix the latch.

One contributing factor to shallow or clamp-down latch is a high arched palate in the nursing baby. These babies often have milk stains on the tongue because the tongue doesn’t rest against the hard palate and clear itself of milk. The milky tongue may look like thrush. Tongue-tie or ankyloglossia is another risk factor.

Sources:
Amir LH, Garland SM, Dennerstein L, Farish SJ: Candida albicans: is it associated
with nipple pain in lactating women? Gynecol ObstetInvest 41:30-34, 1995
Hale TW, Bateman TL, Finkelman MA, Berens PD. The absence of Candida albicans in milk samples of women with clinical symptoms of ductal candidiasis. Breastfeed Med 2009;4:57-61.
http://www.placerconferences.com/wp-content/uploads/2014/05/G.Why-Does-it-Hurt.pdf

What to Do if Your Culture Came Back Positive for Yeast

Medications: Your health care provider can prescribe medications for both you and your baby that are compatible with breastfeeding. Many mothers feel anxiety about medications and breastfeeding. Remember, your doctor prescribes medications because they have more benefits than risks. If you are interested in reading study data on breastfeeding and taking your prescriptions, contact the Infant Risk Center.
Pumping Guidelines: If your baby depends on pumped milk, keep feeding the pumped milk. If you engage in informal milk sharing, it is wise to take a break from donating until the yeast is cured. If you donate to a milk bank, contact the bank about the medications you are using to clear the infection. If you have an open system pump, be careful. Change the tubing completely. The tubing can’t be sterilized well and should be changed if there is thrush. If you have a closed system pump that is functioning properly, just sterilize the pump parts correctly after each time you pump.

Nursing Guidelines: It’s perfectly safe and beneficial to nurse through thrush. The direct mouth-to-breast nursing is a closed system and transfers antibodies and biochemicals back and forth. Infant saliva on the nipple actually helps change the make up of the milk to meet a babies unique immune needs. The living cells in the milk help fight the infection during the nursing process. The sucking also can help relieve some of the discomfort babies experience when baby also has thrush.

Nipple Care: Your health care provider will probably provide a nipple ointment that is anti-fungal. There are many on the market that are perfectly safe for your baby’s mouth. You may want to consider saline nipple soaks to ease the discomfort and facilitate healing any damage. Using disposable breast pads can reduce staining in your nursing bras and clothing from the ointment.

Laundry and Dishes: Many moms are worried their bras, cloth breast pads, and cloth diapers are harboring yeast. Contact your cloth diaper manufacturer for instructions on how to strip your diapers. Other fabrics can be soaked in vinegar for 24 hours then laundered normally. Pacifiers and bottle nipples can be sterilized daily.

This blog post is informational only and does not serve to diagnose or treat any condition. See your healthcare provider if you suspect a nipple infection.

 

Are My Breasts Empty?

Our lactation counselors are frequently told that the mother feels her breasts are empty or not full any more. This anxiety often causes mothers to end exclusive breastfeeding prematurely or begin supplementing with formula when it is not needed. One of the most common misconceptions about breastfeeding is that breasts, like tanks or bladders, fill and empty. Here are some facts about the way human lactation works to help nursing mothers understand what is going on in there.

Fact: Breasts contain glands, not bladders. Milk production is continuous.
Human milk is made by specialized cells called myoepithelial cells. Blood is supplied to these cells, and they turn blood into milk, drop by drop. The milk is continuously being produced by these cell as well as continuously reabsorbed into the blood stream. During periods of engorgement, the body tries to reabsorb the milk faster and slow down the production. When the baby is actively nursing or mom is actively pumping, the reabsorption is slower and production is faster. Breasts can never be empty until after the baby is fully weaned off breastfeeding.

Fact: Babies don’t take all of the available milk during nursing.
Using ultrasound, science has determined that babies take about 65% of the available milk in the breast during a feeding session. This is why pumping milk after feedings is recommended for mothers who are pumping and storing milk for future separations.

Fact: The more rapidly milk is removed from the breast, the more rapidly new milk is made.
When milk is being removed from the breast, the milk making hormone prolactin is highest. Frequency of nursing and pumping is key to making more milk. Women who “save up” or try to wait for the breast to feel full before nursing are actually lowering their prolactin levels. This is why supply and demand is the law for breastfeeding and making more milk. Moms who remove milk the most frequently will make the most breastmilk.

Fact: Even a hospital grade double electric breast pump cannot empty the breast.
Because milk making hormones peak during milk removal (nursing, pumping, or hand expression), the body will always rush to make more milk every time mom is pumping.

The Take Away

Continuous breastfeeding or breast milk removal is the key to high levels of milk production. If a mother is doubting her milk production capabilities, milk production is easily assessed by an LC at a home visit or office visit. LCs employ techniques like weighed feeds and latch assessments to determine how well the baby is “transferring” or getting enough milk. When in doubt, it is always better to nurse more and pump more. Supply and demand is the ruling principle of lactation. Feelings of fullness do not happen for all women who make a full milk supply. Feelings of fullness may come and go but do not indicate milk production levels or how well the baby is eating.

 

Gallery of Pumped Milk

Human milk changes color, texture, and composition throughout the day and as the baby ages. This gallery of milk is for informational purposes so mothers can feel confident that their milk still “looks good.”

Some important points on the look of pumped milk:
– The visible fat layer is not an indication of how much fat is in the milk. Human milk doesn’t fully separate when left standing.

– Human milk varies in fat content from 3-10% throughout the day.

– The color of milk can and will change

– Human milk is about 87% water. Watery looking milk is normal.

– Milk can look blue, white, or other colors. Diet and food coloring may impact the color of pumped milk.

– Separation of milk is not an indicator that the milk is spoiled. Separation is normal.

 

Our gallery is growing! If you’d like to submit a photo of your pumped milk, please include the age of your baby (or babies for twin and tandem nursing moms) and time of day you pumped to milkmakingmom [at] gmail.com

We will keep your identifying information confidential.

This gallery is for informational purposes only and is not meant to treat or diagnose any condition. It is our goal to showcase the wide range of milk pumping experiences.

 

This is refrigerated milk that a tandem nursing mother pumped on day 3 postpartum. She has heavy oversupply.

This is refrigerated milk that a tandem nursing mother pumped on day 3 postpartum. She has heavy oversupply.

Milk pumped after feeding 5 day old baby around midday.

Milk pumped after feeding 5 day old baby around midday.

This milk was pumped by a mom with oversupply at 3 days postpartum.

This milk was pumped by a mom with oversupply at 3 days postpartum.

This milk was pumped at work around 10:30am. Baby is 12 weeks old.

This milk was pumped at work around 10:30am. Baby is 12 weeks old.

This milk was pumped at 8:30AM. The baby is 4 months and 6 days old. The previous pumping session was  4:00AM. This mom pumps 6-8 times daily.

This milk was pumped at 8:30AM. The baby is 4 months and 6 days old. The previous pumping session was 4:00AM. This mom pumps 6-8 times daily.

This milk was pumped while the baby was nursing on the other side. The baby is 11 weeks old. The milk was pumped at 6:30am.

This milk was pumped while the baby was nursing on the other side. The baby is 11 weeks old. The milk was pumped at 6:30am.

What to Expect When Pumping

Expressing milk for your baby can be one of the most affirming or daunting tasks. Filling your pumping bottles to the max can be a real boost of confidence, but is that normal or optimal?

General recommendations for how to pump milk

1. A double electric pump is ideal for mothers who will be expressing milk frequently. (For more information on how to choose a pump, see Finding Your Perfect Pump)
2. A properly fitting flange (the horn or bell shaped piece that presses to the the breast) will be the most comfortable and ensure optimal milk expression
3. Pump both breast simultaneously for about 20 minutes.
4. Normal pump output is 2-4 ounces total from both breasts from one 20 minutes double pumping session.
5. Pump output is not an accurate gauge of milk production. Pumping is a developed skill that improves over time.

Getting a Good Fit

Fitting your pump flange can be a tricky process. Breasts change over time. It is completely normal for a mother to need to change flange sizes over the course of breastfeeding. Many pumps now come with a range of flange options or additional flanges that you can purchase separately. The best fitting flange at week 1 may not be as comfortable or effective at week 28. Human bodies are not symmetrical. It is normal to use different flange sizes for each breast.

Most women use trial and error for testing their flange fit. Learning to hand express milk can also help determine where on the areola the flange should rest for optimal pumping. The flange should be in contact with the same areas of the areola that a woman stimulates to hand express her milk. The flange should not rub the nipple. It should provide even pressure to the areola.

Tips for Double Pumping

Some women find it difficult to hold the pump flanges simultaneously. Pumping bras are easy to find at most baby product stores. They hold the pump flanges for you. This hands-free option means that working mothers may be able to do other tasks while pumping. A sports bra with holes cut in the cups can work in a pinch if you don’t have a pumping bra. Simply feed the flanges through small holes in the bra.

Normal Pump Output

The general understanding of pumped milk output is that 2-4 ounces is normal for both breasts combined. You may notice that one breast expresses significantly more milk than the other. You may notice that time of day influences how much milk you collect. It’s important to remember that pumping milk is not a predictable process, just like all things with parenting. Here is a list of common pumping experiences that cause mothers to worry about their milk supply though they are usually perfectly normal:

–¬† higher pump output in the mornings, lower pump output in the afternoons

– pump output that decreases over time as the baby ages (most women begin with oversupply that noramlizes between 6-12 weeks postpartum)

– one breast pumping a high volume, one breast pumping a low volume

– pump output decreases during menstruation and/or ovulation

– inability to pump the breast “empty,” milk continues to flow after the standard 20 minutes of pumping

– need for new flange sizes over time

– change in nipple shape over time

Blame the Pump First

Some women notice sudden changes in pump output. Always blame the machine before your breasts. Pumps have parts that are designed to be replaced during the course of time. Membranes and tubing are susceptible to small holes and degradation. If these parts are not at top shape, the pump will not work properly. Assembly errors (user errors) are also common. If your pump is not functioning, check  the pump first. Chances are mom is perfectly lactating and the pump needs a tune up. A good rule of thumb for open system breast pumps is to change the tubing every 2-3 months to avoid contamination and improve pump performance. The membranes on open systems pumps often function best when replaced monthly.

Top Tips for Improved Pump Output

1. Make sure the pump is in good working order, properly assembled, and properly fit to the breast

2. Pump in a relaxing environment to facilitate the strongest letdown response. Some mothers look at photos of their babies or watch films on their smart phone. Smelling an relaxing aromatherapy candle or even a “dirty” baby blanket can help some mothers.

3. Heat and massage the breasts before a pumping session. A microwave rice sock is easy to transport and can be tucked in your bra a few minutes before pumping. Rub the breasts all over in firm circular strokes.

4. Stimulate the nerves to the breasts. The thoracic spinal nerves that correspond to the breasts are T3, 4, and 5. They can be stimulated by rubbing your back against a door jamb. Think “bear scratching back on tree.” Or ask your partner to rub your spine a bit while you pump.

5. Drink a glass of water while you pump. It may help relax you and feel more in control of the process.

6. Hand express for about 5 minutes after pumping. Some women are able to express 50% more milk by hand after they pump. Remember, the breast is never truly empty until full weaning happens.

7. Make sure your baby is being fed appropriate amounts while you are away. 1-1.25 ounces is per hour of separation is the recommended amount. Many moms find their pump output is normal but the baby is being overfed. (more information see Bottle Feeding Human Milk)

8. Contact an LC to develop a pump routine that matches your pump output needs. Some mothers need an individualized plan because of workplace constraints or parenting demands.

Bottle Feeding Human Milk

Storage

Guidelines for storing human milk vary slightly depending on the resource you use. This article cites the recommendations from La Leche League International (as posted in the web FAQ) and the Centers for Disease Control website on breastfeeding. Mothers should be encouraged to test their milk whenever they doubt its freshness by smell and taste. It’s impossible to discern freshness visually. Human milk has a wide range of normal colors. The separation of fat can vary greatly as well. When in doubt, throw it out.

On the counter: 4 hours according to LLLI, 6-8 hours according to CDC In a cooler on “blue ice” packs with packs in contact with milk containers: 24 hours according to CDC

In the refrigerator: 3-8 days according to LLLI, 5 days according to CDC
In the freezer (do not store milk in the freezer door. It will be exposed to more drastic temperature changes in the door compartment.): 6-12 months according to LLLI, 3-6 months according to CDC
In a sub zero “deep” freezer: 6-12 months according to CDC

For minimum waste, store milk in 2 ounce portions. Some mothers find storing in 1, 2, and 3 ounce portion gives them more flexibility and less waste.

Heating

Thaw frozen milk in the refrigerator or in a bowl of warm water. Do not microwave. Do not submerge in boiling water. Milk storage baggies are not designed to withstand high heat.

Milk that is thawed can be heated in the bottle in a bottle warmer or pan of warm water. Remember, the milk need only be heated to body temperature, not made hot.

Milk will naturally separate after expression. Swirl heated milk bottle gently to mix fat layer back into solution. Do not shake. Shaking puts bubbles in the milk making the flow out of the bottle less smooth. Bubbles may increase gas. Human milk contains fat chains of long and short lengths. Shaking may disrupt the fats.

 

Choosing a bottle and artificial nipple

A slow flow artificial nipple is ideal for the duration of breastfeeding. Babies who alternate between breast and bottle will continue with a slow flow nipple until they transition to a cup. Slow flow nipples will keep your baby bottle feeding on a pace more similar to the breast to make the transition back and forth easier.

No brand of artificial nipple creates a latch like breastfeeding despite marketing claims. In fact, advertising a teat this way is a violation of the World Health Organization’s international code of marketing breast-milk substitutes. There is no shape, material, or insert that is like a human breast. When choosing an artificial nipple, the one that is slow flow, able to be sanitized, non-allergenic, and agreeable to the baby is the right choice. What works for one family may not work for another.

Breastfed babies rarely have stomachs larger than 3-5 ounces, even at 6-9 months. When choosing a bottle, small bottles are sufficient. Large bottles of 6 ounce capacity or more are for formula feeding.

Many parents are concerned about chemicals in plastics. Many bottle companies now offer BPA free plastics. Glass bottles are also growing in popularity. Glass bottles now are on the market that have rubber sleeves to help prevent shattering. The type of bottle a family chooses is a personal decision.

Paced Bottle Feeding

1. Hold baby mostly upright. Babies cannot regulate the flow of a bottle when lying on their backs or reclined.
2. Hold bottle parallel to the floor. It’s okay if some air is in the tip of the nipple.
3. Place the tip of the nipple on the baby’s upper lip. Baby will open the mouth wide. Gently insert bottle nipple into the mouth completely. The baby’s lips should be flanged at the base of the nipple.
4. Let the baby drink 1 ounce. Gently tip the bottle down to give a rest break without breaking the latch. Babies are able to stop the flow of the breast easily. Gravity prevents babies from controlling the flow of a bottle the same way. These short breaks help the baby bottle feed more similarly to breastfeeding and give them a chance to cue fullness.
5. Feed a second ounce and provide a second break by removing the bottle nipple from the baby’s mouth.
6. If baby shows hunger cues, switch the baby to the other side of the body. Breastfed babies coordinate left-right because they are switched from side to side. The second half of the feed should be done with the care giver holding the baby on the opposite side.
7. Latch the baby to the bottle nipple and feed again just like instructions 1-4. Continue to feed ounce by ounce with breaks in between to allow baby to burp and cue fullness.
8. The baby should spend as much time at the bottle feed as he would at a breast feed.
9. Never encourage a baby to finish a bottle. Always follow cues of hunger and fullness. Scheduled feeds are not recommended by any health organization.

Why is pacing the feed so important?

Many mothers misjudge their milk supply due to incorrect bottle feeding. A baby held in a reclined position during a bottle feed will have milk flood the mouth due to gravity. Babies are smart. They will swallow the milk in order to protect their airway. They don’t want to aspirate the milk into their lungs. This is why many mothers report that their baby “sucked down” a bottle rapidly.

Babies bottle fed this way generally have an easier time feeding at both the breast and bottle. So called “nipple confusion” is decreased. Many babies will learn the flow differences of reclined bottle feeding and breastfeeding. These feeding methods use different facial muscles. Feeding at the breast is shown to provide optimal craniofacial development. Paced bottle feeding can help a baby enjoy the benefits of breastfeeding when mother and baby are together.

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