ADJ+ / C-LA-FAM       Allaiter selon vos désirs

Attention, le recours au fluconazole signifie que vous souffrez d'une infection fongique "qui ne passe pas"; attention, il y a des candidoses ou infections fongiques qui ne sont pas des infections fongiques!!! et quand vous arrêtez l'anti-fongique, ça revient; du coup vous reprenez l'anti-fongique, ça calme; vous arrêtez, ça revient.... c'est peut-être autre chose que fongique!!

Version française - version anglaise 2009 ici en bas de page

Le fluconazole (Diflucan®, Triflucan®) est un fongicide synthétique qui peut être employé pour traiter le Candida albicans ainsi que d’autres infections aux champignons. Chez la mère allaitante en particulière, il peut être utilisé suivant d’autres interventions pour traiter une candidose récurrente des mamelons et, si une telle chose existe, comme je suis porté à le croire, une infection des seins au Candida. Dans le cas d’une mère qui a les mamelons douloureux, les mamelons doivent être premièrement traités sans ménagement et si le traitement est inefficace, alors le fluconazole est ajouté. La candidose des mamelons et des conduits lactifères  Une candidose des mamelons peut se produire n’importe quand pendant la période où une mère allaite. Ce champignon, le Candida albicans, aime les endroits chauds, humides et sombres. On le trouve normalement sur la peau et à d’autres endroits et 90% des bébés en sont colonisés en moins de quelques heures à la naissance. De même que plusieurs autres microbes, il devient un problème seulement dans certaines circonstances.  Les candidoses de la peau ou des muqueuses surviendront davantage dans les cas où la peau ou les muqueuses ne sont pas intactes. C’est une des raisons pour lesquelles une bonne prise du sein est très importante dès le premier jour. Il est probable que plusieurs candidoses ne se seraient pas produites si la mère n’avait pas eu de mamelons douloureux et sans une détérioration de la peau des mamelons et aréoles. Le liquide qui suinte souvent quand les mamelons sont gercés favorise le Candida albicans à passer de la forme inoffensive à une forme envahissante.  L’usage très répandu d’antibiotiques favorise aussi la croissance du Candida albicans. Plusieurs femmes enceintes, durant le travail et après l’accouchement ainsi que leur bébé reçoivent des antibiotiques, parfois sans raison suffisante.  Diagnostiquer une candidose des mamelons et/ou des conduits lactifères.  Aucun test ne peut aider à poser un diagnostic. La culture positive d’un prélèvement des mamelons ne confirme pas que la douleur est causée par le Candida albicans. Pas plus qu’une culture négative ne signifie que votre douleur ne peut être du au Candida albicans. La meilleure façon de diagnostiquer une candidose est d’obtenir une bonne histoire de cas.  Diagnostiquer la présence ou l’absence d’une infection au Candida albicans chez le bébé n’aide pas car il peut avoir du muguet plein la bouche sans que la mère n’ait de douleur. Une mère peut avoir les symptômes classiques d’une candidose des mamelons sans que son bébé ait de muguet ou d’érythème fessier.  Les symptômes caractéristiques de la candidose des mamelons sont :  1. La douleur des mamelons qui commence après une période d’allaitement sans douleur. Il y a pourtant quelques autres causes de douleur aux mamelons qui arrivent plus tard mais la candidose est définitivement la plus fréquente. Toutefois, la douleur aux mamelons due au Candida albicans peut commencer sans une période d’allaitement sans douleur préalable. 2. Une sensation de brûlure au mamelon qui continue pendant toute la durée de la tétée, même parfois après la fin de la tétée, quelquefois commençant au milieu d’une tétée pendant que le bébé boit toujours bien. 3. Une douleur lancinante et ardente dans le sein qui irradie dans le dos et l’épaule de la mère. Cette douleur est habituellement pire vers la fin de la tétée et encore pire après la tétée. La douleur a tendance à empirer pendant la nuit. Cette douleur dans le sein peut se produire sans aucune

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Version anglaise révisée 2009

Fluconazole (Diflucan™) is a synthetic antifungal agent that can be used for the treatment of Candida albicans and other fungal infections. For the breastfeeding mother in particular, it can be used after other first interventions to treat recurrent Candida infections of the nipples, and, if such a thing exists, as I believe it does, Candida infections of the breasts. If a mother has sore nipples, the nipples must be treated aggressively first and then is fluconazole (Diflucan) added if nipple treatment alone is unsuccessful.

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 normally lives on our skin and other areas, and 90% of babies are colonized by it within a few hours of birth. It, like many other germs that live on us normally, 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 membrane—one of the reasons 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 liquid that occurs often from cracked nipples encourages Candida albicans to change from its harmless form to an invasive form.

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 AND/OR DUCTS

There is no good test which helps makes the diagnosis. A positive culture from the nipple(s) does not prove your pain is due to Candida. Neither does a negative culture mean your pain is not due to Candida. The best way to make a diagnosis is by getting a good history.

Diagnosing 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 may have no pain. A mother may have the classic symptoms of a Candida infection of the nipples, and the baby may have no thrush or diaper rash.

THE TYPICAL SYMPTOMS OF A CANDIDA INFECTION OF THE NIPPLES ARE:

• Nipple pain that begins after a period of pain-free nursing. Though there are a few other causes of nipple pain that 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 that continues throughout the feeding, sometimes continuing after the feeding is over, sometimes beginning in the middle of a feeding as baby is still drinking well.
• Pain in the breast that is “shooting” or “burning” in nature and which goes through to the mother’s 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.

TREATING CANDIDA INFECTIONS OF THE NIPPLES

Our first approach to treating these infections is to apply the All Purpose Nipple Ointment (APNO) (see information sheet APNO). Next, the mother can add topical Grapefruit Seed Extract and/or Gentian Violet (information sheets Gentian Violet and Candida Protocol) if the ointment alone does not work. This approach is safe, works rapidly, and almost always, though there seems to have been a decrease in the effectiveness of gentian violet over the past few years. For this reason, we now use the combination of the ointment and the gentian violet as well as the grapefruit seed extract. A good response to gentian violet confirms that the mother’s nipple pain is caused by Candida since little else will respond to gentian violet. It thus also justifies the use of fluconazole, if needed. Even if the above treatment does not help, fluconazole should not be used alone to treat sore nipples and should be added to treatment on the nipples, not used instead. I have not found nystatin to be particularly useful either in treatment of the baby’s mouth or in the treatment of the mother’s nipples. Clotrimazole cream alone is also not particularly effective in my opinion, but others obviously feel differently.

FLUCONAZOLE FOR BREAST PAIN OR VERY RESISTANT NIPPLE PAIN

Fluconazole is an antifungal agent that is taken systemically (by mouth or intravenously). 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 an effect. Fluconazole powder is also available and can be mixed with the all purpose nipple ointment instead of miconazole powder.

Fluconazole tends to work best when used in conjunction with probiotics and oral grapefruit seed extract.

Side Effects

Fluconazole is generally well tolerated, but there is no such thing as a drug that never has side effects. Concern about liver injury is exaggerated, since this complication seems quite rare, 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 and if it does occur, it can be serious.

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 or email 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 breasts 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, even if you are told that you should stop.

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 be inadequate. For resistant cases, a newer antifungal agent, itraconazole, can be used, though it may not be the answer either as it does not have a very powerful effect against Candida.

Your prescription will be for fluconazole 400 mg as a first dose, followed by 100 mg twice daily until you are pain free for a full week, which usually means at least two weeks. This seems, on the basis of our experience, a fairly good guarantee against relapse. If you have nipple pain continue with the “all purpose nipple ointment” (± gentian violet and grapefruit seed extract) while you are taking fluconazole. However, this means that although most mothers require only the usual two weeks, some need longer treatment. Occasionally it may take up to seven to ten days for the pain to even start going away. Call if there is no relief in seven days. If there is no relief in 10 days, none at all, it is very unlikely fluconazole is going to be of any help. For very resistant cases we have used 100 mg 3x/day for 1 week.

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. Preferable is to treat the baby first with probiotics by mouth (see Information Sheet Candida Protocol). This is easy to do and fairly inexpensive. A small amount of probiotic powder placed on mother’s wet finger so baby will suck on it for a few seconds before a feeding 2x/day for 4-7 days is often adequate treatment for the baby with thrush.

Note: The mother’s two week prescription is likely to cost between $300 and $350, though there is now a generic fluconazole available which is less expensive.

The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.

This information sheet may be copied and distributed without further permission on the condition that it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!

©IBC, updated July 2009