"I have stabbing pain between breastfeeds. Is it thrush?" The case of Emily and her 3-month-old baby

What’s been happening with Emily’s breastfeeding?

Emily tells me: “My nipples still hurt, and I’ve had a stabbing pain in my breast between feeds for the last two weeks. Both my nipples are pink and shiny with little white flakes of skin. I’m sure the thrush has come back!”

Her firstborn is now three months old, and she’s endured nipple pain from the very beginning.

“The obstetrician told me it was normal to have nipple pain for the first twenty seconds of a breastfeed, and that I should just count and breathe through it,” she says.

Emily was given different fit and hold (or ‘latch and positioning’) advice from every midwife she saw, both in the hospital and when they visited her at home. For the first eight weeks Emily used nipple shields and pumped her breast milk whenever the pain was too great to feed even with shields.

When the baby was four weeks old, a GP advised Emily to apply miconazole oral gel on her nipples every four hours for a week. The GP also prescribed fluconazole 150 mg orally every second day for six doses. The baby was prescribed nystatin drops 1ml four times daily for a week, then once a day for another seven days. Emily wondered if the pain was improving for a time – but then it seemed to become even worse.

Emily is very committed to breastfeeding her baby. She has already consulted with three International Board Certified Lactation Consultants. Two said that the baby’s latch and positioning was fine; the third recommended that she use the ‘biological nurturing’ or ‘baby-led’ approach, with the baby straddled across her thigh or diagonally across her tummy as she leaned back. Unfortunately this made the pain worse and the baby began to fuss during feeds, so she stopped. One of the lactation consultants referred the baby to a dentist at six weeks, who performed a laser frenotomy for the diagnosis ‘posterior tongue tie’, after which the baby went on a 48-hour feeding strike.

“But once he would breastfeed again, nothing much else changed,” Emily explained. Nevertheless, she diligently stretched open the wound under his tongue three times a day for three weeks, as she’d been instructed.

Another lactation consultant advised Emily to take her baby to an osteopath every week, which she still does. She really likes the osteopath, who is caring and spends a lot of time with her. The osteopath taught Emily to perform various stroking and massaging exercises on the baby’s face, inside the mouth, and under his little tongue. Emily was also taught to perform movement exercises of her baby’s body and limbs, which the osteopath said would help with his sucking action.

Despite all this, her nipple pain persists.

“I’ve come in for more thrush treatment,” she says. “I’m willing to give it one more go.” Then she says with tears in her eyes: “But if it doesn’t work, I think I am going to have to stop breastfeeding. It’s awful having pain all the time! I just can’t keep going like this ….”

Pink nipples with fine white flakes of skin and stabbing breast pain between feeds are not diagnostic of mammary candidiasis

Emily hasn’t been using an antibiotic or topical steroids. Her baby remains exclusively breastfed, settled, and is gaining weight well. The pain with feeding has eased somewhat, though there is often some stinging. But a burning radiating pain from the nipples into the breast between feeds continues to cause Emily distress.

Emily agrees to allow me to examine her breasts and nipples. She removes her bra and breast pads, and winces as she removes the hydrogel discs she’d applied that morning.

“I do try to go without a bra sometimes at home, under a soft cotton shirt,” she says. “And I don’t wear a bra at night.”

“Trying to keep the nipples dry is best!” I respond. “Even hydrogel pads can make the nipple more prone to inflammation and damage because they keep the nipple moist, so we have to use them sparingly.”

There is nothing to find on breast examination, other than the generalised lumpiness of a lactating breast, and no enlarged lymph nodes in her armpits. Both Emily’s nipples are inflamed, without visible cracks or wounds. I note a few fine white flakes of skin on each.

“Is it thrush?” she asks.

I take a deep breath. “No, I don’t believe that you are experiencing a thrush infection,” I reply kindly.

“But shouldn’t we take a swab to be sure?” she asks tentatively.

“I honestly don’t think that will help us,” I say carefully, “because the truth is that Candida albicans occurs normally in any skin microbiome, including on the nipples – it will often show up on a swab, but that doesn’t mean it is causing you breast or nipple pain.”

“But what are those white flakes? Isn’t that thrush? And the shiny pink colour?”

“The white flakes result from what we call hyperkeratosis. That’s an overproduction and shedding of the outer keratin layer in the epithelium, which happens when there is ongoing inflammation. The shiny pink colour again tells us there is persisting inflammation, which is very important for you and me to attend to. But it’s not a sign of thrush, despite what you hear! Same with the stabbing breast pain between feeds – an awful thing to be experiencing, and a sign that we need to address the inflammatory process in both the skin and the tissue in the core of the nipple. But not a sign of breast thrush.”

“But I know women who’ve been taking treatments for thrush for weeks and weeks!”

I nod. “We used to think that the symptoms you describe were due to Candida. But now we know that Candida is found in a woman’s breastmilk and on her nipple and areola, regardless of whether she has pain or not. Breastfeeding mothers experience pain related to ongoing microtrauma of the nipple in various ways, including stabbing breast pain between feeds, but this doesn’t point to thrush.

“The problem with using medications which aren’t absolutely necessary is that the gel or cream on your nipple can make the nipple even more vulnerable to damage, because the application unnecessarily hydrates the skin.”

With Emily’s consent I perform an oral examination on the baby. The little one’s mucosa is clear.

“We don’t need to treat your baby’s mouth with antifungals unless there are visible white plaques from a true thrush infection.”

“My baby has a nappy rash though, and I am also prone to vaginal thrush. That’s why the midwives thought I should get the treatment for nipple thrush,” Emily says uncertainly, trying to make sense of all the different recommendations she’s received.

“There is in fact no connection between your baby’s nappy rash, or your own vaginal thrush infections, and your nipple pain,” I explain gently. “I know everyone says that, but it misunderstands human microbiomes."

Then I say: "This whole situation is awful. You've done all that any woman could - you've tried so much. But would you let me watch a feed? I know it sounds crazy, since you've been told Emily's latch is fine, and you've had the frenotomy - but I'm thinking this could be my best way of making a difference. Would that be ok?"

Emily looks at me doubtfully, but agrees. Both her nipples are visibly inflamed. And when she puts her little one on, with a wince and some deep breathing, it's immediately apparent to me that her nipples have been enduring repetitive micro-trauma from nipple and breast tissue drag.

We get to work.

November 2022

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