Nipple yeast infection

What is a nipple yeast infection?

There are many types of yeast, including one group called Candida. It lives on us and in us, generally without causing disease. Candida prefers damp areas like the vagina, gut, folds of the skin, and the mouths and bums of babies. Many breastfeeding women have it on their nipples and areolas and occasionally it invades the skin causing a condition called mammary candidiasis or nipple yeast infection. This is painful and requires treatment. It can also invade the mouths of babies causing an infection called thrush. This increases the risk of nipple yeast infection and should be treated. Nipple yeast infection is diagnosed when mothers feel characteristic pain and have certain changes in the skin of the areola.  

A) Describing Candida

A typical nipple yeast infection with cracks at the nipple bottom. (The white spot on the nipple is milk.)

1) Candida 

Various types of organisms can infect us, including:

  • Bacteria
  • Viruses
  • Fungi
  • Parasites

The fungus group contains three main members:

  • Mould
  • Mushrooms
  • Yeast

There are about 1,500 yeast species, including the Candida group which has more than 150 species.

2) Colonization with Candida

Candida lives on and in us, generally without causing disease. The medical term for this is colonization. Candida prefers areas that are damp, including:

  • The vagina and genital area
  • The gut
  • Folds of the skin
  • Mouths and bums of babies

One common member of the group is Candida albicans (C. albicans), which is present in or on 30-60% of us (Moran 2012). It is one of the many microbes in the gut (the gut microbiome) (Sam 2017). It is estimated that 20% of women have C. albicans in the vagina (Drell 2013; Sobel 2007). 

Candida is found in breast milk but the results of studies on how often it is present vary with the type of testing (Mutschlechner 2016). One recent study (Moossavi 2020) found that 20% of breast milk samples tested had fungi and of those, 60% had Candida species.

3) Disease caused by candida infection

Most Candida species are harmless, but 15 can infect humans and 6, are the most common offenders. C. albicansis is the most common cause of Candida infection, but other Candida species have caused an increasing number of infections over recent decades (Quindós 2014; Yapar 2014). 

Infection rates by different Candida species vary around the world (Quindós 2014; Wang et al. 2016).

Individuals with a weakened immune system, such as premature babies, can develop a generalized infection (sepsis) with Candida but most infections are local and involve the skin and vagina.

B) Describing nipple yeast infections

In addition to being in breast milk, about one-third of breastfeeding women have Candida on the skin of the nipple (Amir 2013; Zöllner 2003). Given the right conditions, it can invade the skin causing mammary candidiasis or nipple yeast infection. C. albicans is the most common cause of nipple yeast infection (Amir 2013).

Mothers with nipple yeast infections tend to have characteristic patterns of pain and skin changes on the central areola and where the nipple meets the areola (the nipple bottom). It does not generally involve the nipple.  

Some mothers with nipple yeast infections feel shooting breast pains, which has been thought to be caused by Candida growing in the milk ducts. However, the pain may be referred pain from infected areolas and nipples (Hale 2009).  

Nipple yeast infection requires effective treatment.

There are ways of preventing nipple yeast infection.

Breast milk that was expressed before treatment for nipple yeast infection should not be thrown out. It is perfectly good to use.

C) Why Candida infects mothers and babies

Nipple yeast infection does not develop in healthy women who are not breastfeeding. Breastfeeding creates the right conditions to allow Candida to turn from colonization to infection. 

1) Moisture

Candida grows better in moist conditions, which are found when nipples and areolas are wet from leaked milk and the baby’s saliva. Bras and breast pads can trap the moisture.

2) Lowered skin defences

Breastfeeding and expressing can traumatize or damage nipples and areolas, making the skin a less effective barrier to infection.

3) Conditions in the baby’s mouth

Studies have found that between 5% and 65% of babies under the age of one year have Candida in their mouths (Al-Rusan 2017; Issa 2011; Stecksén-Blicks 2015; Yilmaz 2011; Zöllner 2003). Babies also have a slightly weaker immune system than adults. These factors combine to make babies more susceptible to a Candida infection of the mouth. This is called thrush. It increases the risk of nipple yeast infection and should be treated.

4) Other factors

Other individual factors make nipple yeast infections more likely.

D) Diagnosing nipple yeast infection

The diagnosis of nipple yeast infections is made based on the type of pain mothers feel and the changes in the appearance of the central areola and the nipple bottom. It is especially common if their baby has thrush.

Mothers who have a particularly severe nipple yeast infection or one that is not settling with treatment may have other health problems. It is also possible that the diagnosis is wrong.

Laboratory testing is not all that helpful. Some of the challenges to testing include (Amir 2013; Mutschlechner 2016):

  • It is not uncommon to find Candida on the nipples and in the milk of mothers who do not have yeast infections.
  • The most common test for infection (culture) can’t detect Candida very well in breast milk.
  • An ingredient in breast milk (lactoferrin) can prevent the growth of Candida in a culture (Morrill 2003).
  • More sensitive tests can be costly.

Please discuss the diagnosis and treatment of nipple yeast with your health-care providers.

E) The popularity of the nipple yeast diagnosis

Breastfeeding is subject to fads. Nipple yeast infection diagnoses became extremely popular in the early 2000s. At the time, many mothers and babies were given unnecessary medications and mothers agonized over their diets and wasted many hours ”sterilizing” their homes. Over diagnosing it remains a concern (Betts 2021).  

Interestingly, in the past 25 years in our clinic, while many mothers continue to worry about nipple yeast infections, we have seen a steady decline in the number of mothers with actual infections. This may be due to the availability of antifungal cream without prescription, allowing mothers to self-treat.

References

Al-Rusan RM, Darwazeh AM, Lataifeh IM. The relationship of Candida colonization of the oral and vaginal mucosae of mothers and oral mucosae of their newborns at birth. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017;123(4):459–63
 
Amir LH, Donath SM, Garland SM, et al. Does Candida and/or Staphylococcus play a role in nipple and breast pain in lactation? A cohort study in Melbourne, Australia. BMJ Open. 2013 Mar 9;3(3)

Betts RC, Johnson HM, Eglash A, et al. It's Not Yeast: Retrospective Cohort Study of Lactating Women with Persistent Nipple and Breast Pain. Breastfeed Med. 2021 Apr;16(4):318-324

Drell T, Lillsaar T, Tummeleht L, et al. Characterization of the vaginal micro- and mycobiome in asymptomatic reproductive-age Estonian women. PLoS One. 2013;8(1):e54379

Hale TW, Bateman TL, Finkelman MA, et al. The absence of Candida albicans in milk samples of women with clinical symptoms of ductal candidiasis. Breastfeed Med. 2009 Jun;4(2):57-61
 
Issa SY, Badran EF, Aqel KF, et al. Epidemiological characteristics of Candida species colonizing oral and rectal sites of Jordanian infants. BMC Pediatr. 2011 Sep 9;11:79

Moossavi S, Fehr K, Derakhshani H, et al. Human milk fungi: environmental determinants and inter-kingdom associations with milk bacteria in the CHILD Cohort Study. BMC Microbiol. 2020 Jun 5;20(1):146 

Moran G, Coleman D, Sullivan D. An introduction to the medically important Candida species. In Candida and Candidiasis, 2nd Edition, Calderone RA, Clancy CJ (eds.) 2012; Washington, DC: ASM Press

Morrill JF, Pappagianis D, Heinig MJ, et al. Detecting Candida albicans in human milk. J Clin Microbiol. 2003 Jan;41(1):475-8 

Mutschlechner W, Karall D, Hartmann C, et al. Mammary candidiasis: molecular-based detection of Candida species in human milk samples. Eur J Clin Microbiol Infect Dis. 2016 Aug;35(8):1309-13
 
Quindós G. Epidemiology of candidaemia and invasive candidiasis. A changing face. Rev Iberoam Micol. 2014 Jan-Mar;31(1):42-8
 
Sam QH, Chang MW, Chai LY. The Fungal Mycobiome and Its Interaction with Gut Bacteria in the Host. Int J Mol Sci. 2017 Feb 4;18(2). pii: E330
 
Sobel JD. Vulvovaginal candidosis. Lancet 2007;369:1961-71
 
Stecksén-Blicks C, Granström E, Silfverdal SA, et al. Prevalence of oral Candida in the first year of life. Mycoses. 2015;58(9):550–6
 
Wang H, Xu YC, Hsueh PR. Epidemiology of candidemia and antifungal susceptibility in invasive Candida species in the Asia-Pacific region. Future Microbiol. 2016 Oct;11:1461-1477
 
Yapar N. Epidemiology and risk factors for invasive candidiasis. Ther Clin Risk Manag. 2014 Feb 13;10:95-105
 
Yilmaz AE, Gorpelioglu C, Sarifakioglu E, et al. Prevalence of oral mucosal lesions from birth to two years. Niger J Clin Pract. 2011;14(3):349–53
 
Zöllner MS, Jorge AO.  Candida spp. occurrence in oral cavities of breastfeeding infants and in their mothers' mouths and breasts. Pesqui Odontol Bras. 2003;17(2):151–5