Thursday, February 08, 2007

Damnable Yeast

In the sphere of birth and newborn care I am an optimist. Except. Except where yeast is concerned. Nothing rings the death knell of breastfeeding to me quite like a diagnosis of breast yeast.

Partly this stems from my own experience: five weeks of nystatin, Dr. Newman's nipple cream, diflucan, diet change, pumping and pain, pain, PAIN. The classic description of breast yeast pain is the sensation of crushed class in the breast. True, sister, true.

But back up. Where does yeast come from? We have it in our bodies always. When it becomes problematic, it's not a case of yeast colonizing a previous pristine body. Rather, it is an overabundance of yeast in its usual places and its appearance in places it might not ordinarily be. This can happen because of antibiotics administered in labor (or to the baby after labor). It can arise because hormones and fatigue and any other combinations of factors have one's whole system out of whack. In the baby, it often appears in the mouth (thrush), where the sugars of breast milk remain in a dark, warm environment. From baby's mouth to mother's nipple to the milk ducts inside.

So the acquisition of yeast is pretty easy, really. It's the bringing back into balance of it that is so difficult.

One of my biggest pet peeves is that health care providers so often fail to follow the first rule of yeast treatment: TREAT THE MOTHER AND THE BABY. I don't know how many times a mother has reported that her baby has thrush and when I ask is she being treated, too, get a blank look. If the baby has yeast and is being breastfed, the yeast is likely to travel from baby to mother.

Similarly, I know some women who have yeast but cannot get their pediatrician to prescribe a treatment for the baby because the baby is asymptomatic. How can one expect to clear the yeast from one's breasts if the baby who latches on to them 10 times a day is a repository for yeast-tainted milk?

The best results are often through family practice doctors. Because they care for both members of the breastfeeding team, their treatment is for the unit, not the parts. Though even then I've seen some family practice doctors treat only one half of the pair.

Once yeast is established in the milk ducts, it is very stubborn about leaving. Dr. Newman's diflucan protocol is a very hard-hitting systemic dose (because how do you get medicine just to the breast?):

"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. 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.

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."
This last point is an important one, too. At the time I was plagued with yeast, our insurance refused to cover the prescription because it was much higher than medically necessary. !!

And remember that for every feeding, for the duration of the feeding, through the weeks that this last-line treatment is underway, the pain is excruciating. Breasts feel as though they are being lanced from the inside out.

When my yeast infection hit, my son was five months old. He was nursing at 3 hour intervals during the day and not during the night. When yeast appears in new mothers (as it has in my most recent client), babies are often nursing every two hours round the clock. The pain of nursing leads to anxiety. Compound that with sleep deprivation and the situation often feels unbearable. To tell a woman that she may experience relief anywhere from 3-10 days after starting diflucan (if her doctor will even prescribe it) might result in her throwing a copy of "The Womanly Art of Breastfeeding" at your head. Chances are she's already been through several weeks of pain before the diflucan option is presented.

For many women in this position weaning is the only way out. That was my final decision. When the diflucan was too expensive (my husband was in grad school, after all), I began to eliminate feedings. Within a week things were much improved. At that point my son was nursing three times a day and getting formula for his remaining feedings. That was the routine we maintained until he abruptly self-weaned at 11 months.

All of that was fine with me. I'd have liked to breastfeed exclusively, but felt happy that I was still providing breastmilk three times a day. After all, he was already late in his infancy. Had he been 5 weeks old, I don't know what I'd have done. I actually think I'd have thrown in the towel sooner.

I'm crossing my fingers for my client. She's starting the diflucan routine and her baby is on the same medicine.

I realize this is a lot of posting space devoted, basically, to a rant. I just wish breast yeast was taken more seriously. I'd like to see research into managing it as well as more on-the-ball reactions from caregivers when they encounter it. Just as there are few true obstetric emergencies, there are also few real breastfeeding emergencies. In my mind the appearance of yeast, however modest, in either part of the breastfeeding team, is an emergency.

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11 Comments:

Anonymous Anonymous said...

Some moms find 2 visits to a tanning bed take care of it, along with treating the baby....

I know, skin cancer......but still.....I think more moms should consider the pink flamingo salon, they usually appreciate the success!

11:02 AM  
Blogger clara said...

I agree, it can be a disaster.

Giving the baby nystatin is ridiculous though b/c it has a sucrose base, which makes yeast jump for joy. The solution to my 3 mo battle with thrush was diflucan + olive oil on nipples(lineolic acid keeps yeast from multiplying) acidophilus powder in my mouth 3 x a day & bifidus powder in baby`s mouth 3 x a day. In a month or less, gone forever.

4:07 PM  
Anonymous Stephanie said...

I think (and I say this from my position of a 10 year IBCLC) that the reason that it isn't taken very seriously is because 9 times out of 10, it isn't serious. Most mums who get yeast infections report "burning", "tingling" "pinkness"...
Hardly an emergency. Doctors get used to seeing all of that manageable yeast (though still hard to kill) and think that the mum who is having an experience like yours is out of her mind and don't respond appropriately. (Remember, when you read my 9 out of 10 number, that many, many mums don't even seek treatment at all.)

My sister had ductal yeast and other than a wee wince at the beginning of a feed during her first let down, it never troubled her much. She managed the growth of the yeast with other means and went on to nurse my nephew for more than 18 months. Her neighbour? By all appearances, far less yeast, far MORE pain, catastrophic for the breastfeeding.

Doctors hate this sort of infection. It is easier to learn how to manage an infection that has the same effect on all patients. If one woman can have a minor infection that represents an emergency, and another woman can have a serious infection that she isn't even concerned about treating, it means that doctors have to trust and listen, and that's hard for them. (It's not evidence based.) Add to that the fact that unless your patient is immunocompromised that the yeast won't even kill them, and you have something Doctors don't care about.

What should be of great concern to all of us is the frequency with which we are seeing yeast infections, and how much trouble we are having dealing with them. It's an interesting thing to consider, seeing as how this was not a problem (according to the evidence we have now)causing women great pain and destroying breastfeeding relationships in centuries past - nor is it as endemic in other continents.
Gripping.

My sympathies to your BFing mum. Yeast can be really awful.

7:59 PM  
Anonymous naomi dagen bloom said...

fascinating to this grandmother! sending it on to another with breastfeeding DIL.

really wish there was someone my age writing about older women's health issues as you do. maybe you know someone? yours, naomi

12:01 PM  
Blogger S. said...

I still remember 6 years later, it felt like being stabbed with a knitting needle. Luckily for me, diflucan worked. But it was excruciating in the meantime.

11:15 PM  
Blogger Anne said...

As a random surfer on the internet who just stumbled onto your blog... thank you for your inisight. I have been suffering from ductal thrush since my daughter was a week old. She's 7 weeks now. We weren't treated at the same time, I wasn't given the right doseage of diflucan, etc etc. Since I was given smaller amounts of diflucan over a longer time, liver testing came back showing my liver was reacting badly to the third round they put me on, so now I am controlling the symptoms with acidophilus and diet change. If the symptoms get too bad, I am faced with the possibility of weaning a 2 month old!! And this is all because of a bunch of clueless doctors, and lactation consultants (who diagnosed my condition as being dermititus!!)

8:22 PM  
Blogger doulicia said...

Anne,

I'm so sorry! I feel your frustration. You might check in with a La Leche League to see if they have additional suggestions...

I know a lot of midwives are big believers in controling it with diet. But I also think the change is quite gradual. When you're in the thick of it, each feeding is a trial and you need immediate relief.

Best wishes!

8:11 AM  
Blogger Michael said...

I have been suffering from ductal yeast since my baby was 2 weeks old, she is now 6 1/2 months! I still have not gotten relief. I have seen numerous doctors, nurse pratitioners, a midwife and a lactation consultant. Some of which gave me antibiotics to treat it and a small dose of diflucon,a one time pill. I also recieved a two week course of diflucon from the midwife and another 3 week course shortly following. I have tried lotrimin, monistat, gentian violet, nystatin for the baby, diet change, vinegar bath for nipples, coconut oil on my nipples, probitics for me asidopholis powder for the baby all to no avail. Each treatment lessens the symptoms but they always seem to return. The diflucon seemed to get rid of it but then within two weeks of taking it the infection returns. Diet helps a lot, but one tiny slip up and I am right back where I started from. the infection gets so bad at times that I can pump straight blood from my breast instead of milk, this irritates the baby's stomach and she spits up blood for a few hours after the feeding. The yeast seems to only be in one breast and the baby has never shown any signs of thrush. I would love any advice you could give. I really would like to continue breastfeeding but am now considering weaning.

1:26 PM  
Blogger doulicia said...

Oh Michael, I feel your pain! I wish I could offer suggestions/advice. I really don't have anything.

My only thought would be to wean from the one breast but not the other. I remember asking my midwife (did I write about that in this post?). She said women do that. You end up a little lopsided is all.

So what if you kept breastfeeding from the uninfected breast but tapered of the other one?

1:52 PM  
Blogger amity said...

please help!
stopped breastfeeding baby 2.5 months ago and have bad burning in chest wall and breat was treated for mastitis but burning still remains could this be yeast?

5:16 PM  
Anonymous Anonymous said...

Wow, I just have to throw in my 2cents worth here, hoping it will help some of you. I had the most dreadful repeat bouts of yeast in the breast while breastfeeding my daughter. I tried everything to make it go away for good. Diflucan three times, hot water washing of clothing items, treating the baby's thrush, even my OB said I should just give up breastfeeding. Then another Mom suggested Gentian Violet available at Longs applied topically with a q-tip to the nipple. I had to repeat a few more times when it would flare but the relief was immediate. Use the smallest amount poss on nipples blot well and let the baby nurse for his dose to stop the sharing of yeast. Diflucan is pretty intense med to have in your breast milk. Careful because Gentian's staining power is impressive. Bye yeast! Go Purple. What a surprise to finally discover it didn't hurt to breastfeed. Syptoms are the shooting pain and the bubblegum pink nipples for breast yeast.

1:09 AM  

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